ChanBeDu/relevant_section_length · Datasets at Hugging Face

6,520

124,437

53312

Discharge summary

report

Admission Date: [**2129-3-10**] Discharge Date: [**2129-4-7**] Date of Birth: [**2080-12-11**] Sex: M Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 6565**] Chief Complaint: Febrile neutropenia Major Surgical or Invasive Procedure: video assisted thoracic surgery with chest tube and Pleurex catheter placement; subsequent removal of chest tube History of Present Illness: 48 yo male with h/o HIV and metastatic bladder CA s/p taxotere [**2129-3-4**], recently discharged after admission for w/u of L pleural effusion admitted from clinic with fever/neutropenia. Mr [**Known lastname 3389**] came to clinic with symptoms of fever, rash over his chest and back, sore throat and mouth sores. He states that he also couldn't tolerate being in the same house as a cat last night (so stayed in a hotel) due to allergy symptoms, but that he has never previously had an allergy to cats. He has recently taken 2 weeks of levofloxacin followed by Zosyn from [**Date range (1) 79037**] for empiric coverage of a L side effusion that is now thought to be malignant. ROS on admission: as above with the addition of urinary frequency. Past Medical History: Past Onc History: Metastatic bladder cancer: Diagnosed in [**12/2127**] (presented with hematuria/clots - bladder mass revealed on CT). Biopsy showed papillary urothelial cancer with invasion of the lamina propria. On [**2128-3-12**], he had a partial cystectomy, which revealed high-grade urothelial carcinoma that was 4.5 cm described as PT3B with invasion into the perivesical tissue and associated with extravascular mass. He has completed 3 cycles of adjuvant gemcitabine and Cis-platinum completed on [**2128-7-29**]. He then developed metastasis to his small bowel. He recently was considered for a trial, but due to risk of interaction with his psychiatric medications, has elected to pursue single [**Doctor Last Name 360**] therapy-- Cycle 1 Day 1 of Taxotere was administered on [**2129-3-3**]. . Past Medical History: Diverting Ileostomy [**2128-11-19**] recurrent SBO [**1-21**] metastatic disease HIV- CD4 612/ VL: undetectable as of [**9-24**] Metastatic Bladder CA (as above) Bipolar - hospitalization in [**2125**] at [**Hospital1 **] for psychosis h/o MRSA infection GERD h/o herpes simplex hypogonadism recent pna Social History: Occasional ETOH [**1-22**] drinks/wk, denies h/o abuse h/o Heroin, Meth, Marijuana Smoking 1 pack/day. Family History: Father - HIV Mother - ?CA Physical Exam: Vitals: T 99.2, BP 123/59, HR 97, RR 18, Sat 97% on RA, Wt 175# Gen: cachectic man, uncomfortable, diaphoretic but NAD. HEENT: MMM. +ulcerations in posterior OP. Lungs: No BS on L 1/2 up. R lung- CTA. CV: RRR. +gallop. ABD: +BS. flat, soft, ostomy in RLQ draining brown stool. Nontender, nondistended. ostomy dressing - c/d/i, no sign of infxn. SKIN- erythemetous pustular rash over anterior and posterior torso. nonblanching erythema over R hand. . Pertinent Results: [**2129-3-9**] 08:05AM PT-12.4 PTT-33.8 INR(PT)-1.1 [**2129-3-9**] 08:05AM PLT COUNT-330 [**2129-3-9**] 08:05AM WBC-2.7* RBC-3.90* HGB-10.7* HCT-31.1* MCV-80* MCH-27.5 MCHC-34.5 RDW-13.5 [**2129-3-9**] 08:05AM CALCIUM-8.1* PHOSPHATE-2.6* MAGNESIUM-2.1 [**2129-3-9**] 08:05AM GLUCOSE-95 UREA N-13 CREAT-1.1 SODIUM-137 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-29 ANION GAP-11 [**2129-3-10**] 09:35AM PLT COUNT-383 [**2129-3-10**] 09:35AM MICROCYT-1+ [**2129-3-10**] 09:35AM NEUTS-10.9* LYMPHS-77.3* MONOS-4.5 EOS-5.6* BASOS-1.7 [**2129-3-10**] 09:35AM WBC-1.0*# RBC-4.34* HGB-11.4* HCT-34.6* MCV-80* MCH-26.3* MCHC-33.0 RDW-13.4 [**2129-3-10**] 07:16PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2129-3-10**] 07:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2129-3-10**] 07:16PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 . [**3-10**] CXR COMPARISON: [**2129-3-7**]. PA & LATERAL RADIOGRAPHS CHEST (3 IMAGES): Large left pleural effusion has increased slightly in size. There is persistent left mid lung atelectasis or scarring. Retrocardiac opacification persists and may be due to atelectasis or consolidation. The right lung is clear. Cardiac, mediastinal, and hilar contours are normal. IMPRESSION: Slight increase in large left pleural effusion. Persistent retrocardiac opacification is concerning for consolidation and/or atelectasis. Brief Hospital Course: 48yo man with HIV (CD4 [**9-24**] = 612,VL undetectable), large l pleural effusion (likely malignant) admmitted with fever and neutropenia. . #) Fever and Neutropenia- The patient presented with neutropenia due to taxotere [**3-4**]. He was treated with aztreonam (cephalosporins avoided due to recent severe drug rash from zosyn) and vancomycin. He continued to spike to 103; Diflucan was added for fungal coverage on [**3-13**]. His counts began to recover on [**3-12**]. A diagnostic and therapeutic thoracentesis was performed on [**3-14**]; cytology was negative for malignant cells but cultures grew viridans Strep, micrococcus, and stomatococcus. Blood culture and urine cultures have been negative. Antibiotics were narrowed to vancomycin and metronidazole, to continue through [**2129-4-23**]. . #) Rash- The patient presented with a severe drug rash (erythema, puritic, pustular over torso and hands) on admission which was thought to be due to Zosyn. The patient had been on ZOsyn during his previous admission for empiric coverage of his pleural effusion; the medication was discontinued on the day prior to this admission at which point the patient had started to develop a mild rash. He was treated supportively with antihistamines and lotion; the rash improved within a few days. . #) Mucositis- the patient presented with severe mucocytis; he developed oral [**Female First Name (un) **] on [**3-13**]. Supportive care including mouth care, pain control, nystatin swish and swallow and systemic diflucan (started [**3-13**]) were given with improvement. . #) Pleural effusion- The patient has a large L pleural effusion. He received 2 thoracenteses during his prior admission with removal of 1.5 L each time; unfortunately the fluid from the second tap was lost and not sent for analysis. The analysis of the first tap was inconclusive, however, the effusion was initially thought to most likely be malignant. IP followed the patient throughout his admission. A repeat thoracentesis was performed on [**3-14**] and the patient eventually had video assisted thoracic surgery (VATS) for both pleurodesis and chest tube as well as Pleurex catheter placement. Post-operatively, the chest tube clottted and was removed. The Pleurex catheter clotted, as well, and tPA was administered. Subsequently, there was significant bleeding into the L hemithorax requiring 16 units of PRBCs and 2 units FFP. The L hemithorax remains opacified on CXR, likely a combination of clotted blood and effect of pleurodesis; the Pleurex catheter drains only small amounts of fluid, but as the clotted blood degrades, more fluid may be drainable via the Pleurex. He is comfortable on room air but requires supplemental oxygen at night, which is best provided with humidification because of his sensitive mucus membranes and recent mucositis. . #) HIV: The patient has stable on HAART since [**2121**]. Most recent CD4: 612, VL: undetectable ([**9-24**]). H/o thrush in past, no other OI. Recent CD4 check low at 80, however, this was checked during acute illness s/p steroids and chemo so thought to be spurious value per ID consult last admit. He was continued on his outpatient medication regimen. . #)Metastatic bladder cancer: s/p taxotere [**3-4**]. Supportive care. . #) Psych: The patient has a history of bipolar disorder, most recent episode depression. He was continued on his home medication regimen. Social work followed the patient throughout his admission. . #) H/o small bowel obstruction s/p ileostomy: Has had problems with [**Name2 (NI) 109691**] bleeding around the ileostomy, which may be due to irritation with dressing changes. The ileostomy appliance should be applied with as large a margin as is feasible to prevent irritation to the stump. . #) blepharitis: crusting on eyelids and around eye lashes as well as ectropion; started blephamide eye drops after consultation with ophthalmology with good result. . #) sacral decubitis: dressed per wound nursing recommendations Medications on Admission: Dilaudid 2 mg po q2h prn abd pain Keletra 200-50, 2 tab [**Hospital1 **] Viread 300 qd Ziagen 300 [**Hospital1 **] Celexa 40 mg qd Zyprexa 5 mg qday Ativan 1 mg PRN Depakote 500 mg qAM, 1000 mg qHS Wellbutrin SR 150 mg [**Hospital1 **] Discharge Medications: 1. PICC Line Care PICC line care per protocol 2. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 16 days: through [**2129-4-22**] for pleural space infection. 3. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 16 days: through [**2129-4-22**] for pleural space infection. 4. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day. 5. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO q3-4hr as needed for pain. 6. Sulfacetamide-Prednisolone 10-0.2 % Drops, Suspension Sig: Two (2) gtt Ophthalmic four times a day: continue for 1 week after resolution of eyelid crusting/infection. 7. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 9. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical PRN (as needed). 14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 15. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 16. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 17. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)). 18. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 20. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 23. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 24. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital 169**] Center- [**Location (un) **] Discharge Diagnosis: metastatic bladder cancer, HIV, recurrent small bowel obstruction s/p diverting ileostomy, bipolar disorder Discharge Condition: fair Discharge Instructions: Continue taking all your medications as prescribed. Followup Instructions: Call Dr [**Last Name (STitle) **] for an appointment as needed. [**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]

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Discharge summary

report

Admission Date: [**2161-7-9**] Discharge Date: [**2161-7-15**] Date of Birth: [**2095-8-2**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8263**] Chief Complaint: shortness of breath, nausea Major Surgical or Invasive Procedure: none History of Present Illness: 65 yo with ESRD on HD, COPD, and systolic dysfunction (EF 45%), presenting with malaise, nausea, and shortness of breath starting this afternoon after dialysis. Dialysis was uneventful, and the patient went home. At around 3:30 p.m., he was sitting in a chair when he became sweaty, nauseas, warm, short of breath. No chest pain or pressure. He lay down for a couple of hours, experiencing orthopnea. Then at around 5:30 p.m., he asked his family to call 911 and take him to the hospital. He had clear emesis once at home and once in he ER. He also noted a cough. Of note, the patient ran out of one of his blood pressure medications a few days ago, but he is not sure which one. . In the ED, initial vital signs were T 99.8 HR 106 BP 183/109 RR 40 Sat 78%/RA. EKG showed sinus 104, ST depressions in I, V5-6, similar to prior. Labs were notable for WBC 13.2, trop 0.05, lactate 3.9. CXR showed patchy basilar opacities, concerning for pneumonia. CTA negative for dissection (done due to back pain). The patient was given methylprednisolone 125 mg IV, vancomycin 1 gram IV, levofloxacin 750 mg IV, acetaminophen 1000 mg, albuterol nebs x 1, ipratropium nebs x 1, morphine 4 mg IV, and Zofran 4 mg IV. Vital signs on transfer Afebrile HR 104 BP 117/85 RR 28 Sat 94%/4L. Has PIV x 2. . On review of systems, (+)Chills (in ED), +Sweats. +Fatigue. +Lightheadedness. +shortnes of breath. +cough. +nausea/vomiting. +chronic weakness in right hand, otherwise no weakness. (-)No fever. No chest pain or pressure. No loss of consciousness. No diarrhea/constipation. No blood in stool or black stools. No difficulty urinating or pain with urination. No tingling/numbness. No visual changes. Past Medical History: 1. COPD 2. ESRD (on HD since [**2160-10-1**]) 3. hypertension 4. hypercholesterolemia 5. peptic ulcer disease 6. colocutaneous fistula status post low anterior resection, colostomy, and a loop ileo-ostomy [**2154**] 7. history of pneumonia 8. bilateral carotid artery stenosis s/p left carotid endartectomy [**2160-4-3**] 9. h/o left frontoparietal stroke 10. systolic dysfunction (LVEF 45% in [**10/2160**]) Social History: He lives with his daughter, he is retired from instructing at a driving school. He has a significant smoking history, but quit in [**2160-3-17**]. He does not drink alcohol or use drugs. Family History: Brother is on dialysis as a complication of DMII. Mother also had diabetes. Physical Exam: ADMISSION EXAM: Vital signs: T 99.0 BP 143/39 HR 102 RR 25 Sat 96%/2L NC HEENT: Anicteric sclerae. Moist mucous membranes. Neck: Supple. No LAD. JVP not elevated. Resp: Mildly tachypneic. Bibasilar rales L>R. Good air movement. No wheezes. No egophony. CV: Tachycardic. Regular rhythm. No M/G/R. Abdomen: +BS. Soft. NT/ND. Ext: Warm and well-perfused. Radial and DP pulses 2+. Right hand with pain at distal 5th metacarpal. Neuro: A+Ox3. CN II-XII intact. Right hand weak. Strength otherwise [**6-18**] throughout. . DISCHARGE EXAM: Vitals: Tm 99.3, BP 102-129/50-60, P 80s-90s, R 18, 88-96% on RA at rest and with ambulation General: Resting comfortably in NAD HEENT: NCAT, EOMI, no icterus or pallor, MMM Neck: Supple, no JVD Cardiac: RR, nl S1/S2, no m/r/g Lungs: Good respiratory effort, some rales throughout, no wheezing Extrem: RUE in splint, full ROM without pain, no LE edema Neuro: A&Ox3, CN II-XII intact, strength and sensation grossly intact Pertinent Results: ADMISSION LABS: [**2161-7-9**] 06:55PM BLOOD WBC-13.2*# RBC-3.75* Hgb-12.4* Hct-36.1* MCV-96# MCH-33.1*# MCHC-34.4 RDW-15.1 Plt Ct-284 [**2161-7-9**] 06:55PM BLOOD Neuts-82.1* Lymphs-13.6* Monos-2.6 Eos-1.2 Baso-0.6 [**2161-7-9**] 06:55PM BLOOD PT-10.8 PTT-17.7* INR(PT)-0.9 [**2161-7-9**] 06:55PM BLOOD Glucose-109* UreaN-20 Creat-3.6* Na-136 K-4.7 Cl-94* HCO3-28 AnGap-19 [**2161-7-10**] 03:52AM BLOOD LD(LDH)-PND CK(CPK)-35* TotBili-PND [**2161-7-9**] 11:41PM BLOOD CK(CPK)-36* [**2161-7-9**] 06:55PM BLOOD Calcium-9.2 Phos-3.5 Mg-1.8 [**2161-7-9**] 06:55PM BLOOD cTropnT-0.05* [**2161-7-9**] 11:41PM BLOOD CK-MB-2 cTropnT-0.04* [**2161-7-10**] 03:52AM BLOOD CK-MB-2 cTropnT-0.04* . DISCHARGE LABS: [**2161-7-15**] 07:15AM BLOOD WBC-5.8 RBC-2.64* Hgb-8.9* Hct-25.7* MCV-98 MCH-33.7* MCHC-34.5 RDW-15.6* Plt Ct-226 [**2161-7-15**] 07:15AM BLOOD Glucose-124* UreaN-33* Creat-7.2*# Na-137 K-3.8 Cl-91* HCO3-34* AnGap-16 [**2161-7-15**] 07:15AM BLOOD Calcium-8.4 Phos-4.7*# Mg-2.1 . MICRO: [**2161-7-9**] Blood culture x2: no growth to date [**2161-7-9**] Urine culture: no growth [**2161-7-10**] Stool C. diff: negative [**2161-7-10**] Sputum culture: commensal respiratory flora . IMAGING: [**2161-7-9**] Portable CXR: Small patchy opacities in both lung bases, worrisome for either foci of aspiration or possibly multifocal pneumonia. . [**2161-7-9**] CTA Chest: Multifocal pneumonia. . [**2161-7-10**] Right Hand XR (AP/LAT/Oblique): Soft tissue swelling about the small finger metacarpal. There is a transverse fracture through the distal small finger metacarpal with volar displacement, apex dorsal. No other fractures. No dislocation. No degenerative or erosive changes. . [**2161-7-11**] Right Hand XR (AP/LAT/Oblique): Evaluation is limited by an overlying cast. Again seen is the boxer's-type fracture of the fifth metacarpal with radial and volar angulation of the distal fracture fragment grossly unchanged compared to the prior examination. No additional fracture is identified. Brief Hospital Course: 65 year old man with ESRD on HD, COPD, systolic dysfunction, presenting with shortness of breath and nausea and found to have a multifocal pneumonia. . # SOB: Patient was ruled out for MI. He is euvolemic on exam w/o suggestion of heart failure, and we reviewed the CT chest with radiology and confirmed that there is no evidence of pulmonary edema. No evidence of a COPD exacerbation. CXR was suggestive of pneumonia (aspiration vs. multifocal). CTA was negative for PE or dissection, and confirmed a multifocal pneumonia. He was observed eating and does not appear to be aspirating. He was initially treated for HCAP (considering his dialysis treatments) with cefepime/vanc/levofloxacin, but the cefepime was discontinued due to low suspicion for pseudomonas infection. He makes very little urine and we therefore were unable to check a urine legionella antigen. He will complete a 7-day course of levofloxacin and vancomycin (dosed with HD) from [**Date range (1) 8264**]. He was already given his dose of levofloxacin prior to discharge on [**7-15**] and will need his last dose on [**7-16**]. He will receive his last dose of vancomycin at dialysis on [**7-16**]. He remained afebrile with normal WBC and clinical improvement. O2 sats are 88-96% on RA at rest and with ambulation; 92-98% on 1L. He denies any SOB, dizziness, or other symptoms with ambulation. . # COPD: PFTs on [**2161-2-23**] showed FVC 2.48, FEV1 1.10, FEV1/FVC 44. The patient was treated with an inital dose of methylprednisolone 125 mg IV in the ED, but was w/o wheezes on exam and no suggetion of a COPD exacerbation. He was continued on his home famotidine, advair, and spiriva, as well as albuterol and ipratropium nebs prn. He was discharged on his home regimen. . # Pulmonary nodules: On the CT chest there are a few prominent mediastinal and right hilar nodes which do not meet criteria for pathologic enlargement and may be reactive. These were noted on prior imaging and are being followed by his outpatient pulmonologist Dr. [**First Name (STitle) 437**]. He is scheduled for a repeat CT chest in 8/[**2161**]. . # Dizziness/hypotension: The day prior to discharge the patient experienced dizziness and hypotension to the 90s during dialysis. He reported a dry mouth and was found to be orthostatic. His symptoms improved after a 500cc bolus of NS. His symptoms were felt to be secondary to removal of too much fluid in dialysis. In discussion with the renal team, we will adjust his new dry weight to 67kg. His blood pressure has been well controlled despite holding the nifedipine and on a reduced dose of metoprolol. It is unclear why he is requiring fewer anti-hypertensives, but may be due to more aggressive volume removal with dialysis. He was instructed to hold the nifedipine and continue metoprolol succinate 50mg daily (reduced from 100mg daily). . # ESRD on HD: The patient received an extra dialysis session on Friday [**7-10**] for hyperkalemia and possible volume overload, but was then dialyzed per his usual Tu/Th/Sa schedule for the rest of the admission. We continued sevelamer and epo, and started nephrocaps per renal's suggestion. . # Anemia: Likely multifactorial. Baseline Hct appears to be ~25-36. Normocytic. Pt has a h/o anemia of CKD. Iron studies in [**4-/2160**] revealed a low iron and low TIBC suggesting a mixed picture of iron deficiency anemia as well as anemia of chronic disease. B12 and folate wnl. Patient receives epo with outpatient HD. His PCP could consider iron supplementation and to make sure the patient is up to date on colorectal cancer screening. . # Systolic dysfunction: Echo in [**10/2160**] revealed mild regional left ventricular systolic dysfunction with anterior and anterolateral hypokinesis, with an LVEF=45% (stable from [**2159**]). He is currently euvolemic on exam, and there is no evidence of pulmonary edema on the CXR or CT chest, however considering his normal blood pressure despite holding the nifedipine and decreasing the metoprolol dose, there is a question of worsening systolic function. The patient is scheduled for an outpatient echo on [**2161-8-12**]. . # Hyperlipidemia: Continued home simvastatin 80mg daily. . # Right hand pain: Started after the patient punched a wall several weeks prior to admission. X-rays revealed a transverse fracture through the distal small finger metacarpal. Orthopedics evaluated the patient and placed a temporary splint. Occupational therapy later provided the patient with a permanent splint. He has a f/u appt with ortho on [**8-4**]. . # Eyes: Mr. [**Known lastname **] occasionally reported "heavy eyes," but no blurry vision or vision changes, and no eye pain. EOMI and his vision and visual fields are grossly intact, although he wears [**Location (un) 1131**] glasses, but did not have them with him during this admission. Recommend outpatient optometry f/u. . # Cognitive impairment: Mr. [**Known lastname **] was often inconsistent with his history and symptims, and appeared depressed. In speaking with his daughter, it seems that he has been this way for some time and there is concern that he may have mild cognitive impairment and/or depression. We recommend that his PCP consider neuropsychiatric evaluation to screen for depression and dementia. . # Disposition: He will be discharged to rehab and we will arrange for home services on dialysis days, once he returns home. The patient and his daughter are in agreement. He has a f/u appt with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2161-7-20**]. . **A copy of this discharge summary was faxed to the patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]** Medications on Admission: 1. Albuterol nebs [**Hospital1 **] prn 2. Albuterol sulfate HFA 90mcg, 2 puffs q4-6h prn 3. Plavix 75 mg daily 4. Famotidine 20 mg daily 5. Advair 250/50 one puff [**Hospital1 **] 6. Metoprolol succinate 100 mg daily 7. Nifedipine 60 mg daily 8. Sevelamer 800mg, 3 tabs TID with meals 9. Simvastatin 80 mg daily 10. Spiriva 18 mcg inhaled daily 11. Aspirin 325 mg daily Discharge Medications: 1. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): (started [**2161-7-9**] and last day is [**2161-7-16**]). Disp:*1 Tablet(s)* Refills:*0* 2. vancomycin 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous HD PROTOCOL for 1 doses: to be given at dialysis; (started [**2161-7-9**] and last day is [**2161-7-16**]). 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation twice a day as needed for SOB, wheezing. 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 10. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) **] Discharge Diagnosis: PRIMARY: multifocal pneumonia SECONDARY: fifth right metatarsal displaced fracture Discharge Condition: Mental Status: Clear and coherent (though inconsistent story at times) Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], . You were admitted because you were feeling poorly and had shortness of breath. You were found to have a pneumonia which we are treating with antibiotics. . You were found to have a fracture in your hand from punching a wall. The fracture is being managed with a splint and you need to follow up with Orthopedics (appointment listed below). . You are being discharged to a rehab facility to regain your strength prior to going home. . We made the following changes to your medications: - START Levofloxacin (last day is [**2161-7-16**]) - START Vancomycin (given at dialysis; last day is [**2161-7-16**]) - START Nephrocaps (B complex - Vitamin C - folic acid) for your kidneys - STOP Nifedipine because your blood pressure has been low - DECREASE Metoprolol from 100mg daily to 50mg daily - You can take tylenol as needed for pain in your right hand Followup Instructions: Department: [**Hospital1 7975**] INTERNAL MEDICINE When: MONDAY [**2161-7-20**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site . Department: ORTHOPEDICS When: TUESDAY [**2161-8-4**] at 2:10 PM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: ORTHOPEDICS When: TUESDAY [**2161-8-4**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIOLOGY - ECHOCARDIOGRAM When: [**2161-8-12**] at 10:00 AM Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage **An interpretor will be present** Completed by:[**2161-7-15**]

[ "E879.1", "518.89", "276.2", "458.21", "285.21", "276.7", "403.91", "486", "496", "585.6", "815.02", "272.4" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

13417, 13500

5781, 11452

330, 336

13627, 13627

3766, 3766

14717, 15811

2698, 2775

11872, 13394

13521, 13606

11478, 11849

13814, 14299

4468, 5758

2790, 3307

3323, 3747

14328, 14694

263, 292

364, 2046

3782, 4452

13642, 13790

2068, 2478

2494, 2682

72,358

137,403

42765

Discharge summary

report

Admission Date: [**2121-8-20**] Discharge Date: [**2121-9-4**] Date of Birth: [**2039-8-5**] Sex: F Service: MEDICINE Allergies: Sulfanilamide / lisinopril / Penicillins Attending:[**First Name3 (LF) 2265**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 9449**] is an 82 y/o lady with a history of severe aortic stenosis ([**Location (un) 109**] 0.7, transvalvular peak gradient 77mmHg, mean 54mmHg on echo from [**7-/2121**]), ulcerative colitis, breast cancer in [**2109**], presented to ED on [**2121-8-20**] with worsening dyspnea, SOB, dry cough, chills, and a fast heart rate. Over the past 2 weeks she has been having worsening SOB and orthopnea. She denies chest pain, syncope, or edema. No sick contacts or recent hospital admissions. . She was diagnosed with moderate AS in [**2118**], she saw her cardiologist in [**6-/2121**] for occasional shortness of breath with exertion (ie climbing an incline with groceries). Repeat echo showed severe AS (valve area 0.7) and mild AR. She had follow up appt with cardiologist recently where findings from echo were reviewed. At that appt, she was noted to have frequent PACs and there was concern that this may be precurser for A fib. He recommended cardiac surgery evaluation. . In the ED, initial vitals were T 101.4, HR 58, 117/54, RR 20, 97%2L Labs and imaging significant for: WBC 13.4, HCT 34, PLT 580, lactate 1.0. She received Levofloxacin 750mg and tylenol 1000mg. CXR significant for LUL and RLL pneumonia and hyperexpanded lungs consistent with underlying emphysema. Vitals on transfer to unit were Temp 36.9 P 134, BP 125/78, RR 29 92% on 3 L . REVIEW OF SYSTEMS On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: Aortic stenosis, [**Location (un) 109**] 0.7, transvalvular peak gradient 77mmHg, mean 54mmHg on echo from [**7-/2121**] Mild AR 3. OTHER PAST MEDICAL HISTORY: CKD stage 3 (cr 1.1-1.4) Breast CA, in remission Osteoporosis Ulcerative colitis Social History: retired, independent in ADLs, lives with son and daughter in law in 2 story house -Tobacco history: former smoker 80 pack years quit 20 years ago -ETOH: 4 oz /week -Illicit drugs: denies Family History: Mother CAD, [**Name2 (NI) 499**] C, PVD. Father died at 69 of [**Last Name (un) 6722**] cause. [**Name (NI) **] brother with congenital heart disease. Physical Exam: On admission: VS: Temp 36.9 P 134, BP 125/78, RR 29 92% on 3 L GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC:Irregular rhythm, normal S1, soft S2. Late III/VI systolic murmur at RUSB radiating to back and carotids. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Occasional pursed lip breathing. Decreased B/S in RLL, Rare expiratory wheeze. No crackles. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ On discharge: 98.2 90/35mmHg P70 RR18 95%RA GA: A&Ox3, pleasant HEENT: MMM, EOMI, PERRL CV: irregular rhythm, 3/6 systolic murmur at RUSB, no rubs or gallops Pulm: trace bibasilar crackles, no wheezes or rhonchi Abd: soft, NTND, no HSM Ext: no peripheral edema, full pulses throughout Skin: warm, dry Pertinent Results: [**2121-8-20**] 01:30PM PLT COUNT-580* [**2121-8-20**] 01:30PM NEUTS-91.4* LYMPHS-4.8* MONOS-3.3 EOS-0.2 BASOS-0.3 [**2121-8-20**] 01:30PM WBC-13.5* RBC-3.66* HGB-11.3* HCT-34.1* MCV-93 MCH-30.8 MCHC-33.1 RDW-13.1 [**2121-8-20**] 01:30PM TSH-2.9 [**2121-8-20**] 01:30PM estGFR-Using this [**2121-8-20**] 01:30PM GLUCOSE-180* UREA N-25* CREAT-1.2* SODIUM-134 POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16 [**2121-8-20**] 02:10PM LACTATE-1.0 [**2121-8-20**] 02:10PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP [**2121-8-20**] 02:20PM URINE HYALINE-1* [**2121-8-20**] 02:20PM URINE RBC-1 WBC-15* BACTERIA-FEW YEAST-NONE EPI-2 TRANS EPI-1 [**2121-8-20**] 02:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2121-8-20**] 02:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2121-8-20**] 02:20PM URINE UHOLD-HOLD [**2121-8-20**] 02:20PM URINE HOURS-RANDOM [**2121-8-20**] 02:51PM PT-11.4 PTT-25.8 INR(PT)-1.1 [**2121-8-20**] 06:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2121-8-20**] 06:12PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003 [**2121-8-20**] 10:10PM PTT-105.7* . EKG: Afib with RVR HR 150 . 2D-ECHOCARDIOGRAM ([**7-/2121**]): CONCLUSIONS 1. Frequent atrial premature beats. 2. There is mild concentric left ventricular hypertrophy. 3. Tissue and transmitral Doppler demonstrate pseudonormal filling (moderate grade II diastolic dysfunction). 4. The left atrial volume is moderately increased. 5. There is severe aortic stenosis present, with a calculated valve area of 0.7cm2. 6. Compared with the findings of the prior report of [**6-/2121**], the measured gradients are a little higher, resuling in a slightly lower calculated aortic valve area. . ECHO [**8-22**]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal/small. Overall left ventricular systolic function is normal (LVEF 60%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area 0.5 cm2) (may represent an entity known as "low flow/low gradient aortic stenosis with preserved ejection fraction"). Mild to moderate ([**12-9**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-9**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Discharge: [**2121-9-4**] 08:50AM BLOOD WBC-6.5 Hct-30.6* [**2121-9-4**] 08:50AM BLOOD Glucose-147* UreaN-28* Creat-1.5* Na-134 K-4.7 Cl-99 HCO3-25 AnGap-15 Brief Hospital Course: 82F history of critical aortic stenosis ([**Location (un) 109**] 0.7, transvalvular peak gradient 77mmHg, mean 54mmHg on echo from [**7-/2121**]), IBD, breast cancer in remission, presenting with SOB, found to have new atrial fibrillation with RVR, hypotension, and pneumonia. . # Pneumonia: Shortness of breath with decreased O2 sat at 88%, fever (Tmax of 101.4) and chest x-ray consistent with LUL PNA. Initially thought to be community-acquired PNA. However, patient continued to be hypoxic after treatment with levofloxacin. Therefore, pulmonology was consulted, and they recommended broadening with vancomycin and cefepime, which were eventually stopped. On [**8-28**], she completed an 8-day course of levofloxacin for CAP. Sputum and blood cultures did not grow any organisms. . # New AFIB with RVR: Etiology was thought to be pneumonia or valvular (aortic) disease. Given hypotension, diltiazem and metoprolol were not in itially considered, and she was started on amiodarone with an understanding of the thromboemoblic risk of chemical cardioversion. Metoprolol was started on [**8-28**] when BP would tolerate. Her CHADS2 score was 3, and she was started on heparin drip. In preparation for discharge, pt started on Lovenox, renally dosed. On discharge, rhythm still in atrial fibrillation, hemodynamically stable. Pt discharged with amiodarone, Lovenox 40mg SC daily and stopped aspirin in preparation for cardiac surgery in near future. . # Aortic Stenosis: Critical with valve area of 0.7 cm^2, she has had gradual onset dypsnea per her outpatient cardiology notes, which is likely associated with her valvular disease. Initially denied angina and syncope/presyncope, but had an episode of syncope during the hospitalization on [**8-26**]; at that time, further questioning revealed that patient may have had episodes of syncope/presyncope at home. Case was discussed with cardiac surgery who recommended optimization of pneumonia and atrial fibrillation treatment prior to surgery. In preparation for surgery, she underwent catheterization on [**8-28**], which showed minimal coronary artery disease. Aortic valve replacement surgery scheduling will be discussed at [**9-17**] appt with Dr. [**Last Name (STitle) **]. # C.diff colitis: The patient developed diarrhea. Stool studies were sent which showed C. Diff positive. The patient was started on flagyl 500mg q8h on [**9-2**] for 2 week course. At time of discharge, diarrhea improved. # Hyperlipidemia: Simvastatin was continued. . # Blood Pressure: Patient has a history of hypertension, but was hypotensive when she presented, likely due to the atrial fibrillation with RVR. Home losartan was held throughout hospital course as pressures were 90s to low 100s. Pt discharged with metoprolol and instructed to no longer take home Losartan. . Transitional Issues: -Pt is to followup with C-[**Doctor First Name **] on [**9-17**] with Dr [**Last Name (STitle) **] [**Name (STitle) 30412**] is to followup with PCP Dr [**Last Name (STitle) **] on [**9-8**]. -Pt is to have C.diff stool PCR/toxin rechecked 2 weeks after finishing 2 wk course of Flagyl -Spiculated RUL Nodule: Seen on Chest CT. Should be followed up with repeat CT. # CODE: Full code confirmed # EMERGENCY CONTACT: daughter Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientAtriuswebOMR. 1. Losartan Potassium 50 mg PO DAILY 2. Simvastatin 10 mg PO HS 3. Mesalamine 800 mg PO TID 4. Multivitamins 1 TAB PO DAILY 5. Aspirin 81 mg PO DAILY 6. Vitamin B Complex 1 CAP PO DAILY Discharge Medications: 1. Mesalamine 800 mg PO TID 2. Multivitamins 1 TAB PO DAILY 3. Simvastatin 10 mg PO HS 4. Vitamin B Complex 1 CAP PO DAILY 5. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL one syringe daily Disp #*10 Syringe Refills:*2 6. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole 500 mg one tablet(s) by mouth three times a day Disp #*36 Tablet Refills:*0 8. Amiodarone 200 mg PO DAILY RX *amiodarone 200 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Severe Aortic stenosis C Difficile colitis Hypertension Atrial fibrillation Acute on Chronic kidney injury Delerium Community axquired pneumonia 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 Ms. [**Known lastname 9449**], It was a pleasure taking care of you at [**Hospital1 18**]. You had a pneumonia and was treated with antibiotics. During this time, your aortic stenosis was causing you to retain fluid and you needed diuretics to remove the extra fluid. You will need surgery to fix the aortic stenosis. We found that the diarrhea was from an infection called c difficile and you are on a 14 day course of antibiotics to treat this. Dr. [**Last Name (STitle) **] wants to know that this infection is cured before he performs surgery so Dr. [**Last Name (STitle) **] will arrange for another test of your stool to be sent after the antibiotics are finished. Your heart developed an irregular rhythm called atrial fibrillation. This rhythm puts you at increased risk of a stroke so you are on Lovenox, a blood thinner, to prevent blood clots. You will need to have your daughter give you the injection of lovenox every day while you are at home. You will need to save a stool sample after the flagyl is finished to see if the C. difficile infection is gone. Dr. [**Last Name (STitle) **] will help you with this. You should also stop your aspirin in preparation for your aortic valve replacement in the near future. Followup Instructions: Department: CARDIAC SURGERY When: WEDNESDAY [**2121-9-17**] at 2:30pm 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 . Name:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD When: Monday [**9-8**] st at 12:10 Location: [**Hospital1 641**] Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**] Phone: [**Telephone/Fax (1) 88505**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]

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icd9cm

[ [ [] ] ]

[ "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

11414, 11471

7160, 9986

319, 326

11660, 11660

4030, 7137

13104, 13779

2672, 2825

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260, 281

354, 2099

2854, 3708

11675, 11819

2367, 2449

2121, 2187

2465, 2656

23,657

130,222

13530

Discharge summary

report

Admission Date: [**2147-5-14**] Discharge Date: [**2147-5-16**] Date of Birth: [**2112-11-14**] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil / Hydralazine / cefepime Attending:[**First Name3 (LF) 9160**] Chief Complaint: Shortness of breat Major Surgical or Invasive Procedure: None History of Present Illness: This 34 year old male presents for hypertension and shortness of breath. He has a history of type 1 DM since age 19 complicated by nephropathy, neuropathy, retinopathy, and gastroparesis. He has end-stage renal disease with right arm fistula for access, on a Tuesday, Thurs, Saturday schedule for dialysis. He presents for shortness of breath worsening over the past day. One day prior to admission he got dialyzed and had a dry weight of 72.1 (his usual post-dialysis weight is 73). However, following dialysis, he drank more fluids than usual, and then became progressively short of breath. He also has had nausea and abdominal pain, consistent with his gastroparesis. In the ED, he was noted to have a blood pressure of 200 systolic and was started on nitroglycerin drip. He was started on BiPAP initially for his shortness of breath, however he was not able to tolerate this, and he was quickly weaned to a non-rebreather, saturating at 100%. A chest x-ray revealed significant volume overload. He was admitted to the ICU for his hypertension and volume overload. At time of transfer, he was weaned to 6 L NC and was saturating near 100% with improvement in respiratory rate. He continued to endorse significant nausea and abdominal pain. He received Zofran and Reglan in the ED, but had persistent symptoms. Review of systems otherwise negative. Past Medical History: - DM type I since age 19, followed at [**Last Name (un) **]. Complicated by nephropathy, neuropathy, gastroparesis, retinopathy. Multiple prior hospitalizations with DKA, nausea/vomiting [**2-9**] gastroparesis - ESRD on HD T/Th/S via right arm fistula @ [**Location (un) **] [**Location (un) **], dry weight 73kg - Hypoglycemia - Hyperglycemia/DKA: requiring insulin gtt - Hypertension - Nonischemic cardiomyopathy with EF 30-35% - Anemia: [**2-9**] iron deficiency and advanced CKD - Depression - Pulmonary hypertension - Migraines Social History: Lives with girlfriend. Mother also local. College degree in marketing, worked at [**Company 2475**] previously. Tobacco: trying to quit; relapsed and smokes ~1 pack per week EtOH: previously drank heavily (30-40 drinks/week) but has not used alcohol since [**2144-11-14**] Denies other drugs. Family History: Paternal grandfather had DM2. [**Name2 (NI) **] FH DM1. Hypertension in a few family members. [**Name (NI) 6419**] [**Name2 (NI) **] and several siblings alive and healthy, without known medical problems. Physical Exam: FEX ON ADMISSION TO MICU VS: HR 95, BP 182/104, O2 sat 97% on 6 L NC, temp 98, RR 12 Gen: Black male, sitting up in bed with basin in hand, nauseous HEENT: venous access in right EJ Cardiac: Nl s1/s2, RRR, palpable thrill Resp: crackles present bilaterally Abd: soft, nontender, nondistended +BS Ext: no edema noted FEX ON DISCHARGE VS: BP 136-150/90-98 HR 73-82 RR 18-20 O2 100%2L Gen: Comfortable appearing young man in NAD, sitting up in bed HEENT: Anicterica sclera, PERLL, OP clear, MMM, No JVD Cardiac: RRR, nl s1/s2, no mrg Resp: Nonlabored on 2LNC (notably, has been taking it off intermitentently), good air movement, no adventitial sounds noted Abd: soft, nontender, nondistended +BS Ext: no edema noted Neuro: AAOx3, appropriate. CN II-XII grossly intact. No gross strength of sensory deficit. Normal gait. Pertinent Results: ADMISSION LABS: [**2147-5-14**] 10:10PM BLOOD WBC-8.8# RBC-4.24* Hgb-12.7* Hct-39.8* MCV-94 MCH-29.9 MCHC-31.9 RDW-13.4 Plt Ct-207 [**2147-5-14**] 10:10PM BLOOD PT-10.5 PTT-29.5 INR(PT)-1.0 [**2147-5-14**] 10:10PM BLOOD Neuts-90.9* Lymphs-6.0* Monos-1.8* Eos-0.9 Baso-0.3 [**2147-5-14**] 10:10PM BLOOD Glucose-237* UreaN-31* Creat-8.6*# Na-137 K-4.9 Cl-94* HCO3-24 AnGap-24* [**2147-5-14**] 10:10PM BLOOD ALT-25 AST-33 CK(CPK)-198 AlkPhos-198* TotBili-0.5 [**2147-5-14**] 10:10PM BLOOD Lipase-41 [**2147-5-14**] 10:10PM BLOOD cTropnT-0.17* [**2147-5-14**] 10:10PM BLOOD CK-MB-3 proBNP-GREATER THAN [**Numeric Identifier **] [**2147-5-14**] 10:10PM BLOOD Albumin-4.9 Calcium-10.3 Phos-4.2 Mg-1.7 DISCHARGE LABS: [**2147-5-16**] 11:58AM BLOOD WBC-5.6 RBC-3.40* Hgb-10.6* Hct-32.2* MCV-95 MCH-31.0 MCHC-32.8 RDW-13.6 Plt Ct-160 [**2147-5-16**] 11:58AM BLOOD Glucose-246* UreaN-54* Creat-12.7*# Na-132* K-5.2* Cl-90* HCO3-24 AnGap-23* [**2147-5-16**] 11:58AM BLOOD Calcium-9.3 Phos-5.2* Mg-1.7 REPORTS: [**2147-5-14**] Radiology CHEST (PORTABLE AP) Moderate pulmonary edema with stable cardiomegaly [**2147-5-14**] Cardiovascular ECG Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy by voltage criteria with lateral ST-T wave changes which may be due to left ventricular hypertrophy or ischemia. [**Year/Month/Day **] correlation is suggested. Compared to the previous tracing of [**2147-2-28**] the lateral ST-T wave changes on the current tracing look less typical for left ventricular hypertrophy Brief Hospital Course: Mr. [**Known lastname 21822**] is a 34 year old man with significant PMH of Type I DM c/b retinopathy, neuropathy, gastroparesis, ESRD, and ischemic cardiomyopathy who was admitted to the MICU on [**5-14**] for worsening shortness of breath found to have hypertensive emergency with flash pulmonary edema. # Hypertensive crisis: Presented with SBP>200, triggering flash pulmonary edema. Etiology thought to be due to dietary indiscretion with possible medication dosing missed due to nausea and vomiting. Responded well to nitroglycerin drip on night of admission to MICU. By morning after admission, patient was off nitroglycerin drip and back on home antihypertensives including labetolol TID 600mg/600mg/300mg, amlodipine 10mg, lisinopril 40mg, and [**Month/Day (4) 40899**] 0.3mg patch qweekly. His blood pressure remained well controlled over the next 24 hours. # Pulmonary edema: Precipitated by hypertensive crisis. He responded quickly to correction of his hypertension with nitroglycerin gtt overnight (see above). On admission to medicine floor he was saturating well on 2L NC and by morning of admission was ambulating floor on RA without complaint and clear lung exam. Patient received hemodialysis prior to discharge. # End-stage renal disease: Patient received HD on [**2147-5-16**] and was followed by the Nephrology consult service. He will resume his usual schedule of HD on Tuesday, Thursday, and Saturday after discharge. CHRONIC PROBLEMS # Abdominal Pain, nausea and vomiting. Consistent with history of gastroparesis. Was NPO and received IV dilaudid while in MICU. Was transitioned to home dosing of oral dilaudid for pain with oral zofran following transfer to medicine floor. # Type 1 DM - with nephropathy, retinopathy, and neuropathy; also has ischemic cardiomyopathy. History of very labile blood sugars. Blood sugars moderately elevated in ICU with gap, although improved with closing gap following SC insulin morning after admission. Continued glargine 14 units with HISS. # Ischemic cardiomyopathy - In setting of type I DM. LVEF in [**Month (only) 956**] 40%, although improved to >55% in repeat exam later that month. Patient was continued on his lisinopril and aspirin. TRANSITIONAL ISSUES: - Would continue to stress importance of dietary and medication compliance. - Close monitoring of HTN as outpatient. Medications on Admission: 1. amlodipine 5 mg Tablet [**Month (only) **]: Two (2) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable [**Month (only) **]: One (1) Tablet, Chewable PO DAILY (Daily). 3. [**Month (only) 40899**] 0.3 mg/24 hr Patch Weekly [**Month (only) **]: One (1) Patch Weekly Transdermal qMONDAY. 4. insulin glargine 100 unit/mL Solution [**Month (only) **]: Fourteen (14) units Subcutaneous qAM. 5. insulin lispro 100 unit/mL Solution [**Month (only) **]: as directed Subcutaneous QACHS. 6. B complex-vitamin C-folic acid 1 mg Capsule [**Month (only) **]: One (1) Cap PO DAILY (Daily). 7. lisinopril 20 mg Tablet [**Month (only) **]: Two (2) Tablet PO DAILY (Daily). 8. sevelamer carbonate 800 mg Tablet [**Month (only) **]: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. sertraline 50 mg Tablet [**Month (only) **]: Two (2) Tablet PO DAILY (Daily). 10. hydromorphone 2 mg Tablet [**Month (only) **]: Two (2) Tablet PO BID (2 times a day) as needed for pain. 11. ondansetron HCl 4 mg Tablet [**Month (only) **]: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 12. labetalol 200 mg Tablet [**Month (only) **]: Three (3) Tablet PO BID (2 times a day). 13. labetalol 100 mg Tablet [**Month (only) **]: Three (3) Tablet PO QHS (once a day (at bedtime)). Discharge Medications: 1. amlodipine 10 mg Tablet [**Month (only) **]: One (1) Tablet PO once a day. 2. aspirin 81 mg Tablet, Chewable [**Month (only) **]: One (1) Tablet, Chewable PO DAILY (Daily). 3. [**Month (only) 40899**] 0.3 mg/24 hr Patch Weekly [**Month (only) **]: One (1) Patch Weekly Transdermal QMON (every [**Month (only) 766**]). 4. insulin glargine 100 unit/mL Solution [**Month (only) **]: Fourteen (14) Subcutaneous every morning. 5. insulin lispro 100 unit/mL Solution [**Month (only) **]: As directed Subcutaneous as directed: per sliding scale. 6. B complex-vitamin C-folic acid 1 mg Capsule [**Month (only) **]: One (1) Capsule PO once a day. 7. lisinopril 40 mg Tablet [**Month (only) **]: One (1) Tablet PO once a day. 8. sevelamer carbonate 800 mg Tablet [**Month (only) **]: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. sertraline 50 mg Tablet [**Month (only) **]: Two (2) Tablet PO DAILY (Daily). 10. hydromorphone 2 mg Tablet [**Month (only) **]: Two (2) Tablet PO twice a day as needed for pain. 11. ondansetron HCl 4 mg Tablet [**Month (only) **]: One (1) Tablet PO every eight (8) hours as needed for nausea. 12. labetalol 200 mg Tablet [**Month (only) **]: Three (3) Tablet PO BID (2 times a day). 13. labetalol 100 mg Tablet [**Month (only) **]: Three (3) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive emergency 2. Pulmonary edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 21822**], You were admitted to the hospital because you were having worsening shortness of breath. We found the you had extremely high blood pressure and fluid was backing up into your lungs. This may have been caused by eating too much salt and fluids in a short period of time. We gave you an IV infusion of medications to control your blood pressure and you began to feel a lot better. We then put you back on your regular mediations and a low salt diet and your breathing and blood pressure remained well controlled. We made no changes to your medications. It is exremely important for you to be 100% compliant with your medications and to follow a low salt diet. You will need to continue dialysis per your usual schedule. You should weigh yourself every morning, and call your doctor if your weight goes up more than 3 lbs. Please note the following appointments that have already been scheduled. It has been a pleasure taking care of you. Followup Instructions: Department: [**Hospital3 249**] When: FRIDAY [**2147-5-26**] at 10:10 AM With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**] Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] [**Hospital Ward Name **] Ctr [**Location (un) 895**] Central [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] GarageThis appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]

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icd9cm

[ [ [] ] ]

[ "93.90", "39.95" ]

icd9pcs

[ [ [] ] ]

10246, 10252

5230, 7443

343, 350

10341, 10341

3681, 3681

11493, 12344

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2309, 2603

17,190

101,738

5383

Discharge summary

report

Admission Date: [**2104-1-25**] Discharge Date: [**2104-2-1**] Date of Birth: [**2045-12-2**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 10370**] Chief Complaint: CC: elevated blood sugar Major Surgical or Invasive Procedure: PICC Renal Artery Stent History of Present Illness: 56 yo M with history of renal cell cancer s/p nephrectomy and renal transplant in [**2101**], hypertension who presents with 2 days of general malaise, weakness, nausea, polyuria, polydipsia, and chills. Pt notes 1 week h/o nonproductive cough. Denies fever, CP, or SOB. Pt was seen in renal clinic today where he was noted to have a glucose of >500. On arrival to [**Name (NI) **], pt found to have glucose >900, T 99.1, BP 236/108. In ED given 10 units of SC insulin x2 and then started on insulin gtt. Pt had a h/o DM while on Prograf in [**2101**]. Not currently treated for DM. Pt was transferred to the MICU and was placed on an insulin drip with better sugar control was transferred to the floor. Past Medical History: Renal cell ca s/p L nephrectomy [**2093**] s/p cadaveric renal transplant [**8-7**] diabetes mellitus type 2 asthma- not treated, hospitalized as child s/p left AV graft h/o ciguatera poisening from barracuda ingestion nasal polyps hypertension DM type 2 Barrett's esophagus mild pulmonary hypertension trivial MR Social History: married, works in nutrition at [**Hospital1 18**] remote tob hs, no EtOH, no IVDA Family History: mother with renal disease Physical Exam: VS: Tm 98.4 Tc98.1 86 68-96 BP 170/39 150-204/39-82 RR 19 SaO2 96, 95-97 RA I/O 5300/750 Gen: well appearing male in NAD HEENT: dry MM, PERRL, EOMI, No JVD CV: rrr, SEM II/VI greatest RUSB Chest: CTA b/l Abd: soft, NT/ND, +BS Ext: no edema, strong DP/PT pulses Neuro: A&Ox3 Pertinent Results: [**2104-1-25**] 09:15PM GLUCOSE-732* UREA N-18 CREAT-1.8* SODIUM-134 POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-19* ANION GAP-21* [**2104-1-25**] 06:49PM GLUCOSE-931* K+-6.1* [**2104-1-25**] 06:30PM GLUCOSE-837* UREA N-20 CREAT-1.8* SODIUM-127* POTASSIUM-4.6 CHLORIDE-89* TOTAL CO2-23 ANION GAP-20 [**2104-1-25**] 06:30PM CK(CPK)-294* [**2104-1-25**] 06:30PM CK-MB-4 cTropnT-0.03* [**2104-1-25**] 06:30PM CALCIUM-10.7* PHOSPHATE-2.3* MAGNESIUM-2.3 [**2104-1-25**] 06:30PM WBC-4.5 RBC-5.35 HGB-13.8* HCT-43.2 MCV-81* MCH-25.8* MCHC-31.9 RDW-13.7 [**2104-1-25**] 06:30PM NEUTS-67.6 LYMPHS-26.6 MONOS-4.7 EOS-1.2 BASOS-0.1 [**2104-1-25**] 06:30PM HYPOCHROM-3+ MICROCYT-1+ [**2104-1-25**] 06:30PM PLT SMR-NORMAL PLT COUNT-168 LPLT-2+ [**2104-1-25**] 06:30PM PT-12.4 PTT-25.0 INR(PT)-1.0 [**2104-1-25**] 01:14AM GLUCOSE-692* [**2104-1-25**] 01:14AM UREA N-19 CREAT-1.8* SODIUM-134 POTASSIUM-3.7 CHLORIDE-94* TOTAL CO2-30 ANION GAP-14 [**2104-1-25**] 01:14AM ALT(SGPT)-30 AST(SGOT)-19 TOT BILI-0.5 [**2104-1-25**] 01:14AM ALBUMIN-3.7 CALCIUM-10.4* PHOSPHATE-2.1* [**2104-1-25**] 01:14AM rapamycin-14.6* [**2104-1-25**] 01:14AM URINE HOURS-RANDOM CREAT-41 TOT PROT-207 PROT/CREA-5.0* [**2104-1-25**] 01:14AM WBC-4.2 RBC-5.52 HGB-14.0 HCT-44.1 MCV-80* MCH-25.3* MCHC-31.7 RDW-13.3 [**2104-1-25**] 01:14AM PLT SMR-NORMAL PLT COUNT-167 [**2104-1-25**] 01:14AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.036* [**2104-1-25**] 01:14AM URINE BLOOD-TR NITRITE-NEG PROTEIN->300 GLUCOSE->1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0 LEUK-NEG [**2104-1-25**] 01:14AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 CXR in ED: No active lung disease. ECHO: The left atrium is moderately dilated. There is probably moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal. Right ventricular systolic function is normal. The aortic valve leaflets are mildly thickened. The study is inadequate to exclude significant aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no pericardial effusion. CXR [**1-26**] (after unsuccessful SC/IJ line attempts): Cardiac silhouette and mediastinum is within normal limits. No pneumothoraces are identified on either side. No parenchymal opacities are seen. There is no evidence for gross pulmonary edema. RUE US: No evidence of right upper extremity DVT. Renal Artery Cath: 1. Significant renal artery stenosis of the transplanted kidney. 2. Normal central blood pressure. 3. Successful stenting of transplant renal artery. 4. Successful Perclose Proglide closure of right femoral artery. 5. Successful Angioseal closure of left femoral artery. Renal US: Normal appearance of transplant kidney. No evidence of hydronephrosis. V/Q Scan: Low likelihood for pulmonary embolism. Abdominal/Pelvic CT: 1. No evidence of intra-abdominal hematoma. 2. Status post left nephrectomy, with a residual soft tissue nodule of unclear etiology. If there is a neoplasm and any concern for recurrence, comparison to prior studies could be helpful if available. 3. Renal transplant in the right lower quadrant, with delayed excretion of contrast from prior catheterization procedure. 4. Bibasilar atelectasis. Brief Hospital Course: Mr. [**Known lastname **] was initially treated for severe hyperglycemia in the ICU, and once stable, transferred to the [**Location (un) **] Chief Medicine Service for further evaluation of his symptoms and underlying medical problems. During his admission, he was noted to have severe HTN, and received surgical intervention for his renal artery stenosis. He was also noted to be hypoxic on finger pulse oximetry to 85% RA, leading to a workup for causes of this hypoxia which was most likely [**2-7**] venous/arterial mixing of blood in his extremities due to b/l shunts and grafts. SaO2 as measured on his ear was much improved. His creatinine levels rose slightly after the procedure, with concern for renal toxicity from surgical contrast. CT scan was remarkable for a small soft tissue mass in the area of his L nephrectomy, with concern for malignancy. Renal team recommended f/u with repeat CT scan in three months. 1) Hyperosmolar Nonketotic Hyperglycemia: Upon initial presentation to the [**Name (NI) **], pt. had glucose of 837. He had been symptomatic for hyperglycemia for past several weeks (polydipsia, polyuria, malaise). Pt was not on medications for DM2 prior to admission. In [**2100**], he was noted to be hyperglycemic, but this was thought to be [**2-7**] his Prograf and this medication was changed. Random glucose in [**Month (only) 1096**] had been measured at 214. His hyperglycemia was likely exacerbated by his steroid medications. Other possibilities included viral syndrome or bacterial bronchitis, although blood and urine Cxs were negative. There was also a possibility that the renal artery stenosis, combined with mild dehydration, could have lead to a pre-renal azotemia that compounded the underlying hyperglycemia. The pt. was aggressively hydrated in the ICU and started on an insulin drip until glucose levels returned to baseline. He was then transferred to the floor with a RISS and followed by the [**Last Name (un) **] endocrine service for modifications to his sliding scale. Prior to d/c, pt. was educated about the use of insulin and symptoms of hyper/hypoglycemia. 2) HTN: Pt. stated that his BP has not been well controlled for a long time, and that the loss of his R kidney had originally been due to HTN. He was on an extensive list of medications for bp at home, including amlodipine, clonidine, lisinopril, valsartan, furosomide, and metoprolol. These medications were optimized when possible, and hydralazine and nitro prn were also added to his regimen. Metoprolol was switched to labetalol in consult with the renal service out of concern for a paradoxical interaction between his beta-blocker and the alpha-agonist. It was thought that the beta-2 agonism and alpha-1 antagonism effects of labetalol would avoid the risk of unopposed alpha-2 vasoconstriction. When his pressures remained elevated to the 190s on this aggressive regimen, interventional cardiology was consulted to evaluate his known renal artery stenosis. A renal artery stent was placed on [**1-30**], at which time it was determined that the stenosis had occluded 90% of the renal artery, with a 30mmHg pressure gradient across the stenosis. His bps were much improved the next day, and he was able to come off of the nitro. Gradually, he was also taken off of his [**Last Name (un) **], ACE-I, and hydralazine as SBPs remained 120s-140s out of concern for preserved renal function. 3) Hypoxia/SOB: The pt. complained of chest tightness upon admission, and was ruled out for MI with three sets of cardiac enzymes, EKGs, and telemetry. He had an ECHO which did not show any acute processes. His symptoms resolved without intervention. Once out of the ICU, the pt. was noted to have mild SOB on occasion in the AM, stating he found it easier to breathe when sitting upright. His O2 sats as measured on his fingers were typically lowest overnight and in the AM, down to 85% on room air, and ranging from 89-97% on 4LPM via nasal cannula. His O2 sat did not drop appreciably upon ambulation. Ddx for his SOB was considered to be infectious/PNA/PCP [**Last Name (NamePattern4) **]. fluid overload vs. cardiac vs. PE vs. OSA/obestity-hypoventilaion syndrome. He stated that IV fluids made his SOB worse, but CXR showed no acute process and physical exam showed clear lung sounds throughout. The pt. was monitored with telemetry and EKGs to monitor cardiac activity. The pt. was evaluated for PE w/ a V/Q scan (CTA contraindicated given decreased renal function). Blood/urine cultures were obtained and negative at 48 hours, without evidence for an infectious process. An ABG showed hypercapnea, hyperoxemia, and a normal pH and A-a gradient. The level of hyperoxemia did not correlate with the SaO2 as measured on the pulse oximeter on his fingers bilaterally. An oximeter was applied to his ear, which indicated an SaO2 in the middle-to-high 90s on RA, which better fit his clinical picture. A sleep study from the medical record had remarked about his nocturnal hypoxia and symptoms concerning for OSA. Pt. was not using CPAP/BiPAP at home as had been recommended. He was started on BiPAP prior to discharge, with improvement in his oxygenation and symptoms. 4) Anemia: The pt. had a fall in hematocrit from 35.9 -> 29.6 on the day following his cath. This was concerning for a femoral or RP bleed, which was ruled out with a non-contrast CT. Crit remained constant after the initial drop, and the retic count was appropriately elevated. 5) OSA: Pt previously had a sleep study at [**Hospital1 **] showing very bad OSA. He has pHTN, daytime sleepiness, and apnea/[**Last Name (un) 6055**] [**Doctor Last Name 6056**] breathing while sleeping. He was started on BiPAP while in hospital and scheduled for follow-up in the sleep clinic. 6) S/P Renal Transplant: Pt was continued on his home doses of CellCept, Rapamune, and prednisone while in hospital. His rapamycin trough was found to be within the therapeutic range. His creatinine rose gradually on the days following his stent placement, which was concerning for contrast toxicity. The rise was gradual, however, and pt. was not thought to be in renal failure or have the need for HD. He will need creatinine levels monitored as an outpt. 7) Soft Tissue Mass: A 14mm x 8mm soft tissue mass in the area of the pt's L nephrectomy was seen on CT. This could be old scarring, but given pt.'s Hx of RCC, could be malignancy. No CT scan was available for comparison, so pt. was recommended to repeat the CT in three months. 8) FEN: Pt. was monitored with daily lytes, and repleted as necessary. He was kept on a Cardiac/Diabetic diet. RISS was initiated as described above. 9) Access: Given difficultly of placing peripheral lines and need for hydration/medications/procedure, pt. had a PICC placed. It was removed prior to discharge. 10) Code: Pt was FULL CODE on this admission. Medications on Admission: - Diovan 320 mg a day - metoprolol 100 twice a day - lisinopril 40 a day - Norvasc 5 daily - Lasix 40 mg a day - clonidine 0.3 twice a day - Rapamune 4 mg a day - Bactrim single strength MWF - CellCept [**Pager number **] twice a day - baby aspirin - prednisone 5 mg daily Discharge Medications: 1. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*2* 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). Disp:*12 Tablet(s)* Refills:*2* 3. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) Subcutaneous twice a day: Take 24 U in the morning. Take 22 U in the evening. Disp:*1 qs* Refills:*0* 11. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: Use per sliding scale. Disp:*1 qs* Refills:*0* 12. Insulin Needles (Disposable) 29 X [**1-7**] Needle Sig: Four (4) Miscell. four times a day. Disp:*1 qs* Refills:*2* 13. Lab Work Sig: One (1) once a day: On [**2104-2-4**] please go to the lab and have your CBC, Chem-10, drawn and faxed to Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) 5717**] [**Name (STitle) 21867**]10 = sodium, potassium, chloride, bicarbonate, bun, creatine, magnesium, calcium, phosphate. Disp:*1 time* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Hyperosmolar Nonketotic Hyperglycemia, Diabetes Mellitus Type 2, Renal Artery Stenois, Hypertension, Sleep Apnea Secondary: s/p renal transplant Discharge Condition: stable stable Discharge Instructions: -please continue with medications as prescribed -please attend all of your appointments -if symptoms of nausea, vomiting, headaches, shortness of breath, chest pain/palpitations, leg swelling, or any other concerning symptoms occur, please come back to the ED immediately -if you start to feel symptoms of increased thirst, increased urination, dizziness, weakness, or fatigue, check your blood sugar levels. If you are having trouble controlling your blood sugar, please call the [**Hospital **] clinic or your primary doctor. You will need to schedule the following appointment with your primary doctor: CT scan of your abdomen and pelvis in 3 months. Provider: Followup Instructions: You have the following appointments scheduled: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2104-2-20**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2104-2-5**] 8:30 AM [**Last Name (un) **] Diabetes with Dr. [**Last Name (STitle) 978**] on [**2104-2-5**] at 4:00pm [**Last Name (LF) **],[**Name8 (MD) **] MD, SLEEP CLINIC Phone:[**Telephone/Fax (1) 6856**] Date/Time:[**2104-2-5**] 3:00 PM You will need to schedule the following appointment with your primary doctor: CT scan of your abdomen and pelvis in 3 months. Provider:

[ "V10.52", "401.9", "276.51", "780.57", "996.81", "276.8", "530.85", "250.22", "285.9", "780.6", "416.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.50", "00.40", "39.90", "93.90", "00.45" ]

icd9pcs

[ [ [] ] ]

14347, 14353

5303, 12218

296, 321

14557, 14574

1848, 5280

15288, 15987

1508, 1535

12541, 14324

14374, 14536

12244, 12518

14598, 15265

1550, 1829

232, 258

349, 1056

1078, 1393

1409, 1492

42,327

102,929

30879

Discharge summary

report

Admission Date: [**2134-9-27**] Discharge Date: [**2134-10-9**] Date of Birth: [**2066-11-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: Abdominal pain. Major Surgical or Invasive Procedure: [**2134-9-28**]: Right hemicolectomy with end ileostomy and mucous fistula. [**2134-9-30**]: Cardioversion. History of Present Illness: 67 year old male was transferred to [**Hospital1 18**] from [**Hospital3 19345**] where he was admitted on [**2134-9-22**] for bilateral UE pain. Approximately 2 weeks ago he received IM Vidaza for his MDS and then subsequently developed bilateral upper extremity cellulitis and blistering at the injection sites. While hospitalized, his abdomen slowly became more distended and tender. WBC count has trended upward (12 --> 26). Over the past 24 hrs he was also found to be in atrial fibrillation and was transferred to [**Hospital1 18**] this morning for further care. On presentation to the MICU, his abdomen was markedly distended and tender, and he was intubated for respiratory distress. OG placed and 200 cc of bile returned. Past Medical History: Myelodysplastic syndrome, Carpal tunnel syndrome, COPD. Past Surgical History: L knee surgery, back surgery. Social History: Retired, used to work for a chemical company. History of asbestos and other chemical exposure. He has a history of significant alcohol use, which he stopped approximately seven years ago. 60 pack year history of tobacco use. Family History: Sister - died of scleroderma; Another sister - died of unclear etiology; Brother - died of EtOH abuse; Daughter with Marfan's; Two brothers are alive and well; Mother - died of lung cancer; Father - died in an MVC. Physical Exam: 97.7 137 (irregular) 142/72 24 97% CMV .6/500/16/5 Intubated, OG tube in place draining bile PERRL, EOMI, anicteric Tachycardic, irregularly irregular Lungs CTAB Abdomen soft, distended, tympanitic, mildly tender in RUQ and RLQ without obvious guarding. Fullness on right side of upper abdomen, ? liver edge. Old supra-umbilical scar well healed. No hernias.; midline laparotomy wound with steri strips; 4cm area open wound w dry packing in place at inferior aspect midline laparotomy wound; +staple erythema underlying steri-strips; +mucous fistula in RUQ Bilateral upper extremities with erythema and blistering with skin sloughing, L>R. LUE with induration but no obvious fluctuance. LE warm, trace edema Rectal: Guiac positive, soft brown stool Pertinent Results: [**2134-9-27**] 08:21PM WBC-30.2*# RBC-2.83* HGB-9.7* HCT-29.1* MCV-103* MCH-34.2* MCHC-33.2 RDW-21.1* [**2134-9-27**] 08:21PM NEUTS-90.5* LYMPHS-5.6* MONOS-3.5 EOS-0 BASOS-0.4 [**2134-9-27**] 08:21PM PLT COUNT-102*# [**2134-9-27**] 08:21PM SED RATE-66* [**2134-9-27**] 08:21PM CRP-188.9* [**2134-9-27**] 08:21PM GLUCOSE-192* UREA N-71* CREAT-1.1 SODIUM-143 POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-23 ANION GAP-12 [**2134-9-27**] 08:21PM CALCIUM-8.4 PHOSPHATE-4.4# MAGNESIUM-3.2* [**2134-9-27**] 08:21PM ALT(SGPT)-40 AST(SGOT)-37 CK(CPK)-141 ALK PHOS-148* TOT BILI-1.3 [**2134-9-27**] 08:32PM LACTATE-1.5 K+-4.3 [**2134-9-27**] 10:51PM PT-43.7* PTT-40.2* INR(PT)-4.7* CT abdomen [**2134-9-27**] at LGH showed: Dilated small bowel loops without a clear transition point. Several streaks of air in the right colon suspicious for pneumatosis. MRI LUE [**2134-9-25**] at LGH showed: Extensive SC edema which may represent cellulitis. Extensive edema within the muscles of the posterior compartment of the LUE may represent myositis. No abscess. CT abdomen/pelvis [**2134-9-28**] at [**Hospital1 18**] showed: 1. Findings of diffuse small bowel dilatation up to 4.5 cm with segments of decreased bowel wall enhancement, pneumatosis of the small bowel and cecum, mesenteric edema, free fluid and celiac axis origin stenosis concerning for ischemic small and right sided large bowel. 2. Diverticulosis of the descending and sigmoid colon without evidence of diverticulitis. 3. Complex small pericardial effusion might represent hemopericardium. [**2134-9-28**] 2:10 pm SWAB PERITONEAL. **FINAL REPORT [**2134-10-4**]** GRAM STAIN (Final [**2134-9-28**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2134-10-4**]): ENTEROCOCCUS SP.. SPARSE GROWTH. DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Numeric Identifier 14013**]) REQUESTED SENSITIVITIES TO DAPTOMYCIN [**2134-10-2**]. SENSITIVE TO Daptomycin MIC OF 4 MCG/ML, Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final [**2134-10-2**]): NO ANAEROBES ISOLATED. TTE [**2134-9-29**] showed: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild global left ventricular hypokinesis (LVEF = 45-50%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. 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 a probable vegetation on the mitral valve. Mild to moderate ([**12-19**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild global LV hypokinesis. There may be a small mass on the posterior leaflet of the mitral valve - best seen on image #45. This appears to move back and forth through the plane of the valve. It could be a scallop of the mitral valve or an acoustic artifact or a small vegetation. TEE would help to clarify, if clinically indicated. Mild to moderate mitral regurgitation is seen. TEE [**2134-9-30**] showed: 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. A patent foramen ovale is present with transition of agitated saline bubbles from the right to left atrium at rest. Overall left ventricular systolic function is low normal (LVEF 50%) with mild global free wall hypokinesis. There are simple atheroma in the aortic arch and descending thoracic aorta. 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. Mild (1+) mitral regurgitation is seen. IMPRESSION: No atrial thrombus seen. No vegetation/ abscess seen. Patent foramen ovale. Low-normal global left ventricular function. RUQ US [**2134-10-1**] showed: Gallbladder sludge without evidence of acute cholecystitis. CT LUE [**2134-10-1**] showed: 1. Diffuse subcutaneous edema and skin thickening is most consistent with cellulitis. No subcutaneous emphysema. 2. Fluid along the superficial fascial planes of the biceps and brachialis muscles. No deeper fluid or organized fluid collections. 3. Degenerative changes of the left shoulder. 4. Bilateral pleural effusions, with collapse of left lower lobe and atelectasis of the right lower lobe, incompletely evaluated. 5. Small pericardial effusion. Small ascites. Mild anasarca. Brief Hospital Course: On [**2134-9-27**], the patient was admitted to the MICU for resuscitation. Repeat CT abdomen/pelvis again showed pneumatosis coli, and on the [**2134-9-28**], he was brought to the operating theater where necrotic right colon was found and resected. End ileostomy and delayed mucous fistula with [**First Name4 (NamePattern1) 3924**] [**Last Name (NamePattern1) **] clamp was performed to expedite the procedure given his severity of illness. Post-operatively, the patient was admitted to the SICU on acute care surgery. On [**2134-9-30**], the patient's platelet count dropped to 40 (from 102 on admission, 200-300 at previous baseline) and prophylactic heparin SC was held. HIT panel was sent and ultimately returned negative. Arixtra was started in the interim and later switched. Echocardiogram showed no vegetations. The patient was transfused 1 unit platelets. He was extubated with post-extubation atrial fibrillation with RVR and pulmonary edema, intractable to diltiazem gtt, improved with metoprolol boluses, switched to amiodarone gtt. He was re-intubated for poor protection of airway/lethargy. He was cardioverted with 200J once and has since been in sinus rhythm. On [**2134-10-1**], amiodarone was switched to oral dose. On [**2134-10-4**], the patient was weaned to extubation. He passed speech and swallow evaluation and was started on regular diet, which he tolerated. On [**2134-10-5**], he was transferred to the floor. Following his transfer he continued to make good progress. He was tolerating a regular diet well with Ensure supplements and his ostomy was active. The ostomy nurse followed him closely during his stay as he had a little superficial necrosis and some skin separation at the mucocutaneous fistula from 8 - 3 o'clock approx 0.2 cm with minimal depth. There was a 2 cm depth at 3 o'clock with fascia intact. The periphery of the stoma was pink. His right upper quadrant has a pouch over an area where [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3924**] [**Last Name (NamePattern1) **] clamp was placed intraop, egressed and removed on [**2134-10-8**]. He was also followed by the Infectious Disease service as his initial peritoneal fluid culture was positive for VRE. He was treated with a course of Daptomycin which ended on [**2134-10-8**] and he was afebrile with a normal WBC. His left upper arm was improving and not infected. The hematologist also followed him closely due to his MDS and his hematocrit was in the 23-25 range from a baseline of 29. He received 7 UPC during his hospitalization, the most recent being on [**2134-10-8**] for a hematocrit of 23 and complaints of fatigue and lethargy. He also received 2 units of platelets during his stay for a low count of 40K from a baseline of 100K. He will be followed by Dr. [**Last Name (STitle) **] as an outpatient next week. After a long, protracted hospitalization Mr. [**Known lastname **] was discharged to rehab to increase his mobility and prepare for his return home. Medications on Admission: Oxycodone prn, Trazodone QHS, Ca., Fish oil Discharge Medications: 1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for to groin. 2. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical WITH EACH DRESSING CHANGE (). 3. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for Wheeze. 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Necrotic right colon with peritonitis Respiratory failure Atrial fibrillation Acute blood loss anemia Myelodysplastic Syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain 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 resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-26**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Monitoring Ostomy output/Prevention of Dehydration: *Keep well hydrated. *Replace fluid loss from ostomy daily. *Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. *Try to maintain ostomy output between 1000mL to 1500mL per day. *If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Please pack inferior aspect midline laparotomy wound with MOIST to dry dressing [**Hospital1 **]. Thank you. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2134-10-12**] 2:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2134-10-12**] 2:00 Provider: [**Name10 (NameIs) **] CARE CLINIC Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2134-10-19**] 2:30 Completed by:[**2134-10-9**]

[ "518.81", "427.31", "682.3", "038.9", "423.9", "238.75", "569.89", "562.10", "790.92", "496", "427.89", "782.4", "557.0", "995.91", "285.1", "040.82" ]

icd9cm

[ [ [] ] ]

[ "96.72", "46.21", "99.61", "96.04", "38.91", "00.14", "45.73", "88.72", "38.93" ]

icd9pcs

[ [ [] ] ]

12003, 12050

8261, 11279

330, 441

12221, 12221

2598, 8238

14822, 15286

1593, 1809

11373, 11980

12071, 12200

11305, 11350

12397, 13855

13871, 14799

1304, 1335

1824, 2579

275, 292

469, 1202

12236, 12373

1224, 1281

1351, 1577

65,123

138,481

32377

Discharge summary

report

Admission Date: [**2136-3-18**] Discharge Date: [**2136-3-27**] Date of Birth: [**2057-2-18**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2136-3-19**] cardiac catheterization [**2136-3-22**] Coronary artery bypass grafting x3 with a left internal mammary artery to the left anterior descending artery and reverse saphenous vein graft to the ramus intermedius artery and the obtuse marginal artery. History of Present Illness: 79 year old female with aortic stenosis presented last evening with chest pressure which lasted approximately 2 hours. She ruled in for non ST elevation myocardial infarction with troponin 0.[**Street Address(2) 75620**] depressions in leads I, II, III, aVF, V4-6. Past Medical History: coronary artery disease aortic stenosis breast cancer hypertension hyperlipidemia diabetes mellitus carotid artery disease right mastectomy appendectomy oophrectomy Social History: Lives in [**Location **] with her husband She is a retired printing company worker She has a 45 pack year history, but quit >10 yrs ago She denies EtOH or drugs Family History: Mother: Stroke, CAD Father: Stroke, CAD Physical Exam: Pulse: 66SR Resp: 24 O2 sat: 91%2L B/P Right: 119/58 Left: Height: 5'0" Weight: 65.8kg General: Skin: Dry [x] intact [x] many seborrheic keratoses, well healed scar of right mastectomy HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] 1+edema ankles, superficial varicosities/spider veins bilaterally Neuro: Grossly intact x Pulses: Femoral Right: cath Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: Left: Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: no bruits appreciated Pertinent Results: [**2136-3-26**] 05:24AM BLOOD WBC-6.8 RBC-3.40* Hgb-9.5* Hct-28.2* MCV-83 MCH-27.9 MCHC-33.7 RDW-16.2* Plt Ct-224 [**2136-3-24**] 01:02PM BLOOD WBC-11.4* RBC-3.75* Hgb-11.0* Hct-31.7* MCV-85 MCH-29.3 MCHC-34.6 RDW-15.4 Plt Ct-231 [**2136-3-23**] 03:19AM BLOOD PT-12.4 PTT-26.2 INR(PT)-1.0 [**2136-3-26**] 05:24AM BLOOD Glucose-64* UreaN-9 Creat-0.6 Na-139 K-3.8 Cl-102 HCO3-30 AnGap-11 [**2136-3-24**] 01:02PM BLOOD Glucose-178* UreaN-11 Creat-0.6 Na-139 K-4.1 Cl-99 HCO3-30 AnGap-14 Intra-op echo: Conclusions PRE-CPB:1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No thrombus is seen in the left atrial appendage. 2. No thrombus is seen in the right atrial appendage 3. No atrial septal defect is seen by 2D or color Doppler. 4. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). 5. Right ventricular chamber size and free wall motion are normal. 6. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. 7. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. 8. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of phenylephrine. AV pacing for CHB, second V wire attached. Preserved LV systolic function with improvement of mid anterior wall. LVEF is now 45%. 1+ MR, AI. 2+ TR as before. Aortic contour is normal post decannulation. Brief Hospital Course: Presented to [**Hospital6 **] for chest pressure and was transfered to [**Hospital1 18**] for cardiac evaluation. She ruled in for non ST elevation myocardial infarction with peak troponin 0.87 and underwent cardiac catheterization that revealed coronary artery disease. She underwent urgent coronary artery bypass graft surgery on [**2136-3-22**] in which the PDA was unable to be bypassed due to being to small. See operative report for details. She received vancomycin for perioperative antibiotics, due to being in hospital preoperatively. Post operatively she was transferred to the intensive care unit for management. In the first twenty four hours she was weaned from sedation, awoke neurologically intact and was extubated without complications. She continued to do well and on post operative day one she was transferred to the floor for the remainder of her care. Physical therapy worked with her on strength and mobility. She continued to progress and was ready for discharge home with services on post operative day five. Medications on Admission: Metoprolol 100 mg b.i.d. Ramipril 10 mg daily Amplodipine 5 mg daily Atorvastatin 20 mg daily Nitropatch 0.6 mg daily Clopidogrel 75 mg daily Glyburide 5 mg b.i.d. Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Outpatient Physical Therapy physical therapy dx: coronary artery disease, s/p coronary artery bypass x 3 evaluate and treat for deconditioning Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Coronary artery disease s/p CABG Non ST elevation myocardial infarction Aortic stenosis breast cancer s/p right mastectomy Hypertension Hyperlipidemia Diabetes mellitus type 2 carotid artery disease Discharge Condition: alert and oriented x3 nonfocal ambulatory with steady gait pain well controlled with tylenol and ultram Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2136-4-25**] 1:15 Please call to schedule appointments Primary Care Dr. [**First Name (STitle) 28622**] Attar in [**12-17**] weeks [**Telephone/Fax (1) 24306**] Cardiologist Dr [**Last Name (STitle) 11493**] in [**12-17**] weeks Chest CT in [**5-26**] months to evaluate 1.5-cm right adrenal adenoma Completed by:[**2136-3-27**]

[ "414.01", "V45.89", "426.4", "V10.3", "410.71", "433.10", "272.4", "250.00", "401.9", "424.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6652, 6720

3921, 4962

332, 597

6963, 7069

2117, 3898

7633, 8090

1274, 1316

5177, 6629

6741, 6942

4988, 5154

7093, 7610

1331, 2098

282, 294

625, 892

914, 1080

1096, 1258

82,416

153,808

38378

Discharge summary

report

Admission Date: [**2119-7-11**] Discharge Date: [**2119-7-17**] Date of Birth: [**2061-8-22**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain/Past cardiac arrest Major Surgical or Invasive Procedure: [**2119-7-11**] Coronary bypass grafting x4 with pedicled left internal mammary artery to the left anterior descending coronary; pedicled right internal mammary artery through the transverse sinus to the first obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the first diagonal coronary; as well as reverse saphenous vein single graft from the aorta to the distal right coronary artery History of Present Illness: This is a 57 year with an STEMI/VF arrest in [**2118-10-11**], status post drug eluting stent to the proximal left anterior descending artery and angioplasty of the ostium of the second diagonal artery. At the time of angiography, he was noted to have an 80% mid RCA stenosis that was not intervened on. Stress testing in [**2118-11-10**] was notable for mild inferior wall ischemia without symptoms. Repeat stress testing on [**2119-6-9**] showed a modest decrease in the patient's exercise tolerance but no evidence of inferior ischemia that was seen in [**11-18**]. LVEF was normal. Repeat catheterization on [**2119-7-5**] revealed significant left main and right coronary artery disease. He has now been referred for coronary artery bypass grafting. Past Medical History: -Coronary artery disease s/p Myocardial Infartion complicated by VF arrest s/p LAD DES/Diagonal 2 PTCA ([**Hospital **] hospital) -Anxiety/panic disorder -Depression -Hepatitis C -Gastroesophageal reflux disease/Barrettt's esophagous -Recovered alcoholic, no alcohol in 30 years -Age 20-gun shot wound to the right forearm, s/p surgery Social History: Last Dental Exam: upper dentures. Lower native teeth w/o issue Lives with: wife and has one daughter Contact upon discharge: [**Name (NI) 383**] [**Name (NI) 496**] (wife): [**Telephone/Fax (1) 85463**] (cell) Occupation: Patient works the night shift for the [**Company 2318**] doing track maintenance ETOH: None currently. Recovering alcoholic x29 years Tobacco: Quit [**2118**] Family History: Mother CAD died s/p CABG at age 81 Physical Exam: Pulse:60 Resp: 16 O2 sat: 99% RA B/P Right: 124/69 Left: Height: 5'7" Weight:87KG General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: cath site Left:+2 DP Right: +2 Left:+2 PT [**Name (NI) 167**]: +2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit Right: None Left:None Pertinent Results: [**2119-7-11**] ECHO PRE-CPB:1. The left atrium and right atrium are normal in cavity size. No thrombus is seen in the left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. An epiaortic scan was done. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened . There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. Dr. [**Last Name (STitle) 914**] was notified in person of the results. POST-CPB: On infusion of phenylephrine. Sinus rhythm. Well-preserved biventricular systolic function post CPB. LVEF= 70%. Trace MR. Aortic contour is normal post decannulation. [**2119-7-13**] Head CT: There is no evidence of acute hemorrhage, edema, mass effect, or major vascular territory infarction. [**Doctor Last Name **]-white matter differentiation is preserved. Incidental note is made of cavum septum pellucidum et vergae, a normal variant. The ventricles and sulci are normal in size. The visualized paranasal sinuses are clear. No osseous abnormality is identified. [**2119-7-11**] 01:17PM BLOOD WBC-13.6*# RBC-3.19* Hgb-10.1* Hct-30.4* MCV-95 MCH-31.6 MCHC-33.2 RDW-12.8 Plt Ct-138* [**2119-7-14**] 04:45AM BLOOD WBC-9.1 RBC-2.94* Hgb-9.4* Hct-27.7* MCV-94 MCH-31.8 MCHC-33.8 RDW-12.7 Plt Ct-116* [**2119-7-11**] 02:52PM BLOOD PT-14.1* PTT-36.0* INR(PT)-1.2* [**2119-7-11**] 02:52PM BLOOD UreaN-15 Creat-0.8 Cl-117* HCO3-23 [**2119-7-14**] 04:45AM BLOOD Glucose-99 UreaN-14 Creat-0.9 Na-141 K-4.0 Cl-106 HCO3-29 AnGap-10 [**2119-7-17**] 04:30AM BLOOD PT-28.2* PTT-66.8* INR(PT)-2.8* Brief Hospital Course: Mr. [**Known lastname 496**] was admitted to the [**Hospital1 18**] on [**2119-7-11**] for elective surgical management of his coronary artery disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to four vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, Mr. [**Known lastname 496**] awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. On postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. Chest tubes and epicardial pacing wires were removed per protocol. On post-op day two there appeared to be a possible left facial droop (patient himself did not have any subjective complaints). Stat head CT and neurology were consulted. Of note, he has dentures and after removal the asymmetry disappears greatly, probably suggesting some mechanical component. Neurology noted though after a review of old photograph, that there was some asymmetry of the face with left angle of mouth droopier than right. Head CT scan is normal but suspected that he had a small perioperative subcortical infarct, not seen on CT. He was started on Coumadin for atrial fibrillation and was in sinus rhythm on oral Amidarone at the time of discharge. Per the stroke team, he could continue on Coumadin (for Afib) without Plavix but if Coumadin was to be discontinued, he would need to restart on Plavix for questionable neurologic event. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Mr. [**Known lastname 496**] continued to make steady progress and was discharged home on postoperative day 6. VNA is to draw INR [**2119-7-18**] and call results in to Dr. [**First Name (STitle) **] at ([**Telephone/Fax (1) **]. He will follow-up with Dr. [**Last Name (STitle) 914**], Dr. [**First Name (STitle) **] , Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] as an outpatient. Medications on Admission: Plavix 75 mg - STOPPED as of [**2119-7-5**] Lexapro 10 mg daily Nexium 40 mg daily Lorazepam 1 mg as needed Metoprolol succinate (Not Taking as Prescribed: Pt. stopped taking recently d/t hypotension noted on home machine) - 25 mg daily Simvastatin 40 mg daily Aspirin 81 mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Lexapro 10 mg Tablet Sig: One (1) Tablet PO once a day: at 2pm. 7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Take 1 tab on [**2119-7-17**] and then as directed for INR goal 2-2.5. Disp:*60 Tablet(s)* Refills:*0* 10. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO AT 1400 DAILY (). Disp:*30 Tablet(s)* Refills:*0* 11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*1* 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): x 1 week then 200 mg po BID x 2 weeks then 200 mg x 1 week then discontinue. Disp:*50 Tablet(s)* Refills:*0* 15. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): take with food. Disp:*30 Tablet(s)* Refills:*0* 16. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass grafts Past medical history: -Myocardial Infartion complicated by VF arrest s/p LAD DES/Diagonal 2 PTCA ([**Hospital **] hospital) -Anxiety/panic disorder -Depression -Hepatitis C -Gastroesophageal reflux disease/Barrettt's esophagous -Recovered alcoholic, no alcohol in 30 years -Age 20-gun shot wound to the right forearm, s/p surgery Discharge Condition: Alert and oriented x3, nonfocal. Ambulating with steady gait. Incisional pain managed with oral analgesics. Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema: Discharge Instructions: 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. No lotions, cream, powder, or ointments to incisions. Each morning you should weigh yourself and then in the evening take your temperature, These should be written down on the chart . No driving for approximately one month, until follow up with surgeon. No lifting more than 10 pounds for 10 weeks. Please call with any questions or concerns ([**Telephone/Fax (1) 170**]). Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge of sternal wound. **Please call cardiac surgery office with any questions or concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call person during off hours.** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**8-15**] at 1pm Please call to schedule appointments with: Primary Care: Dr. [**First Name11 (Name Pattern1) 7346**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 8506**]) in [**2-11**] weeks Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-11**] weeks Neurologist: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**4-13**] weeks [**Telephone/Fax (1) 657**] VNA to draw INR on [**2119-7-18**] and call Dr. [**First Name (STitle) **] with results for INR goal 2-2.5 for atrial fibrillation **Please call cardiac surgery office with any questions or concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call person during off hours.** Completed by:[**2119-7-17**]

[ "311", "997.02", "427.31", "530.85", "V45.82", "781.94", "412", "414.01", "070.54", "303.93" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9623, 9679

5035, 7141

351, 776

10110, 10337

3025, 4107

11191, 12102

2334, 2370

7472, 9600

9700, 9758

7167, 7449

10361, 11168

2385, 3006

281, 313

2061, 2318

804, 1561

4116, 5012

9780, 10089

1936, 2045

54,655

184,876

7371

Discharge summary

report

Admission Date: [**2151-11-22**] Discharge Date: [**2151-11-27**] Date of Birth: [**2106-2-7**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 4659**] Chief Complaint: lower gastro-intestinal bleed Major Surgical or Invasive Procedure: Sigmoid colectomy History of Present Illness: This is a 45 year-old gentleman with history of ETOH abuse who presented from OSH with bright red blood per rectum. He received 4 units pRBCs for HCT of 19, and HCT increased to 34. The patient was transferred to the [**Hospital1 18**] for repeat tagged scan vs. angio. He denied any pain at this time. Past Medical History: 1. h/o low back and neck pain with 1/06 MRI showing L5-S1 disc buldge. 2. bipolar d/o - Has psychiatrist, but does not know name. 3. h/o ETOH related seizure 4. HTN 5. ETOH abuse 6. ADHD Social History: ETOH abuse, tobacco abuse, 1ppd. Denies any drugs. On probation currently Family History: DM, colon CA, breast CA Physical Exam: Physical exam upon discharge: Vitals T: 99.6 BP: 124/76 HR: 97 RR: 18 02: 96%/RA GENERAL: NAD, alert and oriented HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. Neck Supple, CARDIAC: Regular rhythm,normal S1, S2. No murmurs, LUNGS: CTA bilaterally ABDOMEN: NABS. Soft, NT, ND. EXTREMITIES:warm, no edema,good capillary refill Pertinent Results: [**2151-11-22**] 11:03PM TYPE-ART TEMP-36.1 O2-100 PO2-448* PCO2-50* PH-7.14* TOTAL CO2-18* BASE XS--12 AADO2-238 REQ O2-46 INTUBATED-INTUBATED [**2151-11-22**] 11:03PM LACTATE-3.8* [**2151-11-22**] 11:03PM freeCa-1.05* [**2151-11-22**] 10:55PM GLUCOSE-226* UREA N-9 CREAT-0.6 SODIUM-138 POTASSIUM-5.6* CHLORIDE-115* TOTAL CO2-18* ANION GAP-11 [**2151-11-22**] 10:55PM WBC-8.0 RBC-5.35# HGB-15.7# HCT-47.0# MCV-88 MCH-29.3 MCHC-33.3 RDW-14.7 [**2151-11-22**] 10:55PM PLT COUNT-34* [**2151-11-22**] 10:55PM PT-17.9* PTT-54.4* INR(PT)-1.6* [**2151-11-22**] 08:26PM GLUCOSE-263* UREA N-9 CREAT-0.6 SODIUM-135 POTASSIUM-4.9 CHLORIDE-111* TOTAL CO2-20* ANION GAP-9 [**2151-11-26**] 01:40AM BLOOD WBC-9.4 RBC-3.72* Hgb-11.5* Hct-31.9* MCV-86 MCH-30.9 MCHC-35.9* RDW-15.5 Plt Ct-180 [**2151-11-27**] 09:26AM BLOOD PT-12.8 PTT-23.3 INR(PT)-1.1 [**2151-11-27**] 09:26AM BLOOD Glucose-111* UreaN-5* Creat-0.7 Na-139 K-3.9 Cl-104 HCO3-27 AnGap-12 [**2151-11-27**] 09:26AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.8 [**2151-11-26**] 02:04AM BLOOD Type-ART pO2-95 pCO2-40 pH-7.47* calTCO2-30 Base XS-4 [**2151-11-24**] 08:11PM BLOOD Lactate-0.8 Radiology Report:GI bleed, embolization ([**2151-11-22**]) Small focus of aortic extravasation secondary to microwire perforation while attempting to access inferior mesenteric artery. A 14-mm balloon tamponade of the aorta performed for 15 minutes yielding resolution of extravasation. IMPRESSION: 1. Coil embolization of superior rectal artery off of the inferior mesenteric artery with successful hemostasis of active extravasation. 2. Coil embolization of right middle rectal artery with successful hemostasis of active extravasation of this vessel. 3. Gelfoam pledget embolization at the mid to distal left internal iliac artery resulting in successful hemostasis of left middle rectal artery active extravasation. Coils were not deployed given patient's hemodynamic instability. 5. Arteriograms performed of the aorta, proximal [**Female First Name (un) 899**], selective distal [**Female First Name (un) 899**]/superior gluteal artery, right internal iliac artery, right middle/inferior rectal artery, left internal iliac artery. Brief Hospital Course: This is a 45-year-old patient with a history of alcohol abuse and prior history of detoxifications. The day before his admission he had developed bright red blood per rectum. He had received 7 units at [**Hospital 8**] Hospital and a tag scan there showed no evidence of localization. He was transferred to [**Hospital1 18**], where he remained initially stable. However, he quickly opened up and was subsequently resuscitated ith blood and fresh frozen plasma. A tagged red cell scan showed evidence of a bleed in his distal sigmoid or proximal rectum. He was then taken to Angio for embolization. A distal branch of the [**Female First Name (un) 899**] was localized. On an attempt to embolize the vessel, the catheter came out. During reinsertion the aorta was accidently perforated. The patient started to develop back pain and a balloon was blown up in the aorta for 15 minutes occluding the site of the perforation. The balloon was taken down and there was no evidence of extravasation from the aortic perforation. After the procedure, the patient was brought to the ICU in stable condition.In the ICU he once again started bleeding profusely. He was taken back down to Angio and the internal iliac was catheterized. The bleeding site was seen from collaterals from the internal iliac and Gelfoam was placed. The Gelfoam stopped the bleeding and once again he was hemodynamically stable and did not bleed for several hours. Unfortunately he then opened up again and was taken to the operating room for a sigmoid colectomy and proximal rectal resection. After the procedure the patient was brought back to the ICU, where he remained intubated for three more days. No seizure activity or signs of detoxification were noted under sedation with propofol/fentanyl and benzodiazepine coverage. He was extubated on POD#3 and remained hemodynamically stable. He was subsequently put on a regimen of olanzapine and Valium and was transferred to the floor on POD#4. Upon discharge he is tolerating a regular diet and his pain is well controlled. The patient is homeless. His sister has agreed to take care of him and offer him a place to stay as long as he stays sober. The patient also has been instructed to follow up with his primary care practitioner to adjust for home psych meds. Medications on Admission: Hydroxyzine 50 tid, Propranolol 10 [**Hospital1 **], Benztropine 0.5 [**Hospital1 **], Doxepin 150 qhs, Risperdal 1 tid, Seroquel 200 [**Hospital1 **] Discharge Medications: 1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO DAILY (Daily) for 4 weeks. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0* 2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 2 weeks. Disp:*14 Patch 24 hr(s)* Refills:*0* 3. Propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 weeks. Disp:*56 Tablet(s)* Refills:*0* 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 weeks. Disp:*28 Tablet(s)* Refills:*0* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 weeks. Disp:*28 Tablet(s)* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain for 2 weeks. Disp:*60 Tablet(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks. Disp:*28 Capsule(s)* Refills:*0* 8. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) for 1 weeks. Disp:*12 Tablet(s)* Refills:*0* 9. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 4 weeks. Disp:*56 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Lower gastrointestinal (GI) bleed Discharge Condition: stable 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 steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: For removal of staples, please follow up with Dr. [**Last Name (STitle) **] in [**2-12**] weeks. Call [**Telephone/Fax (1) 8792**] for an appointment. Follow up with your primary care practitioner Dr. [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] to continue your home medications. Call [**Telephone/Fax (1) 6951**] to setup an appointment. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**] Completed by:[**2151-11-27**]

[ "998.2", "291.0", "285.1", "785.50", "518.81", "E870.8", "530.20", "296.80", "V15.81", "E849.7", "578.9", "314.01", "303.91", "530.19" ]

icd9cm

[ [ [] ] ]

[ "00.44", "45.23", "96.72", "45.76", "96.04", "38.93", "39.79", "45.13", "88.47", "88.42", "39.50", "94.62" ]

icd9pcs

[ [ [] ] ]

7360, 7366

3661, 5945

353, 373

7444, 7453

1459, 3638

8983, 9550

1026, 1051

6146, 7337

7387, 7423

5971, 6123

7477, 8622

8637, 8960

1066, 1066

284, 315

1096, 1440

401, 707

729, 918

934, 1010

32,809

162,969

53088

Discharge summary

report

Admission Date: [**2139-7-14**] Discharge Date: [**2139-7-29**] Date of Birth: [**2063-5-31**] Sex: F Service: MEDICINE Allergies: Codeine / Percodan / Sonata / lisinopril / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Cervical Myelopathy Major Surgical or Invasive Procedure: Anterior Cervical Spine Surgery Evacuation of Retropharyngeal Hematoma Intubation History of Present Illness: 76-year-old female with hx of breast cancer s/p mastectomy, chemotherapy, radiation, paroxysmal a-fib, HTN, and chronic propionibacterium acnes infection of her humerus, who presented with cervical myelopathy, with signifcant gait abnormality and was taken for anterior cervical decompression and fusion on [**2139-7-14**]. MICU transfer requested for acute onset hypotension, low urine output, tachypnea, and leukocytosis concerning for sepsis. She underwent 3 level fusion on [**2139-7-14**]. Post-operatively she developed hoarse voice and trouble swallowing and she was transferred to TSICU because of pre-vertebral neck swelling on neck xray. She went to the OR on [**2139-7-15**] for decompression of hematoma which was evacuated. She remained intubated for airway protection post op. Her post op course has been complicated by dysphagia, odynophagia. She has not passed speech and swallow, and is a very high risk for aspiration. While in the TSICU intubated, she was noted to have a lot of secretions. A bronch was done [**7-20**], and cultures are growing Serratia and Staph aureus (no sensitivities). She has been normotensive and on her home anti-hypertensives. She was called out of the TSICU and transferred to the floor on [**2139-7-22**]. Her antibiotics had been amoxicillin which is suppressive therapy for her chronic infection. Today she was noted to be relatively hypotensive in the morning with T 98.1, BP 90/50, HR 64, RR 36, and sat of 95% on 2L. She was given 2L of D51/2NS, and pressures have improved to 100s-120s systolic, and her BP meds are being held. Her RR continues to remain in the 30s. Her I/Os today have been 2075/330 with 160 cc of urine over last 8 hours. She received 3L NS on the floor. WBC had been ranging [**1-26**] throughout majority of hospital stay but increased to 29 this morning. Her antibiotics were increased to Cefepime yesterday. On arrival to the MICU, pt states that she is exhausted and fatigued. The patient was stabilized in the MICU and transfered to the floor for further management. Past Medical History: Multiple surgeries for TB in the [**2067**], upper left lobectomy in [**2096**] C-sections in [**2103**] and [**2105**] Transfer of palatal mucosa to her gingiva in [**2112**] Hysterectomy in [**2113**] Left sided mastectomy with lymph node dissection in [**2118**] Prior TB infection in a sanitorium from [**10-23**] yo and partial lobectomy Stage III left breast cancer s/p mastectomy, chemotherapy, radiation Paroxysmal atrial fibrillation Anemia. Hypertension. Bronchiectasis diagnosed in [**2096**]. Major lung hemorrhage in [**2096**] after left upper lobectomy. Rickets Pyelonephritis Right humerus fracture s/p ORIF [**2139-3-23**] complicated by Propionibacterium acnes growing in two tissue cultures s/p 6 weeks IV ceftriaxone therapy and then on oral amoxcillin suppression Social History: Married for 36 years. Husband with [**Name2 (NI) **] in nursing home. 2 grown children and 2 step children. Lives in split home with her daughter. Denies ever using tobacco, no illicits. Drinks socially. Family History: Her mother died at age 86 with Parkinson's, also had a history of hypertension. Father died at age 33 with pneumonia. No history of lung, colon or breast cancer Physical Exam: MICU PHYSICAL EXAM: General: Alert, oriented, appears fatigued, hoarse voice HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: S/p mastectomy with right implant, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: diffusely rhonchorous, tachypneic Abdomen: soft, mildly tender diffusely, non-distended, bowel sounds present, no organomegaly GU: foley in place; erythematous rash on buttocks, no active drainage Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE EXAM: VSS. Afebrile. BP 120-130s/70-80s, HR 80-90, 95-98% on 3L NC GEN: AOx2-3, hoarse voice HEENT: dry mouth, EOMI, PERRLA NECK: clean, well-healed anterior neck scar. Neck is supple, mild right, chronic shoulder pain CV: chest wall with implant with telangectasias, RRR, no MRG LUNGS: Improved aeration, mild bibasilar crackles, rhonchi improved ABDOMEN: soft, NT, ND, normal BS EXT: WWP, 2+ pulses Pertinent Results: ADMISSION LABS: [**2139-7-14**] 12:35PM BLOOD WBC-6.5 RBC-3.49* Hgb-10.7* Hct-31.9* MCV-92 MCH-30.6 MCHC-33.4 RDW-13.6 Plt Ct-242 [**2139-7-15**] 12:48PM BLOOD PT-14.2* PTT-29.4 INR(PT)-1.3* [**2139-7-14**] 12:35PM BLOOD Glucose-90 UreaN-16 Creat-0.6 Na-137 K-3.2* Cl-102 HCO3-29 AnGap-9 [**2139-7-19**] 02:50AM BLOOD LD(LDH)-138 Amylase-44 TotBili-0.3 [**2139-7-14**] 12:35PM BLOOD Calcium-8.3* Phos-4.1 Mg-1.6 DISCHARGE LABS: [**2139-7-29**] 06:05AM BLOOD Glucose-108* UreaN-22* Creat-0.4 Na-140 K-3.9 Cl-97 HCO3-34* AnGap-13 [**2139-7-29**] 06:05AM BLOOD WBC-18.5* RBC-3.18* Hgb-9.3* Hct-29.7* MCV-94 MCH-29.1 MCHC-31.1 RDW-13.7 Plt Ct-533* SPUTUM CULTURE: [**2139-7-20**] 5:21 pm BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2139-7-27**]** GRAM STAIN (Final [**2139-7-20**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2139-7-27**]): >100,000 ORGANISMS/ML. Commensal Respiratory Flora. STAPH AUREUS COAG +. ~4000/ML. SENSITIVITIES PERFORMED ON REQUEST.. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. SENSIS REQUESTED BY DR.[**Last Name (STitle) 109371**] ([**Numeric Identifier **]) ON [**2139-7-25**] @ 11:16AM. SERRATIA MARCESCENS. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | SERRATIA MARCESCENS | | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- <=0.25 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S <=1 S LEVOFLOXACIN---------- 0.25 S MEROPENEM------------- <=0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S [**7-22**] C diff: NEGATIVE [**7-27**] C diff: NEGATIVE C spine [**7-14**]: Multiple lateral views of the cervical spine from the operating room demonstrates placement of markers at the C6-C7 interspace on the first image, and then markers at the C4-C5 and C5-C6 interspaces on the second image. Hardware in the right shoulder is again seen. Please refer to the operative note for additional details. C spine [**7-17**]: HISTORY: Status post anterior fusion at C4/C5/C6/C7. Degenerative changes with disc space narrowing and osteophytosis seen also at the C3/C4. Support lines are in place. Extensive pleural calcifications noted in the visualized upper lung fields. TTE [**7-20**]: The left atrium and right atrium are normal in cavity size. 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 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 appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Pulmonary artery hypertension. Mild aortic regurgitation. Compared with the prior study (images reviewed) of [**2135-9-1**], the findings are similar. CT chest [**7-25**]: 1. New right lower lobe pneumonia. Aspiration cannot be excluded. Smaller focus of new consolidation in the anterior left upper lobe may represent additional infection or inflammatory change. 2. New further loss of height of the T12 vertebral body consistent with compression fracture, with mild posterior retropulsion of the inferior endplate of T12. Dedicated CT or MRI could be obtained for further evaluation as clinically indicated. 3. Stable, extensive lung parenchymal and pleural abnormalities consistent with prior tuberculosis. 4. Findings consistent with pulmonary arterial hypertension. Video Swallow [**7-27**]: IMPRESSION: Aspiration with thin and nectar-thick liquids. For details, please refer to speech and swallow note in OMR. Brief Hospital Course: 76-year-old female with h/o breast cancer s/p mastectomy, paroxysmal a-fib, HTN, and chronic propionibacterium acnes infection of her surgically repaired humerus, who presented with cervical myelopathy and was taken for anterior cervical decompression and fusion on [**2139-7-14**]. The [**Hospital 228**] hospital course was complicated by post-op retropharyngeal hematoma requiring evacuation, intubation for respiratory compromise, ventilator-associated pneumonia, Dobhoff tube placement for esophageal compression, and diarrhea. 1. Ventilator Associated Pneumonia: The patient has MSSA and pansensitive Serratia growing from a BAL that was obtained during the patient's intubation. She also had a chest CT that showed a RLL pneumonia. The patient was initially empirically treated with cefepime and vancomycin. Once her sensitivities returned, we narrowed the patient to ceftriaxone 2gm Q24hrs. We will treat for 14 days given that she had a non-lactose fermenter (Serratia) on her BAL. Last day of treatment [**8-6**]. The patient remains on 3L O2 by nasal cannula with intermittent nebulizers for wheezing. The patient should continue to be weaned off of oxygen as her infection improves. She will benefit from chest PT, incentive spirometry, and intermittent suctioning of secretions. 2. Leukocytosis: The patient has a discharge white count around 18,000. C diff was negative. The patient had no fevers or signs of untreated infection. The patient should have her white count trended to ensure resolution. 3. Aspiration Precautions Requiring Dobhoff: The patient has posterior pharynx inflammation and swelling after her surgery. Because of the swelling, she has failed multiple speech and swallow evaluations. She has a Dobhoff for tube feeds. She will continue to be NPO (except for swabs, ice, meds). She needs a repeat speech and swallow exam in 3 weeks to determine whether she can eat at that time. The patient should remain on aspiration precautions at all times. 4. Cervical Myelopathy, s/p anterior surgical procedure: The patient needs to wear the soft collar when in bed. While she is ambulating, she should wear the [**Location (un) 2848**] J. If the patient becomes disoriented, she should wear the [**Location (un) 2848**] J to prevent neck injury. The patient has follow-up with Spine as scheduled. 5. Diarrhea: Concern was for C diff given leukocytosis and loose stool. She was started empirically on IV Flagyl 500mg TID, then switched to PO Vanc as white count continued to be high. Repeat C diff PCR was sent and was negative, so the PO vanc was discontinued. Her diarrhea is improved and she can take Imodium PRN. 6. Metabolic Alkalosis: Unclear etiology. Patient has had this early on in the hospitalization, which was treated with acetazolamide. Patient does not have evidence of primary respiratory acidosis. No GI losses to explain abnormality. 7. Benign Hypertension: Diltiazem 60mg QID. HCTZ 12.5mg Qday. 8. Parosysmal Atrial Fibrillation: On Diltiazem 60mg QID. On Amiodarone 100mg Qday. 9. Infection of R humerus hardware: The patient is on Amoxicillin prophylaxis for suppression of hardware infection. After the ceftriaxone is discontinued, the patient should be restarted on her amoxicillin prophylaxis. TRANSITIONAL ISSUES: - O2 monitoring - repeat speech and swallow in [**3-13**] weeks - Code Status: DNR/DNI Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Amiodarone 100 mg PO DAILY 2. AMOXicillin Oral Susp. 500 mg PO Q8H 3. Aspirin 81 mg PO DAILY 4. Diltiazem Extended-Release 60 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. Vitamin D3 *NF* (Ca cmb no.1-vit D3-B6-FA-B12; cholecalciferol (vitamin D3)) 1,000 unit Oral DAILY 7. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Medications: 1. Amiodarone 100 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. CeftriaXONE 2 gm IV Q24H 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H 5. Diltiazem 60 mg PO QID 6. Heparin 5000 UNIT SC TID 7. Ipratropium Bromide Neb 1 NEB IH Q6H 8. Ferrous Sulfate 325 mg PO DAILY 9. Hydrochlorothiazide 12.5 mg PO DAILY 10. Loperamide 4 mg PO QID:PRN diarrhea Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital - [**Hospital1 392**] Discharge Diagnosis: Cervical Myelopathy Ventilator Associated Pneumonia Diarrhea Malnutrition Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital due to cervical spine disease, for which you underwent a spinal surgery and fusion. You developed swelling after the procedure, which required a re-look operation as well as breathing tube placement. You developed a lung infection from the breathing tube, for which we are treating you with antibiotics. Due to continued neck swelling, you had difficulty swallowing and, therefore, we placed a Dobhoff feeding tube to give you nutrition. You will need to keep in the feeding tube for 4-6 weeks as the inflammation of the neck resolves. At that point, we can reevaluate your swallowing and let you eat if indicated. Followup Instructions: Department: ORTHOPEDICS When: FRIDAY [**2139-8-7**] at 9:30 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: SPINE CENTER When: FRIDAY [**2139-8-7**] at 9:50 AM With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 8603**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "518.81", "780.09", "507.0", "V49.87", "427.31", "787.20", "263.9", "514", "276.8", "730.12", "787.91", "997.31", "276.3", "V10.3", "401.1", "E878.8", "494.0", "E879.8", "478.31", "V12.01", "041.84", "995.92", "V49.86", "998.12", "721.1", "038.9", "E849.7", "008.45", "041.11" ]

icd9cm

[ [ [] ] ]

[ "96.6", "39.98", "96.71", "38.97", "81.63", "77.79", "83.09", "33.24", "84.51", "81.02", "80.51", "00.94", "38.91" ]

icd9pcs

[ [ [] ] ]

14112, 14208

9925, 13177

332, 416

14326, 14326

4712, 4712

15177, 15762

3544, 3708

13752, 14089

14229, 14305

13312, 13729

14504, 15154

5143, 9902

3743, 4281

4297, 4693

13198, 13286

273, 294

444, 2498

4729, 5126

14341, 14480

2520, 3306

3322, 3528

4,872

184,715

10169

Discharge summary

report

Admission Date: [**2150-7-21**] Discharge Date: [**2150-8-13**] Service: CT [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: This patient was admitted to [**Hospital3 3583**] on [**2150-7-14**] in congestive heart failure and severe aortic stenosis. She was treated medically there. However, a discussion with the patient and her family led them to the conclusion that she did require valve replacement surgery and she was transferred to [**Hospital1 190**] on [**2150-7-21**] to pursue valve replacement. PAST MEDICAL HISTORY: The past medical history was significant for hypertension, congestive heart failure, coronary artery disease, noninsulin dependent diabetes mellitus, breast cancer status post lumpectomy times three, psoriasis and glaucoma. MEDICATIONS ON ADMISSION: Glyburide 5 mg p.o. b.i.d. Toprol XL 100 mg p.o. q.d. Zestril 10 mg p.o. q.d. Isosorbide Sustained Release 30 mg p.o. q.d. Lipitor 20 mg p.o. h.s. Hydrochlorothiazide 50 mg p.o. q.d. Enteric coated aspirin 81 mg p.o. q.d. Multivitamin p.o. q.d. PHYSICAL EXAMINATION ON ADMISSION: Vital signs on admission revealed a temperature of 97.3??????F, a pulse of 54, a blood pressure of 130/70 and an oxygen saturation of 99% on three liters by nasal cannula. In general, the patient was a pleasant, comfortable female in no apparent distress. On head, eyes, ears, nose and throat examination, the patient had a slight droop of her left eyelid noted. The neck was unremarkable. The coronary examination revealed a grade II/VI holosystolic murmur. On pulmonary examination, the patient had bibasilar crackles. The abdomen was soft, nontender, obese and nondistended. The groin was without ecchymosis or bruit. The extremities had 1+ edema. There were nonpalpable pulses; however, there were positive Doppler signals in both of her feet. Neurologically, the patient was grossly intact. LABORATORY DATA ON ADMISSION: Laboratory values on admission to the hospital were unremarkable. BUN on admission was 21 with a creatinine of 1.3. HOSPITAL COURSE: The patient was taken to the cardiac catheterization laboratory on [**2150-7-21**], where she was found to have severe aortic stenosis, severe mitral regurgitation, a left ventricular ejection fraction of 35% and three vessel coronary artery disease. She had previously refused coronary artery bypass grafting in [**2149-2-5**]. However, she had agreed to a consultation at this time. The patient was seen on [**2150-7-22**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], who felt that the patient was a surgical candidate. The patient remained on the medical service until she was taken to the operating room on [**2150-7-24**], at which time she underwent an aortic valve replacement and a mitral valve replacement with tissue valves as well as coronary artery bypass grafting times one by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. Postoperatively, the patient was transported from the operating room to the cardiac surgery recovery unit on propofol, Levophed and milrinone intravenous drips. On postoperative day #1, the patient remained intubated, on a mechanical ventilator. She was improving hemodynamically. She was atrioventricularly paced with her temporary epicardial wires. She remained on insulin drip as well as the milrinone intravenous drip. On postoperative day #2, the patient was placed on a low dose dopamine drip. She remained on insulin drip. She also remained on mechanical ventilation following an unsuccessful attempt to wean her from the ventilator. The patient remained in the intensive care unit over the next three days, on mechanical ventilation due to tachypnea and marginal hypoxia with attempted ventilator weaning. On [**2150-7-29**], the patient was noted to have significant pleural effusions by x-ray and a right chest tube was placed. Approximately 500 cc of serosanguinous fluid were obtained. The patient was being diuresed. On postoperative day #6, the patient remained on the ventilator. She was weaned and extubated later in the day on postoperative day #6. The patient's dopamine was weaned slowly and was presently at 2 mcg/kg per minute. The patient was restless and agitated requiring intravenous Haldol at times. Her chest tube was discontinued and the patient remained hemodynamically stable in the cardiac surgery recovery unit. On postoperative day #8, [**2150-8-1**], the patient was on nasal cannula oxygen with marginal oxygen saturation in the 90% to 93% range. She had gone into atrial fibrillation with a stable blood pressure. She was begun on amiodarone for the atrial fibrillation and had been maintained on tube feedings during her intensive care unit stay. On postoperative day #9, the patient was begun on oral intake. She was started on NPH insulin and had been progressing, although slowly, in a stable fashion. On postoperative day #10, the patient remained on intravenous heparin drip to anticoagulate her for her atrial fibrillation, low dose dopamine drip, amiodarone and Lopressor 25 mg p.o. b.i.d. The patient had remained somewhat agitated and disoriented during this time. On [**2150-8-4**], postoperative day #11, the patient was noted to have a drop in her hematocrit over the previous 24 hours. A chest x-ray was obtained and it was noted that the patient had a significant left sided pleural effusion, thought to be a hemothorax. A chest tube was placed in the left pleural space and 1400 cc of dark blood were obtained. The patient tolerated the procedure well and a subsequent chest x-ray showed the tube to be in good position with evacuation of the effusion. On [**2150-8-5**], the patient remained hemodynamically stable. The chest tube had remained in place. Her respiratory status significantly improved over the next 24 hours with an oxygen saturation up to 100%. The patient had been started on levofloxacin for a question of tracheobronchitis. She did not have positive sputum cultures; however, she clinically improved from a pulmonary standpoint after the levofloxacin was initiated. The patient was transferred out of the intensive care unit to the telemetry floor on postoperative day #12. On postoperative day #13, the patient remained in atrial fibrillation. Anticoagulation had been previously discontinued due to the hemothorax. However, this was being re-initiated since the patient had remained stable with a stable hematocrit for the prior few days. Her oxygen saturation was stable at 99%. She was tolerating diuresis and physical therapy was initiated. On postoperative day #14, the patient had a prothrombin time of 14.3 with an INR of 1.4 on her newly resumed Coumadin. it was felt that her chest tube should stay in until she was again therapeutically anticoagulated to be sure that she did not have any increased bleeding associated with her anticoagulation. On [**2150-8-8**], the chest tube was discontinued when her INR had reached 2.1 and there was no evidence of bleeding. In the evening of [**2150-8-9**], the patient had a telemetry strip with what appeared to be ventricular tachycardia and an electrophysiology consultation was obtained. It was their feeling that this was artifact, as it had not recurred since that one episode. On the following day, [**2150-8-10**], it was noted that the patient had a significant inflammation of the right lower extremity in the area of the wound, thought to be a cellulitis. The patient had already been on levofloxacin for five days and, at this time, was begun on vancomycin intravenously. A culture of that wound was sent and the result of that was sparse growth of E. coli. However, since the patient clinically improved over the next few days on the vancomycin, it was felt judicious to leave her on the vancomycin despite not having specific bacteria to be treated with it. The patient remained hemodynamically stable over the next few days. The patient is to continue on her antibiotic course of levofloxacin for tracheobronchitis as well as vancomycin for cellulitis of her right lower extremity, which is improving. She is oxygenating well and remains stable. The patient is ready to be discharged today, [**2150-8-13**], to a rehabilitation facility to progress with cardiac rehabilitation for increased strength and endurance. The patient's most recent chest x-ray is from [**2150-8-10**], which showed cardiomegaly and some degree of congestive heart failure with bilateral atelectasis, left greater than right, which was essentially unchanged from her previous film. The patient has a temperature of 98.4??????F, a pulse of 61 in normal sinus rhythm, a respiratory rate of 18 and a blood pressure of 135/56 with an oxygen saturation of 97% on two liters by nasal cannula. Her blood sugars have ranged from 140 to 220. Her weight today is 78.8 kg, which is still up somewhat from her preoperative weight of 73.4 kg. MOST RECENT LABORATORY DATA: The patient's most recent laboratory values reveal a white blood cell count of 6100, hematocrit of 29.2, sodium of 131, potassium of 4.4, BUN of 26, creatinine of 1.1 and magnesium of 1.9. These laboratory values are from [**2150-8-12**]. The patient's INR on [**2150-8-11**] as well as on [**2150-8-12**] was 1.9 and on both of those days she received 3 mg of Coumadin. Her INR from today, [**2150-8-13**], is pending. Her target INR should be 2 to 2.5 for treatment of postoperative paroxysmal atrial fibrillation. This is to be continued and the length of anticoagulation is ultimately to be determined by the patient's primary care physician or cardiologist. PHYSICAL EXAMINATION ON DISCHARGE: Neurologically, the patient is alert and oriented with no apparent deficits. On pulmonary examination, the lungs were clear to auscultation bilaterally in the upper lobes with a few bibasilar crackles. The coronary examination is a regular rate and rhythm. The abdomen is obese and slightly distended with positive bowel sounds. The patient states that she has not had a bowel movement in a number of days and feels somewhat constipated. She will receive a laxative today. The patient's sternum is stable. Her sternal incision is clean, dry and intact with Steri-Strips in place. Her extremities are warm and well perfused. Her right lower extremity has a large cellulitic area; however, this has significantly improved over the past 48 hours since she has been on the vancomycin. DISCHARGE MEDICATIONS: Levofloxacin 250 mg p.o. q.d. times one more week. Vancomycin 1 gm intravenous q. 18 h. times one more week. Amiodarone 400 mg p.o. q.d. Lopressor 50 mg p.o. b.i.d. Aspirin 81 mg p.o. q.d. Glyburide 10 mg p.o. q.d. Lipitor 20 mg p.o. h.s. Colace 100 mg p.o. b.i.d. Percocet 5 mg/325 mg one p.o. every four hours p.r.n. Salt tablets, two tablets p.o. b.i.d. Lasix 40 mg p.o. b.i.d. Potassium chloride 20 mEq p.o. q.d. Sliding scale regular insulin before meals and at bedtime as follows: for a blood sugar of 150 to 200, three units subcutaneously; for 201 to 250, six units; and, for 251 to 300, nine units. DISPOSITION: The patient is being discharged to a rehabilitation facility to assist with increasing strength, mobility and endurance and cardiac rehabilitation. ANTICOAGULATION: The patient's Coumadin dose for today has not yet been determined, pending prothrombin time results; her target INR should be 2.0 to 2.5 for atrial fibrillation. FOLLOWUP: The patient is to follow up with her primary care physician upon discharge from the rehabilitation facility. She is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] at [**Telephone/Fax (1) 170**] approximately one month after her surgical procedure. CONDITION ON DISCHARGE: The patient's condition upon discharge is stable. DISCHARGE DIAGNOSES: Aortic stenosis. Mitral regurgitation. Coronary artery disease. Status post aortic valve replacement. Status post mitral valve replacement. Status post coronary artery bypass grafting. Diabetes mellitus. Hypertension. Postoperative atrial fibrillation. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2150-8-13**] 09:56 T: [**2150-8-13**] 10:02 JOB#: [**Job Number 32173**]

[ "682.6", "998.11", "285.1", "511.8", "466.0", "427.31", "396.8", "414.01", "997.3" ]

icd9cm

[ [ [] ] ]

[ "39.63", "35.23", "96.72", "35.33", "36.11", "39.61", "35.21", "39.64", "37.23" ]

icd9pcs

[ [ [] ] ]

11856, 12377

10500, 11759

802, 1069

2057, 9673

9688, 10477

145, 528

1921, 2039

551, 776

11784, 11835

51,006

176,724

37233

Discharge summary

report

Admission Date: [**2145-6-7**] Discharge Date: [**2145-6-8**] Date of Birth: [**2067-9-12**] Sex: M Service: MEDICINE Allergies: Coreg Attending:[**First Name3 (LF) 2880**] Chief Complaint: Recurrent Ventricular tachycardia and syncope Major Surgical or Invasive Procedure: central line placement intubation ABG History of Present Illness: HPI: This 77 year old male patient with non ischemic cardiomyopathy with an EF of 20%, a fib (on warfarin at home), DM, HL, prior CVA, s/p BiV ICD re-placement for VT 6 weeks prior, who originally presented to [**Hospital3 417**] Hospital for ICD firing. Was transferred to [**Hospital1 18**] for further management. . Per OSH, family reports that after starting metolazone and lasix (once 6 weeks ago and once last week),he developed several shocks from AICD which he has never had before. With firings, has brief loss of consciousness lasting less than one minute. He was noted to fall in the bathroom with injury to his right knee and shoudler. Was brought to [**Hospital3 417**] ([**6-6**]), where he had several episodes of VT on presentation where his device fired several times converting him to AV paced rhythm. Blood pressures were reportedly stable. However he did have 1 episode on that admission where he became [**Doctor Last Name **] [**Doctor Last Name 352**] and had diffuculty repiratory effort and was slow to recover.Pacer interrogation demonstrated eight shocks delivered since [**2145-6-5**] due to VT with rates from 180-250, fourteen VT since since [**2145-5-16**] treated with ATP. 2 AT/AF episodes noted. Lidocaine bolus at 80mg IV followed by gtt, Given IV lopressor and 1L fluid bolus, and 2 g magnesium sulfate. Continues on PO amiodarone from recent admission to hospital. Per OSH records, echo with EF <20% and global hypokinesis, mod MR/TR, mild pulm HTN. Cardiac enzymes negative times three. . Given diuretics and fluid alternating for few rounds with diuretics finally held because of creatinine 2.1 and SBP in the 90s. . On review of systems, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Denies claudication, orthopnea, PND, lightheadedness Pitting edema to ankles, (+) CVA [**2130**] . Cardiac review of systems is notable for absence of chest pain (+), dyspnea on exertion (+), paroxysmal nocturnal dyspnea (+), orthopnea, ankle edema (+), palpitations (+), syncope (+) or presyncope (+). . Past Medical History: Paroxysmal atrial fibrillation Pacemaker [**2140-6-14**] CHF CVA in [**2130**] no residual [**12-30**]+ mitral regurgitation and tricuspid regurgitation moderate pulmonary hypertension Diabetes Hypertension Sciatica Cardiac catheterization at [**2144**]??????s Renal stent Cancer melanoma chest and basal on forehead Hyperlipidemia GERD Hyperthyroidism Hyperlipidemia Social History: (-) CIGS quit 12 years ago smoked 1 PPD Residing at [**Hospital **] Nursing Home since AICD insertion Worked in garment factory retired in [**2129**] ETOH: family denies. . Family History: Mother MI and died at 80. 1 brother and 1 sister with heart disease Physical Exam: VS: T=99.6 BP=100/80 HR=85 RR=15 O2 sat= 94% NC 2L GENERAL: Patient cyanotic lips and cheeks. Oriented x1. Confused and talking nonsense. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Systolic murmer heard in left 4th intercostal space ([**1-30**]), radiating to the left axilla. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, crackles at lung bases bilaterally on expiration and inspiration, no wheezes or rhonchi. ABDOMEN: Soft, NTND. Hepatomegaly which crosses midline and down to 11th rib, non tender to palpation. Abd aorta not enlarged by palpation. No abdominial bruits.Abdomen is distended, BS +,Neg fluid wave. EXTREMITIES: Bilateral pedal edema 2+. No femoral bruits. SKIN: stasis sacral dermatitis, no ulcers, scars, or xanthomas. Neuro: Flapping tremor with general body tremors. No focal neuro signs. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: Admission Labs [**2145-6-7**] 11:23PM PT-29.6* PTT-42.3* INR(PT)-2.9* [**2145-6-7**] 11:23PM PLT COUNT-335 [**2145-6-7**] 11:23PM WBC-7.2 RBC-3.49*# HGB-9.6*# HCT-29.7*# MCV-85 MCH-27.6 MCHC-32.5 RDW-14.8 [**2145-6-7**] 11:23PM CALCIUM-8.7 PHOSPHATE-4.9* MAGNESIUM-2.6 [**2145-6-7**] 11:23PM CK-MB-2 [**2145-6-7**] 11:23PM CK(CPK)-63 [**2145-6-7**] 11:23PM estGFR-Using this [**2145-6-7**] 11:23PM GLUCOSE-109* UREA N-67* CREAT-2.4*# SODIUM-134 POTASSIUM-6.1* CHLORIDE-90* TOTAL CO2-32 ANION GAP-18 . Labs on floor [**2145-6-8**] 10:54AM BLOOD WBC-10.4 RBC-3.01* Hgb-8.2* Hct-26.3* MCV-87 MCH-27.3 MCHC-31.2 RDW-15.3 Plt Ct-277 [**2145-6-8**] 03:12AM BLOOD WBC-8.6 RBC-3.69* Hgb-10.2* Hct-32.0* MCV-87 MCH-27.6 MCHC-31.9 RDW-14.8 Plt Ct-342 [**2145-6-8**] 10:54AM BLOOD Plt Ct-277 [**2145-6-8**] 03:12AM BLOOD Plt Ct-342 [**2145-6-8**] 03:12AM BLOOD PT-35.1* PTT-44.8* INR(PT)-3.6* [**2145-6-8**] 10:54AM BLOOD Glucose-60* UreaN-56* Creat-2.1* Na-GREATER TH K-3.4 Cl-109* HCO3-GREATER TH [**2145-6-8**] 03:12AM BLOOD Glucose-117* UreaN-68* Creat-2.7* Na-134 K-4.9 Cl-88* HCO3-31 AnGap-20 [**2145-6-7**] 11:23PM BLOOD Glucose-109* UreaN-67* Creat-2.4*# Na-134 K-6.1* Cl-90* HCO3-32 AnGap-18 [**2145-6-8**] 10:54AM BLOOD CK(CPK)-38* [**2145-6-8**] 03:12AM BLOOD ALT-25 AST-30 LD(LDH)-279* AlkPhos-158* TotBili-2.4* [**2145-6-8**] 10:54AM BLOOD CK-MB-2 [**2145-6-7**] 11:23PM BLOOD CK-MB-2 [**2145-6-8**] 10:54AM BLOOD Calcium-5.7* Phos-4.9* Mg-1.9 [**2145-6-8**] 03:12AM BLOOD Albumin-3.5 Calcium-8.9 Phos-5.3* Mg-2.6 [**2145-6-7**] 11:23PM BLOOD Calcium-8.7 Phos-4.9* Mg-2.6 [**2145-6-8**] 03:12AM BLOOD Ammonia-6* [**2145-6-8**] 03:12AM BLOOD Digoxin-2.3* [**2145-6-8**] 12:53PM BLOOD Type-ART Temp-37.0 pO2-93 pCO2-78* pH-7.04* calTCO2-23 Base XS--11 Intubat-INTUBATED [**2145-6-8**] 11:25AM BLOOD Type-ART pO2-57* pCO2-78* pH-7.06* calTCO2-24 Base XS--10 [**2145-6-8**] 10:57AM BLOOD Type-ART pO2-VERIFIED,Q pCO2-74* pH-7.08* calTCO2-23 Base XS--11 Intubat-INTUBATED Vent-CONTROLLED [**2145-6-8**] 12:53PM BLOOD K-4.8 [**2145-6-8**] 11:25AM BLOOD Glucose-58* Lactate-11.5* K-4.5 [**2145-6-8**] 10:57AM BLOOD Lactate-9.6* [**2145-6-8**] 12:53PM BLOOD O2 Sat-90 [**2145-6-8**] 11:25AM BLOOD freeCa-1.17 [**2145-6-8**] 10:57AM BLOOD freeCa-0.96* . Reports . CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 83830**] Reason: please evaluate for aspiration, PNA [**Hospital 93**] MEDICAL CONDITION: 77 year old man with BiV pacer/ICD in place admitted for multiple episodes V Tach with ICD firing, altered mental status and recent asystole requiring CPR. REASON FOR THIS EXAMINATION: please evaluate for aspiration, PNA Final Report INDICATION: Insertion of biventricular pacemaker, decline in cognitive function, cardiac arrest with subsequent intubation and frank hemoptysis. Supratherapeutic INR. FINDINGS: Comparison made with a radiograph dated [**2145-6-8**] at 01.47 hours (pre-cardiac arrest). There is new asymmetric opacity in the right lung and new bilateral alveolar and interstitial opacities in both lungs on a background of moderate cardiomegaly. No rib fractures or pneumothorax. An endotracheal tube and nasogastric tube have been inserted since the previous radiograph and are in satisfactory positions. The positions of the right atrial, right ventricular and epicardial pacing wire are satisfactory and unchanged. Moderately severe bilateral glenohumeral subluxation is incidentally noted. IMPRESSION: Alveolar and interstitial pulmonary edema, worse on the right. The diffuse ground-glass opacity in the right lung may be attributable in part to pulmonary hemorrhage, which would fit with the given clinical history. The study and the report were reviewed by the staff radiologist. . CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 83831**] Reason: Any acute lung process? [**Hospital 93**] MEDICAL CONDITION: 77 year old man with with non ischemic cardiomyopathy with an EF of 20%, CVA, DM, A fib (on warfarin at home), 6 weeks ago had BiV ICD re-placement s/p VT, who was transferred from [**Hospital3 **] hospital after ICD interrogation demonstrated 86 episodes of VT with intermittent firing REASON FOR THIS EXAMINATION: Any acute lung process? Final Report HISTORY: Ischemic cardiomyopathy. FINDINGS: No previous images. There is enlargement of the cardiac silhouette with pulmonary vascular congestion and a dual-channel pacemaker device in place. Epicardial lead is also seen. Mild retrocardiac opacification consistent with atelectasis. No definite pleural effusion. DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**] Approved: TUE [**2145-6-8**] 9:56 AM . Overall left ventricular systolic function is severely depressed (LVEF= 20%). The right ventricular cavity is markedly dilated with depressed free wall contractility. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. Ech [**6-8**]: IMPRESSION: Severe left ventricular systolic dysfunction. Dilated right ventricle with systolic dysfuction. No pericardial effusion. Ascites. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2145-6-8**] 12:04 . [**6-7**] EKG: A-V paced rhythm. Baseline artifact. No previous tracing available for comparison. Clinical correlation is suggested. Brief Hospital Course: ASSESSMENT/PLAN: This 77 year old male patient with non ischemic cardiomyopathy with an EF of 20%, CVA, DM, A fib (on warfarin at home), 6 weeks ago had BiV ICD re-placement s/p VT, who was transferred from [**Hospital3 **] hospital after ICD interrogation demonstrated 86 episodes of VT with intermittent firing. . #Nonsustained Ventricular Tachycardia- No V tach tracing was available from outside hospital. Patient presented with persisitent episdoes of ventricular tachycardia while on Sotalol and Biv ICD. Most likely caused by arrythmic substrate from past myocardial infarctions. There is a question if zaroxolyn is related.We continued Lidocaine gtt and continued Amiodarone 400mg [**Hospital1 **] p.o. We Hemodynamically monitored the patient with frequent vital signs check and kept him NPO in anticipation of a possible EP study in the AM.We also continued metoprolol tartrate 25mg [**Hospital1 **] p.o . #Atrial Fibrilliation- He was being A-V paced on presentation. Patient took Warfarin at home. -INR was 2.9 and we held his coumadin with continued rate control with metoprolol. . # Acute on chronic systolic CHF- appeared to be volume overloaded on exam. Noted to have [**12-30**]+ MR/TR on last echo.He could have been volume overloaded however intravascular depleted because of his high creatinine. We Continued Digoxin as well as ordered a chest radiograph. We Followed I's and O's and considered a echo in the AM. We waited to recheck lytes and make sure his potassium level was normal which it was prior to giving lasix 80mg IV . #Acute on Chronic Renal Failure: recent baseline 2-2.2. Ordered Urine lytes, serum lytes , and UA, and held diruetics. . #Altered Mental Status- Patient had experienced delirium for the past 6 weeks which was acute in onset. His first altered mental status coincided with his first hospital admission for V tach. 6 weeks ago. -Frequent reorientation. Held sedating medications. Measured ammonia levels for suspicion of hepatic encephalopathy, the ammonia levels were normal. . #DM Held oral diabetic medications (glyburide).Started insulin sliding scale. . #HTN- -Continued Metoprolol, however held hydralazine and isosorbide given SBP in 90's. . #Hyperlipidemia -Continued Simvastatin . #History of CVA: Without any persistent neurologic sequelae on presentation. . #Musculoskeletal pain: Secondary to trauma. -Considered imaging and X ray of right shoulder, ordered pain control with tylenol . #Sciatica -Held Lyrica for potential sedating effects. . #Melanoma . #GERD: Continued Famotidine . FEN: NPO . ACCESS: PIV's . PROPHYLAXIS: -DVT ppx with pneumoboots -Pain management with tylenol -Bowel regimen with Senna and Colace . CODE: Presumed full . Cardiac arrest call at 10:37 after found unresponsive, CPR was commenced and found to be in PEA. Pt was intubated and central/arterial line access was established. 1x shock when rhythm returned to VT. Pulse came and went and required 3 vials of epinephrine, 2 vials of atropine and 2 vials of bicarbonate with good CPR. Bloody ++ secretions on suction via ETT. ROSC 10:57 with blood pressure on A-line A dopamine infusion was commenced at 11:08. 2nd cardiac arrest call at 12:30 in PEA requiring 2 amps epinephrine,1 amp bicarb 1 amp atropine and dopamine titrated to maximum. Despite maximum pressors unable to sustain adequate blood pressure. Following this a family meeting was held and decision to make the patient comfort measures only was made. Time of death and confirmation: Time of death 13:50 with no pulse trace on A-line with no recordable although still ventilated at the request of family. Daughters and next of [**Doctor First Name **] present at time of death. Confirmation of death at 14:47 when ventilator was switched off. Relatives and next-of-[**Doctor First Name **] were offered and declined an autopsy at 14:50. Full external examination and vital signs at 14:47: No A-line trace. No BP. O2 sats 0. No respiratory effort, no breath sounds on auscultation for 1 minute. No carotid pulse palpable for 1 minute and no heart sounds on auscultation for 1 minute. Pupils bilaterally fixed and dilated Death certificate documentation completed by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: Chief cause of death: end-stage congestive heart failure Immediate cause of death: Electro-mechanical dissociation Other antecedent causes: Acute aspiration I, Dr [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hereby confirm the death of Mr [**Known firstname 3613**] [**Known lastname **] ([**2067-9-12**]) at 14:47 on [**2145-6-8**], an in-patient on the CCU of the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] Total time spent: 15 minutes Dr [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MB ChB MRCP Intern in medicine Pager [**Numeric Identifier 38143**] License No [**Numeric Identifier 83832**] Medications on Admission: (at the time of transfer) - amiodarone 400mg PO BID - famotidine 20mg PO daily - lidocaine gtt at 2 mg/min - isosorbide dinitrate 10mg PO TID - pregabalin 50mg PO daily - coumadin - hydralazine 10mg PO TID - simvastatin 20mg PO daily - digoxin 0.125mg PO daily - metoprolol 25mg PO BID - plavix 75mg PO daily . HOME MEDS: - glyburide 5mg PO daily - amiodarone 400mg PO BID - lidoderm patch to lower back - lasix 120 PO BID - hydralazine 10mg PO TID - zocor 20mg PO daily - digoxin 0.125mg PO daily - coumadin 2mg PO daily - plavix 75mg PO daily - folic acid 1mg Po daily - lyrica 50mg PO daily - colace 100mg PO BID - metoprolol 25mgPO [**Hospital1 **] - isosorbide dinitrate 10mg PO TID Discharge Medications: patient has expired Discharge Disposition: Expired Discharge Diagnosis: patient has expired Discharge Condition: patient has expired Discharge Instructions: patient has expired Followup Instructions: patient has expired [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]

[ "584.9", "272.4", "403.90", "416.8", "428.23", "V45.02", "250.00", "427.31", "585.9", "397.0", "427.1", "428.0", "425.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

16065, 16074

10200, 15282

310, 350

16137, 16158

4538, 6925

16226, 16380

3255, 3326

16021, 16042

8424, 8720

16095, 16116

15308, 15998

16182, 16203

3341, 4519

225, 272

8752, 10177

378, 2656

2678, 3048

3064, 3239

21,640

144,632

11774+56282

Discharge summary

report+addendum

Admission Date: [**2157-4-1**] Discharge Date: [**2157-4-14**] Service: NEUROSURG HISTORY OF PRESENT ILLNESS: The patient is a 78 year old woman who had multiple compression fractures and left anterior thigh pain. MRI scans in [**2157-1-28**], showed worsening compression fracture of T12 with moderate thoracic cord compression. The patient was admitted for T12 vertebrectomy. PHYSICAL EXAMINATION: On physical examination, the patient was in no acute distress. She was nonicteric. Pupils equally round and reactive to light. No lymphadenopathy. Neck was supple. Chest was clear to auscultation. Cardiac S1 and S2, regular rate and rhythm. Abdomen soft, nontender, nondistended, positive bowel sounds. No bruits. Extremities: In lower extremities she had positive pitting edema of her pretibial area one to two plus, in both lower extremities. HOSPITAL COURSE: She was admitted status post a T12 vertebrectomy with Synthes cage. There were no interoperative complications. Postoperatively, the patient was monitored in the surgical Intensive Care Unit. She had a chest tube in place secondary to a trans-thoracic approach. Her incision was clean, dry and intact. She was easily arousable and moving all four extremities with five out of five muscle strength. She was extubated on postoperative day number one. Her vital signs remained stable. She was transferred to the Floor on [**2157-4-2**]. She remained in the hospital and went back to the Operating Room on [**2157-4-6**] for T5 to L1 trans-reticular screw fixation with hooks and rods. There was an episode of acute drop in her systolic blood pressure down to the 80s. Her saturations showed a positive A:A gradient. She was ruled out for a pulmonary embolism interoperatively. Postoperatively, her vital signs were stable. She was afebrile. CT scan angiography was negative for a pulmonary embolism. Chest tube may have been near the aorta causing some irritation. On examination, she was intubated, awake and alert following commands, on [**2157-4-7**], moving all extremities. Her IP was four plus out of five. She was five out of five with quad, [**Last Name (un) 938**] and AT strength. She was weaned to extubate. She was transferred to the Regular Floor on postoperative day number two. She was seen by Physical Therapy and Occupational Therapy and found to require rehabilitation prior to discharge to home. MEDICATIONS AT THE TIME OF DISCHARGE: 1. Zantac 150 mg p.o. twice a day. 2. Colace 100 mg p.o. twice a day. 3. Percocet one to two tablets p.o. q. four hours p.r.n. 4. Norvasc 5 mg p.o. q. day. 5. Toprol XL 200 mg p.o. q. day. 6. Tylenol 650 mg p.o. q. four hours p.r.n. Her vital signs remained stable. She was afebrile and neurologically intact at the time of discharge. DISCHARGE INSTRUCTIONS: 1. Follow-up with Dr. [**Last Name (STitle) 1327**] in ten days for staple removal. DISPOSITION: The patient will be transferred to rehabilitation. CONDITION AT DISCHARGE: Stable. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2157-4-11**] 11:05 T: [**2157-4-11**] 11:18 JOB#: [**Job Number 37218**] Name: [**Known lastname **], [**Known firstname 4193**] Unit No: [**Numeric Identifier 6663**] Admission Date: [**2157-4-1**] Discharge Date: [**2157-4-14**] Date of Birth: Sex: F Service: ADDENDUM: This addendum will cover the dates [**4-11**] through [**2157-4-14**]. The patient remained hospitalized from [**4-11**] through [**4-14**] while awaiting transfer to a rehabilitation hospital for aggressive physiotherapy and rehabilitation. A bed became available on [**4-14**] and the patient was subsequently transferred to the rehab hospital in stable condition with all plans and discharge medications as indicated above. [**Name6 (MD) 863**] [**Last Name (NamePattern4) 864**], M.D. [**MD Number(1) 865**] Dictated By:[**Doctor Last Name 6664**] MEDQUIST36 D: [**2157-7-8**] 10:24 T: [**2157-7-11**] 07:33 JOB#: [**Job Number 6665**]

[ "722.72", "276.5", "285.9", "530.81", "401.9", "458.2", "733.13", "733.00" ]

icd9cm

[ [ [] ] ]

[ "78.49", "81.04", "03.53", "81.05", "96.71" ]

icd9pcs

[ [ [] ] ]

889, 2805

2829, 2992

417, 871

3008, 4212

123, 394

27,888

162,722

32272

Discharge summary

report

Admission Date: [**2142-2-12**] Discharge Date: [**2142-2-17**] Date of Birth: [**2080-8-11**] Sex: F Service: UROLOGY Allergies: Celexa / Erythromycin Attending:[**First Name3 (LF) 11304**] Chief Complaint: Renal tumor Major Surgical or Invasive Procedure: Laparosopic right radical nephrectomy History of Present Illness: [**Known firstname **] is a very pleasant and well informed a 61-year-old woman who back in [**Month (only) 205**] had what appeared to be a pneumonia. The lung CT unfortunately revealed a right renal tumor and left adrenal mass. She denies gross hematuria, urinary tract infections, or other urinary symptoms such as urgency. She does state that she has been very thirsty with urinary frequency over the past couple of weeks. She has not checked her blood sugar in many weeks she says. She states also admits to fatigue and crampy bilateral lower abdominal pain, which is not associated with nausea, vomiting, fever, or chills. It does not seem to be associated with food intake, urinary, or bowel habits. She has had a weight loss of 27 pounds over the past five months, denies night sweats. Past Medical History: Past medical history of coronary artery disease (CABG in [**2137**], afib, hypertension), type 2 diabetes, obesity, cataracts, diverticulitis, COPD, arthritis, borderline personality/obsessive compulsive disorder/PTSD, carpal tunnel. Past Surgical History: Tonsils and adenoids [**2086**], D&C [**2102**]/76, hysterectomy [**2116**], lumpectomy [**2126**] CABG [**2137**]. Medications: Glipizide, Procardia, metoprolol, fluoxetine, guaifenesin, valsartan, ranitidine, stress tablets, vitamin C, nitroglycerin p.r.n., albuterol p.r.n., syllium powder, eyedrops, Vicodin, lorazepam, aspirin. Physical Exam: General: comfortable Abd: soft, non tender, non distended Incisions: clean, dry, intact; no signs of infection Brief Hospital Course: Patient was admitted to Urology after undergoing laparoscopic right radical nephrectomy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, provided with pneumoboots and incentive spirometry for prophylaxis, and ambulated once. On POD1, the patient was restarted on home medications, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced to a clears/toast and crackers diet. On POD2, urethral catheter (foley) removed without difficulty and diet was advanced as tolerated. Pulmonary edema and atelectasis noted on CXR, she was weaned off ocysgen with diuretics. The remainder of the hospital course was relatively unremarkable. On POD4, the patient had chest pain but serial cardiac enzymes and EKG were negative x3 and the chest pain spontaneously resolved. The patient was discharged in stable condition, eating well, ambulating independently with oxygenation >91% on room air, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic with Dr. [**Last Name (STitle) 3748**] in 3 weeks. Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain for 1 weeks: No alcohol or driving on this medication. Disp:*25 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 weeks: Take while you are on narcotics. Stop when you are having regular bowel movements. . Disp:*20 Capsule(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*0 Capsule(s)* Refills:*0* 4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*0 Tablet(s)* Refills:*0* 5. Glipizide 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*0 Tablet(s)* Refills:*0* 6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual q5min as needed for angina. Disp:*0 * Refills:*0* 7. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*0 Capsule(s)* Refills:*0* 8. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*0 Tablet(s)* Refills:*0* 9. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily). Disp:*0 Packet(s)* Refills:*0* 10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety, insomnia. Disp:*0 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Renal tumor Discharge Condition: Stable Discharge Instructions: -You may shower but do not bathe, swim or immerse your incision. -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids. -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by Dr. [**Last Name (STitle) 3748**] in follow-up. -Do not drive or drink alcohol while taking narcotics. -Resume all of your home medications. -Call Dr.[**Name (NI) 11306**] office to schedule a follow-up appointment in 3 weeks AND if you have any questions. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER. Followup Instructions: Call Dr.[**Name (NI) 11306**] office to schedule a follow-up appointment in 3 weeks AND if you have any questions. [**Telephone/Fax (1) 3752**] Dr. [**Last Name (STitle) **], [**2142-2-20**] 2PM, [**Location (un) 75442**], [**Last Name (un) 75443**], [**Numeric Identifier 75444**]

[ "311", "427.31", "250.00", "496", "278.00", "189.0", "518.4", "724.5" ]

icd9cm

[ [ [] ] ]

[ "54.21", "55.51" ]

icd9pcs

[ [ [] ] ]

4821, 4859

1933, 3450

294, 334

4915, 4924

5611, 5898

3473, 4798

4880, 4894

4948, 5588

1446, 1783

1798, 1910

243, 256

362, 1165

1187, 1422

71,280

183,292

39215

Discharge summary

report

Admission Date: [**2153-1-11**] Discharge Date: [**2153-1-15**] Date of Birth: [**2083-11-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1936**] Chief Complaint: Anemia, GI bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: Mr. [**Known lastname 86810**] is a 69yo male with no significant PMH who is admitted to the MICU with coffee ground emesis and melena. Per patient, he started vomiting blood 3 days ago. He describes the vomitus as dark brown in color. He was vomiting several times per day. He has been constipated with some abdominal bloating. He has had only one BM in the past four days (usual is 1/day), which he describes as black and tarry. He reports one episode of possible syncope. He denies NSAID use or alcohol. When EMS arrived to his house, apparently "blood was found all over". . Review of systems is negative for fevers, chills, chest pain, SOB, abdominal pain, bloody stools, or diarrhea. Past Medical History: None Social History: Lives in retirement home. Rare Etoh, not heavy drinker. 20-30 yr history of cigars and pipes, quit 8 yrs ago. Family History: Father had gastric ulcer. Mother with pancreatic Ca. Physical Exam: vitals 97 107 101/52 22 98%RA Gen: Well appearing male HEENT: Anicteric sclerae Heart: Sinus tachycardia; no m,r,g Lungs: CTA, no crackles Abdomen: Soft, NT/ND, +BS Extremities: No edema, well perfused Pertinent Results: Admission Labs: [**2153-1-11**] 01:00PM BLOOD WBC-18.8* RBC-3.57* Hgb-11.1* Hct-33.4* MCV-94 MCH-31.1 MCHC-33.2 RDW-13.5 Plt Ct-354 [**2153-1-11**] 01:00PM BLOOD Neuts-85.2* Bands-0 Lymphs-11.7* Monos-2.7 Eos-0.2 Baso-0.2 [**2153-1-11**] 01:00PM BLOOD PT-13.4 PTT-24.4 INR(PT)-1.1 [**2153-1-11**] 01:00PM BLOOD Glucose-210* UreaN-60* Creat-1.4* Na-139 K-4.5 Cl-105 HCO3-20* AnGap-19 [**2153-1-11**] 01:00PM BLOOD ALT-29 AST-29 CK(CPK)-131 AlkPhos-47 Amylase-19 TotBili-0.2 [**2153-1-11**] 01:00PM BLOOD cTropnT-<0.01 [**2153-1-11**] 01:00PM BLOOD Calcium-8.5 Phos-3.1 Mg-2.0 . CT Abd [**1-11**]: IMPRESSION: 1. Right-sided colitis involving the proximal cecum. Finding is nonspecific and could be related to infection or inflammation. Right-sided distribution raises possibility of more atypical infections such as Yersinia or Salmonella. The patient is not neutropenic, which excludes possibility of typhlitis. 2. If there is concern for a gastrocolonic fistual, this would be better evaluated with upper GI. . KUB [**1-11**]: Two views of the abdomen and pelvis including one obtained in the left lateral decubitus position demonstrate a non-obstructive bowel gas pattern. No loops of small or large bowel are dilated. Air is seen within the rectum. No free air is present. Small rounded calcifications in the pelvis likely represent phleboliths. IMPRESSION: No obstruction, ileus, or free air identified . . ECHO [**1-12**]: 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%). 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 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. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion . EGD [**2153-1-12**]: [**Doctor First Name **] [**Doctor Last Name **] tear noted at GE junction with white ulcer base. No active bleeding noted. Otherwise normal EGD to second part of the duodenum Brief Hospital Course: Acute Blood Loss Anemia/GI bleed: Patient was found to having findings consistent with an upper GI bleed, given his dark guaiac positive gastric contents on NG lavage. He was given aggressive IVF with Hct drop of 33->23. He was given 2 units PRBCs. LFTs were wnl. CT abd showed colonic thickening. GI was consulted and he underwent EGD on [**1-12**] showing a healing [**Doctor First Name 329**] [**Doctor Last Name **] tear. His Hct stabilized therafter. He was transferred to the medical floor. He did NOT require further transfusions. He will follow up with GI in [**2-22**] weeks for a repeat EGD, as well as colonoscopy to assess his CT findings. The patient had some lightheadedness on day of discharge, orthostatics checked and were normal. Patient will follow up with new PCP next week as well as [**Hospital **] clinic. Discharged with Prilosec 20mg twice daily . Colonic Thickening: As above. Likely an incidental finding here. He will need a colonoscopy as an outpatient. . Leukocytosis: Initially he was placed on antibiotics, but with negative cultures his antibiotics were held. Medications on Admission: None Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Acute blood loss anemia/GI bleed [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear Leukocytosis Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted with a gastrointestinal bleed. You were given blood transfusions. Upper endoscopy showed a small lesion called [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear which was healing. It will take time to heal on its own. It will be very important to follow up with your new PCP and gastroenterologist as soon as possible. You will need another upper endoscopy in [**2-22**] weeks, as well as a colonoscopy. . Please take all medications as prescribed and keep all follow up appointments. The following changes were made to your medication regimen: 1. Please take Prilosec 20mg twice daily Followup Instructions: New PCP: [**Name Initial (NameIs) 2169**]: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 275**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2153-1-22**] 1:45. Address is [**Location (un) **]. [**Location (un) **] of the [**Hospital Ward Name **] building GI doctor: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2153-1-24**] 3:30. [**Location (un) **]. [**Hospital Unit Name 1825**] [**Location (un) 453**]. Repeat Upper Endoscopy and Colonscopy. You will get instructions for this in the mail. you can discuss this plan with Dr. [**Last Name (STitle) **] at your appt next week. Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2153-2-15**] 1:00 Completed by:[**2153-1-16**]

[ "288.60", "569.9", "530.7", "276.2", "V15.82", "564.09", "276.52", "285.1", "584.9", "780.2", "530.20" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

5418, 5424

3952, 5048

332, 338

5585, 5585

1522, 1522

6400, 7239

1229, 1284

5103, 5395

5445, 5564

5074, 5080

5730, 6377

1299, 1503

276, 294

366, 1058

1538, 3929

5599, 5706

1080, 1086

1102, 1213

55,688

149,479

37697

Discharge summary

report

Admission Date: [**2105-10-23**] Discharge Date: [**2105-10-24**] Date of Birth: [**2027-8-14**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: intracranial hemorrhage Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 48684**] is a 78 yo man with DM2, L CVA w/ hemiplegia who was transferred from his nursing home to OSH when noted to be unresponsivle. He was intubated, CT scan revealed ICH in the posterior fossa and he was brought to [**Hospital1 18**] for care. He has been DNI/DNR status but it was reversed by his family for neurosurgical evaluation. Per neurosurgery assessment, surgical intervention is not indicated. The family decided to ultimately pursue comfort care, but would like his supported until additional family and priest can be present. Past Medical History: DM 2, Left CVA [**2097**] with baseline hemiplegia (left), orthopedic deformities of both legs, immobile and bedbound. Social History: NH resident, does not smoke, no alohol Family History: not contributory Physical Exam: Vitals: T - not registering BP 73/38 Gen: unresponsive, intubated, ?minimal gag HEENT: Pupils: 1 mm BL fixed non reactive, EOMs- no movement of eyes Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: deformities in both legs Neuro: No response to verbal or tactile stimuli Pertinent Results: [**2105-10-23**] WBC-8.2 RBC-4.16* Hgb-12.0* Hct-37.2* Plt Ct-220 Neuts-91.1* Lymphs-5.7* Monos-2.8 Eos-0.1 Baso-0.2 PT-27.0* PTT-32.4 INR(PT)-2.6* Glucose-166* UreaN-24* Creat-0.8 Na-142 K-5.1 Cl-106 HCO3-24 AnGap-17 ALT-12 AST-24 CK(CPK)-81 AlkPhos-164* TotBili-0.5 CK-MB-NotDone cTropnT-0.03* Brief Hospital Course: 78 M with multiple medical problems on coumadin who presented with massive post fossa bleed with GCS 3, who was unresponsive. . # Massive ICH: Pt was evaluated by neurosurgery and there was no indication for intervention. The family was aware of the patient's poor prognosis and watned to make him comfort measures. They were interested in making him comfort measures. They also wanted all of the family to be present at the time of death. He was maintained on a ventilator, given IVF and periopheral dopamine to support him until his extubation. The organ bank was contact[**Name (NI) **] and the decision to become a tissue donator, as he did not qualify to be an organ donator based on his age. On [**10-24**] in the afternoon, pt was extubated. Time of death was 7:26pm. Autopsy was decline. Medications on Admission: simvastatin coumadin B 12 FeSo4 MVI prilosec bisacodyl mirtazepine senna Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: intracranial hemorrhage Discharge Condition: . Discharge Instructions: . Followup Instructions: . [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2105-10-24**]

[ "780.01", "431", "V58.61", "V66.7", "250.00", "438.20", "780.72", "736.89" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

2786, 2795

1826, 2633

329, 335

2862, 2865

1505, 1803

2915, 3084

1143, 1161

2757, 2763

2816, 2841

2659, 2734

2889, 2892

1176, 1486

266, 291

363, 928

950, 1070

1086, 1126

32,023

127,709

19320

Discharge summary

report

Admission Date: [**2184-2-4**] Discharge Date: [**2184-2-24**] Date of Birth: [**2101-8-4**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: Bradycardia and hypotension Major Surgical or Invasive Procedure: EVAR [**2-19**] Pace maker placement / Dual chamber History of Present Illness: 82 yo woman w/ h/o CAD s/p CABGx4 on [**2184-1-5**] (LIMA-LAD, SVG-Diag, SVG-OM, SVG-PDA), DM, HTN, h/o myelodisplastic syndrome, and AAA (7 x 6.7 x 9.7cm, s/p hip repair in [**11-12**] scheduled for repair with Dr [**Last Name (STitle) **] [**2184-2-18**]), who was referred to [**Hospital1 **] [**Location (un) 620**] with bradycardia and hypotension from [**Name8 (MD) 11851**] RN staaff. She also complained of "quesiness." Per the patient, she has been unable to eat for the past 2 days because of epigastric burning as well as a bitter taste in her mouth. 3 days ago, the patient also had 2 episodes of emesis. She denied any fevers, chills, night sweats, diarrhea, constipation, dysuria, cough. On cardiac review, denied CP, SOB, LE edema, palpitations. At [**Hospital1 18**] [**Location (un) 620**], she was noted to have bradycardia to the 30s, but her BP was good to the 140s. She had ARF (Cr @ 2.2 - up from 1.3 on [**2184-1-28**]) and hyperkalemia 5.9. She also had guaiac pos brown stool, anemia (seems to be her baseline ~ 27). Bedside u/s shows AAA 6 x 5.6cm. Given kayexalate, Ca gluconate, D50, NS x 1L, atropine 0.25 x 3 (with improvement of BP), ASA 81mg x 2, Zofran 4mg x 1, morphine 2mg x 2. In the ED: Continued sinus bradycardia to the 40s, SBP mid90's-100s. EP consulted. EKG was faxed to EP fellow, thought to have shows sinus conduction, but ?sinus arrest with escape rhythm, so started on dopamine gtt--with improvement of SBP to 110s and HR to 70s. No central line given hemodynamic stability and desire to preserve site for ?pacer. At [**Hospital1 18**], given more kayexalate: K5.5->5.3, 1L NS, zofran and morphine. Past Medical History: 1. Left femoral neck fracture status post hemiarthroplasty on [**2183-11-20**]. 2. Myelodysplastic syndrome requiring packed red blood cell and platelet transfusion. 3. Diabetes. 4. Hypertension. 5. AAA -- infrarenal Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension . Cardiac History: CABG, in [**2184-1-5**] anatomy as follows: (LIMA-LAD, SVG-Diag, SVG-OM, SVG-PDA) . Percutaneous coronary intervention, in [**2184-1-2**] anatomy as follows: 70% distal LMCA stenosis, LAD with 90% ostial LAD stenosis and an ostial 90% lesion of a small D1, LCx with 50% ostial stenosis, RCA RCA had diffuse <50% disease with an 80% ostial PDA stenosis. . Pacemaker/ICD: NA Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. She is married, does not smoke cigarettes. Does not do any regular exercise or follow a particular diet. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: AFVSS Gen: Elderly female AAO x 3 alert and communicating appropriately. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple without JVD CV: +S1, +S2. No murmurs. Chest: Emaciated. Midline sternotomy scar well healed. Abd: Soft. Mild distension. No rebound or guarding. No HSM or tenderness. Abd aorta not palpated. No abdominal bruits. Ext: No c/c/e. feet are warm with dopplerable pulses. Pertinent Results: EKG demonstrated: Sinus @ 62 with IVCD, normal axis. Intervals preserved; ,maybe slight Qt prolongation. This was on dopamine. TELEMETRY demonstrated: Sinus brady at 53 2D-ECHOCARDIOGRAM performed on [**2184-1-2**] (preop) demonstrated: There is mild regional left ventricular systolic dysfunction with hypokinesis of the septum and anterior walls. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. Mild pulmonic regurgitation is seen. Compared with the prior study (images reviewed) of [**2182-1-15**], the septal and anterior wall motion abnormalities are more pronounced and the severity of mitral regurgitation has increased. [**2184-2-4**] ABD/PELVIS CT: 1. Slightly increased size of massive infrarenal AAA, now measuring 7 x 7 cm, increased from 6.7 x 6.6 cm. No periaortic stranding or fluid to suggest rupture at this time. High density along the anterior thrombus is roughly stable from prior exam and may represent calcification within intramural hemorrhage. 2. Previously seen pseudoaneurysm associated with left hip prosthesis is not evaluated due to metallic artifact. 3. New moderate-sized bilateral pleural effusions. 4. Cholelithiasis within a distended gallbladder, however, no surrounding stranding to suggest cholecystitis. Recommend correlation with clinical symptoms. 5. Diverticulosis. [**2184-2-22**] 06:35AM BLOOD WBC-4.6 RBC-3.47* Hgb-10.4* Hct-30.9* MCV-89 MCH-30.0 MCHC-33.8 RDW-14.6 Plt Ct-86* [**2184-2-11**] 05:25AM BLOOD Neuts-83.8* Lymphs-10.4* Monos-4.0 Eos-1.7 Baso-0.1 [**2184-2-20**] 03:46AM BLOOD PT-14.0* PTT-32.9 INR(PT)-1.2* [**2184-2-24**] 06:55AM BLOOD Glucose-96 UreaN-29* Creat-1.1 Na-139 K-3.7 Cl-102 HCO3-32 AnGap-9 [**2184-2-10**] 03:10PM BLOOD ALT-8 AST-30 AlkPhos-72 Amylase-24 TotBili-1.0 [**2184-2-9**] 03:30PM BLOOD LD(LDH)-198 TotBili-1.3 DirBili-0.5* IndBili-0.8 [**2184-2-19**] 09:24AM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.010 URINE Blood-LG Nitrite-POS Protein-100 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG URINE RBC->50 WBC-21-50* Bacteri-MANY Yeast-RARE Epi-0-2 Brief Hospital Course: 82 yo woman w/ h/o CAD s/p CABG on [**2184-1-5**] (LIMA-LAD, SVG-Diag, SVG-OM, SVG-PDA), DM, HTN, h/o myelodisplastic syndrome, and AAA (7 x 6.7 x 9.7cm), transferred from [**Hospital1 **] [**Location (un) 620**] with bradycardia admitted to EP/cardiology service. - Dual chaber PM placed / metoprolol and amiodarone restarted after. Post-operatively was transferred to Vascular service for management of a knowm AAA. Transferred from ICU to [**Hospital Ward Name 121**] 5 VICU. EP continous to follow. Patient was taken to OR/ Dr. [**Last Name (STitle) **] for EVAR. Post-operatively, patient has done well. No complications from EVAR. -Neuro: The patient was alert and appropraite the whole hospital stay, received appropriate pain medications for adequate pain control. -CV: Placed on telemetry monitor, patient ruled out for MI. Telemetry d/c'd. Vitals remained stable. Continued on asa and statin per cardiology. -GU: Ucx UA nitrite +, 21-50WBC, 0-2 epi, foley d/c'd, placed on Cipro, DC on discharge -Endo: covered with HISS protocol. -ID: Developed fever, CXR ? PNa, treated with PO levo, [**2-19**] UA + foley d/c'd, patient completed a course of Cipro. -Labs/Heme: Labs monitored, elevated K - keyaxalate given. Creatinine increased, improved with hydration. - positive for HIT and anti-K/E positive, heparin discontinued, SRA neg. -Myelodysplastic d/o: Hct and platelet counts at baseline. [**2-10**] Hem/onc consulted for known myelodysplastic syndrome, low HCT and Patelets- cleared to have EVAR. Patient had multiple units packed red cell transfusions and some platelets. Medications on Admission: Oxycontin 10mg QAM, 20mg QPM Ferrous Gluconate 325 mg daily Furosemide 40 mg DAILY Potassium Chloride 20 mEq Daily Glipizide 10 mg [**Hospital1 **] carvedilol 6.25mg [**Hospital1 **] Metoprolol Tartrate 25 mg [**Hospital1 **] Amiodarone 200 mg daily Docusate Sodium 100 mg [**Hospital1 **] Aspirin 81 mg Pantoprazole 40 mg Atorvastatin 10 mg Ascorbic Acid 500 mg [**Hospital1 **] 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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO QAM (once a day (in the morning)). 11. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO QPM (once a day (in the evening)). 12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 15. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO four times a day: please give if SBP greater then 130. 16. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 17. Insulin Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-70 mg/dL 4 oz / crackers 71-150 mg/dL 0 Units 151-200 mg/dL 2 Units 201-250 mg/dL 4 Units 251-300 mg/dL 6 Units 301-350 mg/dL 8 Units 351-400 mg/dL 10 Units > 400 mg/dL Notify M.D. 18. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 19. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 20. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 21. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 22. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation ONCE (Once) for 1 doses. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: AAA s/p EVAR [**2184-2-18**] UTI bradycardia hyperkalemia hypotension ARF (b-blocker+amio toxicity?) anemia of chronic desease PNA - nosocomial Discharge Condition: Good Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**2-8**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**4-11**] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**], call to make an appointment, this should be done in 4 weeks. Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2184-3-29**] 2:15 You have a CTA of the pelvis and torso scheduled for 0800 on the morning of [**3-29**]. You have have to be at the Day Care Unit at 0700. This is located in the [**Hospital Ward Name **] building [**Location (un) 453**]. There you will get pre-hydration. You will remain here after yout CT scan for more hydration. This is to protect your kidneys. You will then report to Dr [**Last Name (STitle) **] office. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2184-3-29**] 8:00 Completed by:[**2184-2-24**]

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icd9cm

[ [ [] ] ]

[ "99.62", "39.71", "37.72", "37.83", "89.45" ]

icd9pcs

[ [ [] ] ]

9993, 10059

5756, 7355

340, 394

10247, 10254

3599, 5733

12860, 13701

3018, 3101

7786, 9970

10080, 10226

7381, 7763

10278, 12280

12306, 12837

3116, 3580

273, 302

422, 2072

2094, 2772

2788, 3002

13,548

170,564

52654

Discharge summary

report

Admission Date: [**2150-2-20**] Discharge Date: [**2150-2-28**] Date of Birth: [**2096-1-27**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: Admit for planned surgery Major Surgical or Invasive Procedure: Left colectomy Small Bowel Resection Excision of Retroperitoneal mass Left uretero-ureterostomy History of Present Illness: 51-year-old female with sigmoid lesion discovered during surveillance colonoscopy for reassessment of sessile polyp. Family history of colon cancer, biopsy proven hyperplasia, plastic polyp at 50 cm with 270 degree growing sessile lesions at approximately 35 cm. Pt underwent sigmoid colectomy in [**2147**], and presented recently with new-onset L leg weakness. Evaluation revelaed a large mass from the L colon invading the psoas muscle. She is admitted for subtotal colectomy and possible colostomy. Past Medical History: 1. Colon CA s/p sigmoid colectomy in '[**47**]. No chemo or rad tx. 2. Report of multiple episodes of bleeding; hematologic workup and two workups for vWF have been normal. 3. Uterine CA s/p TAH BSO [**2144**] 4. HTN 5. Anxiety/depression 7. Cervical neuropathy 8. Hep C 9. OA 10. Asthma 11. H/o EtOH abuse 12. CCY [**2148**] 13. Appendectomy 14. Tonsillectomy 15. Ventral hernia repair Social History: Quit tob and EtOH last month. EtOH: [**1-25**] pint of rum 2-3x/week. On nicotine patch. No IVDU. On disability. Lives with daughter, granddaughter, and ex-husband. Family History: Non-contributory Physical Exam: Physical exam on discharge: VS: 98.0 103 110/70 20 96%RA REgular rate and rhythm Clear lung fields Abd soft, mildly distended, with good healing of surgical incision. Pertinent Results: [**2150-2-21**] 11:50AM BLOOD Hct-23.6* [**2150-2-22**] 12:10AM BLOOD WBC-14.7* RBC-3.65* Hgb-10.6* Hct-30.5* MCV-84 MCH-29.1 MCHC-34.8 RDW-15.9* Plt Ct-303 [**2150-2-23**] 07:28PM BLOOD Hct-26.9* [**2150-2-27**] 04:59AM BLOOD WBC-13.2* RBC-3.40* Hgb-9.8* Hct-29.5* MCV-87 MCH-29.0 MCHC-33.4 RDW-16.0* Plt Ct-475* Brief Hospital Course: Pt admitted on day of surgery. She tolerated the procedure well and was transferred to the SICU post-operatively, as she remained intubated. She was extubated on [**2-21**], and continued to do well. On [**2-22**], it was noted that her hematocrit had dropped to 23 from 30, and she was transfused 2 Units. No source of bleeding was found after extensive examination. Pt's SICU course was otherwise uneventful, and she was transferred to the floor on [**2-24**]. Here she continued to do well, with stable crits, vital signs, and a generally reassuring course. ALthough the output from her [**Location (un) 1661**]-[**Location (un) 1662**] drain remained elevated, the creatinine of this fluid was reassuring that there was no urine leak, and the drain was removed. She began tolerating oral intake on [**2-26**], and by [**2-28**] was doing very well. She was discharged home with services, and instructed to return to clinic for follow up. Medications on Admission: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 5. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital **] Homecare Discharge Diagnosis: Metastatic Adenocarcinoma of Colon Discharge Condition: Good Discharge Instructions: Please keep wound area clean. Please perform sterile wet to dry dressing changes with sterile saline water twice daily to open wound area. Take medications as prescribed. Followup Instructions: Please call Dr.[**Name (NI) 1745**] office at [**Telephone/Fax (1) 6554**] within one week after discharge to schedule a follow-up appointment. PLEASE CALL DR [**First Name (STitle) **] [**Name (STitle) **] OFFICE in [**2-26**] Wks for f/u and removal of URETERAL STENT. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

[ "197.6", "198.1", "401.9", "153.8", "593.4", "196.2" ]

icd9cm

[ [ [] ] ]

[ "45.62", "45.75", "59.8", "56.75", "99.04", "54.4" ]

icd9pcs

[ [ [] ] ]

4454, 4509

2140, 3083

340, 438

4588, 4594

1802, 2117

4815, 5220

1580, 1598

3608, 4431

4530, 4567

3109, 3585

4618, 4792

1613, 1613

1642, 1783

275, 302

466, 972

994, 1382

1398, 1564

5,460

152,632

15088

Discharge summary

report

Admission Date: [**2125-1-10**] Discharge Date: [**2125-1-15**] Date of Birth: [**2064-3-12**] Sex: M Service: SURGERY Allergies: Codeine / Penicillins Attending:[**First Name3 (LF) 974**] Chief Complaint: nausea/vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 60 M p/w N/V weakness and URI symptoms times two weeks, also epigastric burning and diarrhea. No fevers, tolerating clears only. Past Medical History: + smoking, NSTEMI [**8-19**] s/p CABG (no LIMA), HTN, HLD, Hodkins dz age 14 s/p XRT, splenectomy age 20, facial basal & squamous cell removal, Right eye ? embolus 2.5 yrs ago Social History: see PMH Family History: Noncontributory Physical Exam: Gen: NAD Chest: CTAB, RRR Abdomen: S/NT/ND Ext: WNL Pertinent Results: [**2125-1-14**] 08:45AM BLOOD WBC-25.8* RBC-3.75* Hgb-11.0* Hct-32.0* MCV-85 MCH-29.3 MCHC-34.3 RDW-14.5 Plt Ct-634*# [**2125-1-9**] 03:30PM BLOOD WBC-33.0*# RBC-4.44* Hgb-13.5* Hct-37.4* MCV-84 MCH-30.5 MCHC-36.1* RDW-15.0 Plt Ct-473* Brief Hospital Course: Mr. [**Known lastname 1349**] [**Last Name (Titles) 1834**] an abdominal CT scan which showed thrombosis of the IMV extending into the portal vein with air observed in the IMV. Neurosurgery was consulted for clearance to anticoagulate given a left occipital mass concerning for metastasis for which the patient had seen Dr. [**Last Name (STitle) **] in clinic. They felt that head CT obtained at this time was not concerning and approved anticoagulation provided the patient was admitted to the ICU for frequent neuro checks. This was done and he was started on a heparin drip. His neurological checks remained unremarkable and he was transferred to the floor on HD1. He was also started on vancomycin, ciprofloxacin and flagyl. Blood cultures were drawn, and came back as Gram negative rods in one culture. His urine culture was negative. At this time the GNR's have not been speciated so the patient was switched to PO Cipro and Flagyl, which he will continue for a total of fourteen days. On HD1 he was advanced to clears, on HD2 to fulls, and HD3 to regular diet which he tolerated without difficulty. Warfarin was started and he became therapeutic on HD6, at which time his heparin drip was discontinued. Medications on Admission: Metoprolol Tartrate 75 mg po BID, Prochlorperazine 10 mg po TID prn nausea, Simvastatin 80 mg po daily, ASA E.C. 325 mg po daily Studies: Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tablet(s) 2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO twice a day. 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 12 days. Disp:*36 Tablet(s)* Refills:*0* 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. Disp:*24 Tablet(s)* Refills:*0* 7. Outpatient Lab Work Please draw blood for INR [**2125-1-16**] 8. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Home Discharge Diagnosis: IMV thrombosis extending to portal confluence GNR bacteremia Discharge Condition: Good. INR therapeutic. HD stable. Afebrile. Tolerating regular diet. Discharge Instructions: You were given a prescription for coumadin. Please take as directed by your primary care physician. [**Name10 (NameIs) **] must have your coumadin levels closely monitored. Please call Dr. [**Last Name (STitle) **] today following your discharge to obtain an appointment for lab work on [**2125-1-16**] days to test your coumadin levels. Please follow up with Dr. [**Last Name (STitle) **] regarding the appropriate dosing of your coumadin levels and regular blood testing. If you cannot follow up with Dr. [**Last Name (STitle) **], please call Dr. [**Last Name (STitle) 816**] or return to the ER. You had blood tests to determine the cause of your blood clot that were still pending at the time of your discharge, please follow up with Dr. [**Last Name (STitle) **] with regards to the results of these hypercoagulability studies or call the hematologists to schedule an appointment at ([**Telephone/Fax (1) 14703**]. Call your doctor or return to the emergency room for any of the following: *Worsening pain *Abdominal pain *Shortness of breath *Chest pain *Fevers * Followup Instructions: You must have your coumadin levels closely monitored. Please call Dr. [**Last Name (STitle) **] today following your discharge to obtain an appointment for lab work in [**1-19**] days to test your coumadin levels. Please follow up with Dr. [**Last Name (STitle) **] regarding the appropriate dosing of your coumadin levels and regular blood testing. If you cannot follow up with Dr. [**Last Name (STitle) **], please call Dr. [**Last Name (STitle) 816**] or return to the ER. Please call Dr. [**Last Name (STitle) 816**] @ ([**Telephone/Fax (1) 3618**] to schedule an appointment for follow up in [**1-19**] weeks. You had blood tests to determine the cause of your blood clot that were still pending at the time of your discharge, please follow up with Dr. [**Last Name (STitle) **] with regards to the results of these hypercoagulability studies or call the hematologists to schedule an appointment at ([**Telephone/Fax (1) 14703**].

[ "790.7", "272.4", "041.82", "557.0", "276.51", "401.9", "V45.81", "V10.83", "201.90", "V58.61", "V10.11", "562.11", "412", "452" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3235, 3241

1067, 2278

296, 303

3346, 3417

807, 1044

4538, 5479

703, 720

2467, 3212

3262, 3325

2304, 2444

3441, 4515

735, 788

241, 258

331, 462

484, 661

677, 687

63,619

134,917

25514

Discharge summary

report

Admission Date: [**2148-9-5**] Discharge Date: [**2148-9-10**] Date of Birth: [**2071-8-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4588**] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: 77 year old male with advanced COPD (3 1/2L at home), severe pulmonary hypertension, right sided heart failure with chronic leg edema, history of pulmonary embolism on coumadin who was admitted last Saturday to [**Hospital **] Hospital in NY after having large amounts of "hemoptsis". At the OSH, he had an EGD found to have shallow gastric ulcers and they took multiple biopsies. He received multiple blood transfusions, approx. 4 units. He was taken off coumadin/asa all week and discharged yesterday. Arrived back today, he had more vomiting (x2) at home with large amount bright red blood and large clots. He brought in about 150cc of bloody vomitus with him to the ED. . In the ED, initial vital signs were: T P 124 BP 83/51 R 18 O2 sat 92% 4L. NG lavage had 150cc of blood, then washed for additional 700cc and did not clear. NG tube placed. Patient was given pantoprazole, then placed on gtt. Has 2x18Gs, 1L fluid was given, getting 2 Unit of blood. He had brown melenatic stool from below, had guaiac positive. Last vs, P93 BP114/78 RR20 Sat97% 4L. GI will come and evaluate and scope, once get to floor. . On the floor, patient is alert and oriented, without any active signs of bleeding. . Review of systems: (+) Per HPI Positive: fatigue, melena, hematochezia, baseline shortness of breath Past Medical History: - [**5-5**] pulmonary embolus while in [**State 8449**] - 15 years ago episode of "Heart lining inflammation" for which he was hospitalized (per patient) - BPH - right inguinal hernia repair as a child - depression - basal cell skin cancer - atrial "arrhythmia", denies having AFIB - RBBB - Sleeps with an oxygen concentrator - coronary artery disease - Pulmonary hypertension - Aortic insufficiency - Hypertension - Depression - Obesity - COPD Social History: Married, retired bank president. Recently moved to [**Location (un) 63734**]in [**Location (un) 1456**], Mass. Prior regular ETOH use, but recently stopped altogether. Family History: Non-contributory Physical Exam: Vitals: T: 98 BP: 100/69 P: 92 R: 18 O2: 94% NC General: Alert, oriented, mild distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2148-9-5**] 12:15PM BLOOD WBC-7.6 RBC-3.27* Hgb-9.8* Hct-29.6* MCV-90 MCH-29.9 MCHC-33.0 RDW-14.4 Plt Ct-219 [**2148-9-6**] 02:10AM BLOOD WBC-6.5 RBC-3.23* Hgb-9.7* Hct-29.0* MCV-90 MCH-30.2 MCHC-33.6 RDW-15.0 Plt Ct-202 [**2148-9-7**] 02:52AM BLOOD WBC-6.2 RBC-3.14* Hgb-9.7* Hct-28.2* MCV-90 MCH-30.7 MCHC-34.2 RDW-14.9 Plt Ct-184 [**2148-9-8**] 06:37AM BLOOD WBC-5.6 RBC-2.98* Hgb-9.2* Hct-26.9* MCV-90 MCH-30.9 MCHC-34.2 RDW-14.8 Plt Ct-189 [**2148-9-9**] 06:50AM BLOOD WBC-5.4 RBC-3.08* Hgb-9.3* Hct-27.9* MCV-91 MCH-30.3 MCHC-33.5 RDW-14.9 Plt Ct-240 [**2148-9-5**] 12:15PM BLOOD Neuts-84.7* Lymphs-8.7* Monos-4.4 Eos-2.0 Baso-0.3 [**2148-9-5**] 12:15PM BLOOD PT-12.7 PTT-19.4* INR(PT)-1.1 [**2148-9-8**] 06:37AM BLOOD PT-13.0 PTT-23.5 INR(PT)-1.1 [**2148-9-5**] 12:15PM BLOOD Glucose-109* UreaN-45* Creat-1.7* Na-141 K-4.9 Cl-106 HCO3-26 AnGap-14 [**2148-9-6**] 02:10AM BLOOD Glucose-93 UreaN-62* Creat-1.6* Na-143 K-4.3 Cl-108 HCO3-30 AnGap-9 [**2148-9-7**] 02:52AM BLOOD Glucose-106* UreaN-54* Creat-1.5* Na-143 K-4.2 Cl-108 HCO3-31 AnGap-8 [**2148-9-8**] 06:37AM BLOOD Glucose-106* UreaN-45* Creat-1.3* Na-142 K-4.0 Cl-108 HCO3-30 AnGap-8 [**2148-9-9**] 06:50AM BLOOD Glucose-102* UreaN-35* Creat-1.3* Na-139 K-4.0 Cl-105 HCO3-28 AnGap-10 [**2148-9-5**] 12:15PM BLOOD ALT-16 AST-26 CK(CPK)-187 AlkPhos-40 [**2148-9-6**] 02:10AM BLOOD ALT-14 AST-17 CK(CPK)-99 AlkPhos-33* TotBili-0.7 [**2148-9-5**] 12:15PM BLOOD Phos-1.7* Mg-2.1 Imaging: CXR: The lungs are clear with no evidence of pneumonia. Cardiac silhouette remains moderately enlarged, but stable. Procedure: EGD: erosive gastritis and duodenitis. [**2148-9-7**] 02:52AM BLOOD Calcium-8.1* Phos-2.2* Mg-1.8 [**2148-9-9**] 06:50AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.9 Brief Hospital Course: # Upper GI bleed: Patient presented after two significant episodes of hemoptysis and was initially admitted to the medical ICU. He received a total of 6 units of pRBC during his ICU stay and his Hct stabilized ~28. He was kept on 8mg/hr pantoprazole drip, then transferred to 40 mg IV BID. His extensive home blood pressure medications including metolazone, metoprolol, torsemide, warfarin, aspirin, and ramipril were held. He was given erythromycin and an emergent EGD was performed in the ICU which showed erosive gastritis and duodenitis but no active bleeding. He had no further episodes of hematemesis or hemoptysis, with stable vital signs, and so was transferred to the medical floor. There, his Hct remained stable and he did not require any more transfusions. He was found to be positive for H. pylori and discharged with a 14 day dose of triple therapy with amoxicillin, clarithromycin, and omeprazole (the last of which he will continue). . # Pulmonary hypertension: His medications Ambrisentan and Sildenafil were initially held while his active GIB was managed. He was restarted on sidenafil at his home dose upon transfer to the floor. Patient has a chronic 3.5 L home oxygen at baseline but did not require more than 2L oxygen during this hospitalization with oxygen saturation >95%. On discharge, ambrisentan was discontinued after extensive discussion between his outpatient cardiologist, primary care physician, [**Name10 (NameIs) **] inpatient geriatrics attending. . # Hypertension/Cor Pulmonale: His medications including including metolazone, metoprolol, torsemide, and ramipril were initially held in the context of his GIB. His blood pressure remained stable, ranging from 90-110/65-75, with HR ranging 80-90s. This raised the question of whether patient needs his extensive medication regimen at baseline. After extensive discussion with his outpatient cardiologist, primary care physician, [**Name10 (NameIs) **] inpatient geriatrics attending, the decision was made to discharge him without his hypertensive medications. His primary care physician agreed to manage his hypertensive medications as an outpatient and followup appointment was made for 3 days after discharge. . # Benign prostatic hyperplasia: Initially, Tamsulosin was held for his acute GIB. It was restarted after patient was transferred to the medical floor. In the contect of his lowish blood pressure, the Geriatric attending decided, after consultation with patient's primary care physician, [**Name10 (NameIs) **] stop this medication. . Medications on Admission: Ambrisentan 10 mg daily metolazone 5 mg five days a week metoprolol succinate 100 mg daily torsemide 60mg once daily warfarin 3 mg or as directed daily aspirin 81 mg daily Zocor 20 mg daily Revatio 20 mg three times daily ramipril 10mg every other day Paxil CR 50 mg once a day Flomax 0.4 mg twice a day Spiriva 18 mcg 1 capsule inhalation [**Last Name (un) **] morning Mucinex 1,200 mg once a day as needed for congestion naproxen 220 mg by mouth twice daily as needed omega-3 fatty acids Zyrtec Tylenol prn Multivitamin Supplemental oxygen five or four liters continuous flow Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 2. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 14 days. Disp:*56 Tablet(s)* Refills:*0* 3. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours) for 14 days. Disp:*112 Capsule(s)* Refills:*0* 4. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*1 Cap(s)* Refills:*0* 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 7. Paroxetine HCl 20 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], you were admitted to the [**Hospital1 **] Hospital because you coughed up a large amount of blood on two different occasions. You were initially admitted to the medical intensive care unit, where they transfused you with 4 units of red blood cells. You had two esophagogastroduodenoscopy (EGD) which showed that you had erosive gastritis and duodenititis, which was the most likely source of your bleeding. We held your blood pressure lowering medications as well as blood thinners given that you had recently lost a lot of blood. Your primary care physician and outpatient cardiologist will work with you on restarting these medications. After one day in the intensive care unit, your blood cell count stablized and you were transferred to the regular medicine floor. There, we continued to monitor your blood count which remained stable and you did not require any further blood transfusions. Your blood pressure which is normally on the low side remained that way throughout the hospitalization. We did a blood test which showed that you have a chronic infeciton in the stomach by a bacteria called helicobacter pylori. You will be discharged with medication to treat that. The following changes were made to your medications: * These medications were stopped* 1. Ambrisentan 10 mg daily: this was stopped 2. Metolazone 5 mg five days a week: this was stopped 3. Metoprolol succinate 100 mg daily: this was stopped 4. Torsemide 60mg once daily: this was stopped 5. Warfarin 3 mg or as directed daily: this was stopped 6. Aspirin 81 mg daily: this was stopped 7. Ramipril 10mg every other day: this was stopped 8. Tamsulosin 0.4 mg twice a day: this was stopped 9. Omega-3 fatty acids: this was stopped *We added the following medications*: 1. Amoxicillin 1000 mg twice a day for 14 days 2. Clarithryomicin 500 mg twice a day for 14 days 3. Omeprazole 40 mg twice a day Followup Instructions: Department: GERONTOLOGY When: THURSDAY [**2148-9-12**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: ENDO SUITES When: THURSDAY [**2148-10-10**] at 9:30 AM Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2148-10-10**] at 9:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6925**],MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage Completed by:[**2148-9-10**]

[ "041.86", "424.1", "311", "414.01", "278.00", "496", "403.90", "V58.61", "416.8", "V12.51", "428.0", "285.1", "535.41", "585.9", "600.00", "535.60" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

8721, 8727

4683, 7220

328, 356

8786, 8786

2916, 4660

10871, 11660

2367, 2385

7848, 8698

8748, 8765

7246, 7825

8937, 10848

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1611, 1696

274, 290

384, 1592

8801, 8913

1718, 2165

2181, 2351

24,807

163,478

9843+9844

Discharge summary

report+report

Admission Date: [**2145-6-3**] Discharge Date:[**2145-6-7**] Date of Birth: [**2104-11-11**] Sex: F Service: [**Doctor Last Name **]-GREE CHIEF COMPLAINT: Pneumonia. HISTORY OF PRESENT ILLNESS: The patient is a 40 year old female with a past medical history of quadriplegia following C3-C4 spinal injury in [**2139**] status post MVA. She has anemia, osteomyelitis, GERD, depression, renal insufficiency for which she is on chronic steroids, multiple aspiration pneumonia, intubation five times in the last nine months. She is MRSA positive with penicillin and sulfa allergies. She was in her usual state of health prior to hospitalization when at 5:30 p.m. the patient was smoking outside. She called the hospital staff for shortness of breath. Patient wanted nasal suction for "jelly stuff." Patient was given neb treatment which increased her O2 sat to 89% which later fell to 87%. Patient was taken to [**Hospital1 190**] by ambulance. In the emergency room patient was given vanco, levo, Flagyl, hydrocortisone, multiple nebs with improvement in sats. Patient had sats of 89% in room air and 100% on 100% nonrebreather. Patient had increasing PCO2 blood gas 7.35, 49, 86. Subsequent blood gas 7.26, 65, 103. Patient intubated with purulent material rising through the tube. Patient received 6 liters of normal saline in the E.D. She had previous been admitted for aspiration pneumonia in [**2145-3-17**]. She was treated with vanc, levo and Flagyl. PHYSICAL EXAMINATION: Temperature was 96.5, blood pressure 123/90, heart rate 106, respirations 17, sating 100% with 7.5 ET tube. She had no JVD. Cardiac regular rate and rhythm. She was tachy, normal S1, S2. She had bilateral crackles. Abdomen had positive bowel sounds, soft, nontender. Extremities had multiple decubs, yeast and 2+ edema. LABORATORY DATA: White count 10.4, bandemia 17, hematocrit 40.1, platelets 119. All other labs were normal. UA has large blood, positive nitrites, pH 8, small leukocyte esterase, greater than 50 red blood cells, 20 white blood cells, moderate bacteria. Chest x-ray pertinent left lower lobe collapse versus consolidation, blunting of the left diaphragmatic angle, haziness at the right base, atelectasis, no effusion and no left catheter tip. EKG sinus tachy, normal intervals, axis, no ST-T changes. HOSPITAL COURSE: Patient was subsequently extubated on [**2145-6-5**] in the morning and patient did very well from then. Patient continued on levo, vanc and Flagyl until [**6-7**], day of discharge when levo and Flagyl were discontinued because culture came back MRSA positive sensitive to vancomycin. Blood cultures remained negative. Patient will need PFTs for questionable COPD and respiratory mechanics studied as an outpatient since this pneumonia might not be aspiration, but might be due to poor diaphragmatic and chest wall muscular function with C3-C4 quadriplegia. Patient probably has low respiratory reserve. Would also recommend that patient discontinue smoking stat. Infectious disease. Patient with pneumonia. Discussed cultures and previous antibiotics. Also gave nystatin powder. Cardiac. Patient was tachy. When we treated the pneumonia and gave fluids, patient was brady which is her normal state with C3-C4 quadriplegia. Neuro. Patient was sedated over the course of the stay with propofol because it is easily turned off. Propofol was discontinued on the 20th and patient was extubated as previous mentioned. Psych. At the time we just continued her outpatient psych meds. GI. Patient was given an aggressive bowel regimen with a large bowel movement on [**6-6**]. Renal. Patient has Foley with leaking around the Foley. Was evaluated by GU, but they wanted to do a dye study and the patient has sulfa allergy, so patient with continue with 30 French catheter Foley. Extremities. Patient has multiple decubs which were treated with wet to dry. Had wound care nurse evaluate. Patient was given frequent turns and First Step mattress was continued on an outpatient basis. Decubs are getting better. Pain. Patient was treated with Neurontin, Valium, oxycodone and morphine IV with continued outpatient pain. Endocrine. Patient was started on hydrocortisone for renal insufficiency. It was subsequently decreased. Will give outpatient dose as necessary. DISPOSITION: Patient is ready to go back to [**Hospital3 28354**]. CONDITION ON DISCHARGE: Patient is in stable condition. DISCHARGE STATUS: Patient is stable, ready for [**Hospital3 28354**], status post pneumonia. DISCHARGE DIAGNOSIS: Pneumonia. DISCHARGE MEDIAL: 1. Oxycodone 5 q.four. 2. Zinc. 3. Prednisone 5 mg p.o. q.day. 4. Scopolamine q.72 hours. 5. Albuterol. 6. Klonopin 0.05 b.i.d. 7. MS Contin 15 b.i.d. 8. Zoloft 25 q.day. 9. Iron 325 t.i.d. 10. Dulcolax and lactulose. 11. Prilosec 20 q.d. 12. Atrovent. 13. Estraderm 0.05 q.three days. 14. Baclofen 38 q.six hours. 15. Neurontin 900 t.i.d. 16. Reglan 10 q.d. 17. Ditropan 5 b.i.d. 18. Valium 5 b.i.d. Would also recommend for outpatient facility PFTs and ventilatory mechanics as an outpatient. Please emphasize once again that patient has had five intubations in nine months as a pertinent point. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Doctor Last Name 10188**] MEDQUIST36 D: [**2145-6-7**] 10:32 T: [**2145-6-7**] 10:40 JOB#: [**Job Number 33089**] RP [**2145-6-7**] cc:[**Hospital3 33090**] Admission Date: [**2145-6-3**] Discharge Date: Date of Birth: [**2104-11-11**] Sex: F Service: [**Doctor Last Name **]-GREE CHIEF COMPLAINT: Pneumonia. HISTORY OF PRESENT ILLNESS: The patient is a 40 year old female with a past medical history of quadriplegia following C3-C4 spinal injury in [**2139**] status post MVA. She has anemia, osteomyelitis, GERD, depression, renal insufficiency for which she is on chronic steroids, multiple aspiration pneumonia, intubation five times in the last nine months. She is MRSA positive with penicillin and sulfa allergies. She was in her usual state of health prior to hospitalization when at 5:30 p.m. the patient was smoking outside. She called the hospital staff for shortness of breath. Patient wanted nasal suction for "jelly stuff." Patient was given neb treatment which increased her O2 sat to 89% which later fell to 87%. Patient was taken to [**Hospital1 190**] by ambulance. In the emergency room patient was given vanco, levo, Flagyl, hydrocortisone, multiple nebs with improvement in sats. Patient had sats of 89% in room air and 100% on 100% nonrebreather. Patient had increasing PCO2 blood gas 7.35, 49, 86. Subsequent blood gas 7.26, 65, 103. Patient intubated with purulent material rising through the tube. Patient received 6 liters of normal saline in the E.D. She had previous been admitted for aspiration pneumonia in [**2145-3-17**]. She was treated with vanc, levo and Flagyl. PHYSICAL EXAMINATION: Temperature was 96.5, blood pressure 123/90, heart rate 106, respirations 17, sating 100% with 7.5 ET tube. She had no JVD. Cardiac regular rate and rhythm. She was tachy, normal S1, S2. She had bilateral crackles. Abdomen had positive bowel sounds, soft, nontender. Extremities had multiple decubs, yeast and 2+ edema. LABORATORY DATA: White count 10.4, bandemia 17, hematocrit 40.1, platelets 119. All other labs were normal. UA has large blood, positive nitrites, pH 8, small leukocyte esterase, greater than 50 red blood cells, 20 white blood cells, moderate bacteria. Chest x-ray pertinent left lower lobe collapse versus consolidation, blunting of the left diaphragmatic angle, haziness at the right base, atelectasis, no effusion and no left catheter tip. EKG sinus tachy, normal intervals, axis, no ST-T changes. HOSPITAL COURSE: Patient was subsequently extubated on [**2145-6-5**] in the morning and patient did very well from then. Patient continued on levo, vanc and Flagyl until [**6-7**], day of discharge when levo and Flagyl were discontinued because culture came back MRSA positive sensitive to vancomycin. Blood cultures remained negative. Patient will need PFTs for questionable COPD and respiratory mechanics studied as an outpatient since this pneumonia might not be aspiration, but might be due to poor diaphragmatic and chest wall muscular function with C3-C4 quadriplegia. Patient probably has low respiratory reserve. Would also recommend that patient discontinue smoking stat. Infectious disease. Patient with pneumonia. Discussed cultures and previous antibiotics. Also gave nystatin powder. Cardiac. Patient was tachy. When we treated the pneumonia and gave fluids, patient was brady which is her normal state with C3-C4 quadriplegia. Neuro. Patient was sedated over the course of the stay with propofol because it is easily turned off. Propofol was discontinued on the 20th and patient was extubated as previous mentioned. Psych. At the time we just continued her outpatient psych meds. GI. Patient was given an aggressive bowel regimen with a large bowel movement on [**6-6**]. Renal. Patient has Foley with leaking around the Foley. Was evaluated by GU, but they wanted to do a dye study and the patient has sulfa allergy, so patient with continue with 30 French catheter Foley. Extremities. Patient has multiple decubs which were treated with wet to dry. Had wound care nurse evaluate. Patient was given frequent turns and First Step mattress was continued on an outpatient basis. Decubs are getting better. Pain. Patient was treated with Neurontin, Valium, oxycodone and morphine IV with continued outpatient pain. Endocrine. Patient was started on hydrocortisone for renal insufficiency. It was subsequently decreased. Will give outpatient dose as necessary. DISPOSITION: Patient is ready to go back to [**Hospital3 28354**]. CONDITION ON DISCHARGE: Patient is in stable condition. DISCHARGE STATUS: Patient is stable, ready for [**Hospital3 28354**], status post pneumonia. DISCHARGE DIAGNOSIS: Pneumonia. DISCHARGE MEDIAL: 1. Oxycodone 5 q.four. 2. Zinc. 3. Prednisone 5 mg p.o. q.day. 4. Scopolamine q.72 hours. 5. Albuterol. 6. Klonopin 0.05 b.i.d. 7. MS Contin 15 b.i.d. 8. Zoloft 25 q.day. 9. Iron 325 t.i.d. 10. Dulcolax and lactulose. 11. Prilosec 20 q.d. 12. Atrovent. 13. Estraderm 0.05 q.three days. 14. Baclofen 38 q.six hours. 15. Neurontin 900 t.i.d. 16. Reglan 10 q.d. 17. Ditropan 5 b.i.d. 18. Valium 5 b.i.d. Would also recommend for outpatient facility PFTs and ventilatory mechanics as an outpatient. Please emphasize once again that patient has had five intubations in nine months as a pertinent point. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Doctor Last Name 10188**] MEDQUIST36 D: [**2145-6-7**] 10:32 T: [**2145-6-7**] 10:40 JOB#: [**Job Number 33089**] RP [**2145-6-7**] cc:[**Hospital3 33090**]

[ "507.0", "530.81", "255.4", "482.41", "496", "344.00", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

10094, 11013

7863, 9919

7014, 7845

5676, 5688

5717, 6991

9944, 10072

50,636

194,847

37257

Discharge summary

report

Admission Date: [**2168-2-15**] Discharge Date: [**2168-2-27**] Date of Birth: [**2096-5-4**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 106**] Chief Complaint: s/p PEA arrest Major Surgical or Invasive Procedure: Arctic Sun Induced Hypothermia Intubation Cardiac Catheterization History of Present Illness: 71-year-old female with a history of diabetes mellitus type II, hypertension, is transfered from outside hospital s/p cardiac arrest. . The patient was in her ususal state of health until 2 weeks prior to presentation. At that time she developed right leg weakness and numbness. She presented to [**Hospital6 33**] where she was evaluated at it was determined that she had compression of her spinal cord and needed a laminectomy. The patient was set to get the laminectomy and was getting sedated with fentanyl and versed when she developed chest pain. She had an EKG which showed inferior STEMI and she was taken to the catheterization lab instead. At that time she was found to have diffuse disease and had 3 BMS placed in her mid and distal left circumflex. Her peak CK was 452, MB 27.1 and Trop T 0.93 (per obtained labs). These downtrended and the patient was observed. The decision was made to withhold from spinal surgery for 6-weeks. On [**2168-2-15**] the patient was sent to rehabilitation. Per the family, she arrived at rehab and felt unwell. She initially had chills and then became very warm. She had episodes of nausea and some episodes of vomiting. She then collapsed at which point it is unclear if she was responsive or had a rhythm. An ambulance was called and she was taken to [**Hospital3 3583**]. En route the patient has ?PEA arrest which progressed to ?asystole. The patient received 4 rounds of CPR and epinephrine, atropine, calcium gluconate and apparently resumed a perfusing rhythm. The patient arrived at [**Hospital3 3583**] and was med-flighted to [**Hospital1 18**]. Past Medical History: 1. Hypertension 2. Diabetes mellitus type II 3. h/o right septic knee joint 4. h/o spinal stenosis 5. h/o right lower extremity weakness 6. L3-L4 disk herniation and spinal stenosis s/p lumbar laminectomy 7. multivessel coronary artery disease 8. recent STEMI s/p PCI to left circumflex x3 BMS 9. h/o Mobitz type II AV block 10. Parkinson's Disease 11. s/p total hip replacement Social History: Married, has 2 kids. -Tobacco history: Never -ETOH: Social -Illicit drugs: Never Family History: Diabetes in brother, father with lung cancer, no premature coronary artery disease Physical Exam: GENERAL: Intubated HEENT: 4mm dilated pupils, minimally reactive, no blink to stimulus NECK: JVP 8cm. CARDIAC: RR, normal S1, S2. II/VI SEM at RUSB. No thrills, lifts. No S3 or S4. LUNGS: Clear anterolaterally. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. Neuro: Unable to assess CNs. Pupils dilated, minimally reactive. PULSES: Right: DP dopplerable PT dopplerable Left: DP dopplerable PT dopplerable Pertinent Results: CARDIAC CATH (at OSH): [**2168-2-8**] LM nl Mid LAD 70% stenosis Distal LAD 80% stenosis 1st diagonal 100% stenosis Mid circumflex 99% stenosis - TIMI grade 1 flow Distal circumflex 99% stenosis - TIMI grade 1 flow 2nd obtuse marginal 70% stenosis Proximal RCA 90% stenosis Mid RCA 90% stenosis Right PDA 70% stenosis 3 BMS to mid and distal L circumflex lesion - improved to TIMI grade 3 flow -------- Portable TTE (Complete) Done [**2168-2-16**] at 8:43:26 AM FINAL The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the inferolateral wall, and the mid to distal anterolateral wall. The remaining segments contract normally. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild concentric left ventricular hypertrophy. Mild regional left ventricular dysfunction c/w CAD. Elevated estimated filling pressures. Mild pulmonary hypertension. Mild to moderate mitral regurgitation. Mild aortic stenosis. ------- CT HEAD W/O CONTRAST Study Date of [**2168-2-15**] 11:40 PM IMPRESSION: 1. No evidence of intracranial hemorrhage. 2. Slightly ill-defined [**Doctor Last Name 352**]-white differentiation, which may be technical. However, close interval followup is suggested ---- CHEST (PORTABLE AP) Study Date of [**2168-2-16**] 2:01 AM FINDINGS: In comparison with study of [**2-15**], there has been placement of an OG tube that extends well into the stomach. Endotracheal tube tip remains in good position. Extensive calcification is again seen in the mitral annulus. Opacification at the left base with obscuration of the hemidiaphragm is consistent with increasing atelectasis involving the left lower lobe. The right lung is essentially clear. ----- CHEST (PORTABLE AP) Study Date of [**2168-2-20**] 7:48 AM One view. Comparison with the previous study of [**2168-2-19**]. Bilateral pleural effusions and increased density at the left base consistent with atelectasis or consolidation persist. The heart and mediastinal structures are unchanged. A right internal jugular catheter remains in place. IMPRESSION: No significant notable change. ----- Cardiology Report Cardiac Cath Study Date of [**2168-2-22**] COMMENTS: 1. Selective coronary angiography of this co-dominant system demonstrated 2 vessel coronary artery disease. The LMCA was normal. The LAD had a 70% long proximal-mid lesion and an occluded diagonal. There was also diffuse distal LAD disease. The LCx had patent stents with jailed LPLs with slow flow. The RCA had a diffuse mid 90% lesion, and a small PDA. 2. Limited resting hemodynamics revealed moderate systemic hypertension of 154/81 mmHg. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Consult cardiac surgery regarding CABG vs. PCI ----- [**2168-2-15**] 10:00PM BLOOD WBC-18.8* RBC-2.94* Hgb-8.9* Hct-27.5* MCV-94 MCH-30.3 MCHC-32.4 RDW-14.7 Plt Ct-447* [**2168-2-23**] 04:14AM BLOOD WBC-9.7 RBC-2.84* Hgb-8.4* Hct-25.7* MCV-91 MCH-29.5 MCHC-32.6 RDW-15.3 Plt Ct-363 [**2168-2-15**] 10:00PM BLOOD Neuts-89.6* Lymphs-5.2* Monos-4.6 Eos-0.3 Baso-0.3 [**2168-2-15**] 10:00PM BLOOD PT-14.6* PTT-34.5 INR(PT)-1.3* [**2168-2-18**] 05:12AM BLOOD PT-13.4 PTT-59.4* INR(PT)-1.1 [**2168-2-22**] 03:04AM BLOOD PT-14.7* PTT-43.9* INR(PT)-1.3* [**2168-2-15**] 08:35PM BLOOD Glucose-156* UreaN-30* Creat-1.6* Na-134 K-5.1 Cl-100 HCO3-10* AnGap-29* [**2168-2-19**] 05:47AM BLOOD Glucose-164* UreaN-12 Creat-0.7 Na-137 K-3.9 Cl-104 HCO3-23 AnGap-14 [**2168-2-23**] 04:14AM BLOOD Glucose-142* UreaN-9 Creat-0.7 Na-135 K-4.0 Cl-99 HCO3-28 AnGap-12 [**2168-2-15**] 08:35PM BLOOD CK(CPK)-677* [**2168-2-16**] 05:33AM BLOOD CK(CPK)-1240* [**2168-2-16**] 12:29PM BLOOD CK(CPK)-1042* [**2168-2-16**] 11:15PM BLOOD CK(CPK)-704* [**2168-2-18**] 05:12AM BLOOD CK(CPK)-427* [**2168-2-15**] 08:35PM BLOOD cTropnT-0.50* [**2168-2-15**] 10:00PM BLOOD cTropnT-0.41* [**2168-2-16**] 12:29PM BLOOD CK-MB-35* MB Indx-3.4 cTropnT-0.95* [**2168-2-19**] 10:17AM BLOOD Vanco-14.4 [**2168-2-22**] 07:05AM BLOOD Vanco-23.9* [**2168-2-16**] 01:02PM BLOOD Type-ART Temp-33.5 pO2-77 pCO2-29* pH-7.46 calTCO2-21 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED [**2168-2-19**] 05:56PM BLOOD Type-ART pO2-92 pCO2-23* pH-7.50* calTCO2-19* Base XS--2 Intubat-NOT INTUBA [**2168-2-15**] 08:45PM BLOOD Glucose-150* Lactate-9.0* Na-136 K-5.1 Cl-104 calHCO3-13* [**2168-2-15**] 10:00PM BLOOD Glucose-164* Lactate-6.2* Na-134* K-5.3 Cl-104 calHCO3-17* [**2168-2-16**] 01:40AM BLOOD Lactate-2.5* [**2168-2-16**] 05:57AM BLOOD Glucose-209* Lactate-1.3 [**2168-2-18**] 01:00PM BLOOD Lactate-0.6 Brief Hospital Course: Ms. [**Known lastname **] is a 71-year-old female with a history of diabetes mellitus type II, hypertension, coronary artery disease who was transfered from an outside hospital s/p cardiac arrest. # s/p PEA arrest: Patient was intubated and hemodynamically stable when transferred. Her PEA arrest at the rehabilitation facility was of unclear etiology. She received 4 rounds of epinephrine. Upon arrival to [**Hospital1 18**], she was hemodynamically stable with MAPs>60, not requiring any pressors for support. She did have a few episodes of hypotension in the first couple of days of hospitalization, responsive to small fluid boluses. She was started on an induced hypothermia protocol on presentation, cooled for 24 hours, then was rewarmed. Per Arctic Sun protocol, Neurology team was following and a 24hr EEG was done. Head CT did not show any intracranial hemorrhage or any obvious lesions. She was also started on a heparin drip due to possibility of an in-stent thrombosis, which was considered because her arrest was about one week after her previous stent placement; however, her recovery was too rapid for this to be likely. Because of her known 3-vessel coronary artery disease, the patient had been considered for future potential CABG as an outpatient. After extubated and stable, a Cardiac Catheterization was done which did not show any signs of acute thrombosis/occlusion that could have led to an arrest. The patient's daughter also mentioned that she had some type of arrhythmia which may have included pauses or conduction system delays that led physicians at the outside hospital to believe that she may require a pacemaker. PEA arrest could have been secondary to an arrhythmia but no abnormalities were noted on telemetry during this hospitalization that would require a pacemaker. # MRSA Pneumonia: Patient was found to have MRSA in sputum on presentation with thick sputum while intubated. No clear consolidation was seen on CXR, though she was spiking fevers. She was treated with seven day course of vancomycin. Her fevers resolved with a normal WBC and there was no evidence of consolidation on chest x-ray although her cough persisted. # Coronary Artery Disease: Patient is s/p STEMI with cardiac catheterization with multivessel CAD s/p BMS x 3 to mid to distal L circumflex, placed at outside hospital on previous admission within a couple of weeks of this hospitalization. She underwent another Cardiac Catheterization with no intervention during this hospitalization after stabilized to confirm that PEA arrest was not secondary to an acute ischemic event. She will need to follow up as an outpatient with interventional cardiologist Dr. [**Last Name (STitle) **] and will be set up for percutaneous coronary intervention in the next couple of weeks to her other two diseased coronary arteries. During this hospitalization, she was continued on her aspirin, plavix, beta blocker and statin. # Acute Systolic Congestive Heart Failure: Patient was slightly volume overloaded on exam on presentation, likely from volume resusitation at outside hospital in setting of decreased EF 40-45% as on recent Echocardiogram. She was not diuresed initially in setting of possible sepsis secondary to pneumonia on presentation, but her fluid status normalized prior to discharge. # Diabetes mellitus type II: Patient's blood sugars were controlled with Humalog insulin sliding scale during hospitalization. She was restarted on oral medications per previous regimen. # Hypertension: Blood pressures were in 110s and stable on presentation and remained well controlled throughout hospitalization. She was started initially on captopril, which was then switched to her home lisinopril dosing. She was also continued on metoprolol for cardioprotection. # Spinal stenosis: The patient originally presented to the OSH for spinal stenosis. The surgery was delayed due to her chest pain and then cardiac arrest. She will undergo a PCI in a few weeks. Further management of her spinal stenosis is deferred to her PCP, [**Name10 (NameIs) **] cardiologist and neurosurgeon. She continues to have weakness and pain in her Right leg, in addition to bowel incontinence and bladder incontinence. Medications on Admission: 1. Valium 2.5mg PO q8H PRN 2. Glipizide 10mg PO BID 3. Lopressor 50mg PO TID 4. Lantus insulin 10 units qHS 5. Trazadone 25mg PO qHS 6. Zantac 150mg PO BID 7. Lipitor 80mg PO qHS 8. Lisinopril 5mg PO daily 9. Aspirin 325mg PO daily 10. Plavix 75mg PO daily 11. Humalog insulin 3units before breakfast 12. Sinemet 25/250 one tablet PO TID 13. Miralax 17g PO daily 14. Percocet 2gabs PO q4H PRN 15. Verapamil 240mg PO daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 9. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) vial Inhalation q4h () as needed for wheeze. 10. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold SBP < 100. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours). 15. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime. 18. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-5**] hours as needed for pain. 19. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Last Name (un) 57733**] - [**Location (un) 2203**] Discharge Diagnosis: Primary Diagnosis: PEA arrest Secondary Diagnoses: Coronary Artery Disease Pneumonia Hypertension Diabetes Mellitus Type II Discharge Condition: Mental Status: Clear and coherent Activity Status: Out of Bed with assistance to chair or wheelchair Mental Status: Clear and coherent Discharge Instructions: Dear Mrs. [**Known lastname **], You were admitted to the hospital after you had a cardiac arrest. We are still uncertain as to what caused your cardiac arrest, though we feel you did not have an acute heart attack. You did undergo another Cardiac Catheterization, during which we found your coronary arteries to have significant disease. At the other hospital, only one of your coronary arteries was stented. You will need to return in a couple of weeks to get the other arteries stented as well. You have an appt with Dr. [**Last Name (STitle) **] on [**3-25**] , and you will be scheduled for the procedure in a couple of weeks -- the Cardiac Catheterization lab will contact you. The following changes have been made to your medications: - Please START taking Gabapentin 300mg before bedtime - STOP taking Miralax, Verapamil and Valium - change the Metoprolol to long acting at 100 mg daily - You were started on Benzonatate and Guaifenesin as needed for your cough - You were started on colace and senna for bowel regulation - You can take Ipratropium and levalbuterol nebulizers if you have trouble breathing. - You are on Heparin shots to prevent blood clots. - we have agreed to stop your Sinemet for now as you have had no hand tremors while off this medicine in the hospital. - Omeprazole was discontinued, take Ranitidine twice daily instead. - Decrease lisinopril to 5 mg daily - Start Trazadone to help you sleep at night - Start percocet for left sided pain with coughing. - Start Aspirin and Plavix to help keep your coronary arteries open . Please seek medical attention if you experience any symptoms concerning to you. Followup Instructions: Please be sure to keep all of your follow-up appointments. Cardiology: the Interventional cardiology office will contact you about scheduling a catheterization in 2 weeks. . Primary Care: Please make an appt to see Dr. [**First Name (STitle) **] after you get out of rehabilitation.

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icd9cm

[ [ [] ] ]

[ "88.72", "37.22", "38.91", "96.71", "38.93", "96.6", "88.56", "99.81" ]

icd9pcs

[ [ [] ] ]

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8198, 12423

281, 348

14744, 14744

3040, 6263

16570, 16856

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196,654

18139

Discharge summary

report

Admission Date: [**2178-11-7**] Discharge Date: [**2178-11-23**] Date of Birth: [**2158-5-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: Found down, unresponsive Major Surgical or Invasive Procedure: Intubated in [**Hospital Unit Name 153**], CT Head History of Present Illness: HPI: 20 M with history of paraplegia s/p MVA [**2176**], transferred from OSH on [**11-7**] for pna, ARDS, bacteremia, rapid-antigen +influenza B. Being transferred from [**Hospital Unit Name 153**] to floor. . At OSH, patient was admitted [**11-3**] to [**Hospital **] Hospital for being found down, unresponsive, at home. Patient had fever, cough, severe SOB, purulent discharge from indwelling foley. Patient was found to have +tox screen for opiates, benzos, cannabinoids. . At OSH, [**11-3**] Urine cx was +Klebsiella, +[**Female First Name (un) 564**] (not albicans). [**11-4**] sputum cx was +MRSA, beta hemolytic Strep B, [**Female First Name (un) 564**] (not albicans). [**11-4**] blood cx +MRSA. He was antigen + for influenza B and negative for influenza A. . At [**Hospital1 18**] ED, patient was intubated, was found to have purulent sputum, was on dopamine briefly for hypotension. Patient was admitted to [**Hospital Unit Name 153**] from [**11-7**] to [**11-16**]. Patient was extubated [**11-14**], and transferred to floor on [**11-16**]. Past Medical History: PMH: Paraplegia s/p MVA in [**2176**] with C1 fracture and C2-T2 cord edema, s/p splenectomy for same. Social History: SH: Patient lived with mother up until 3 weeks ago and then moved in with father into basement apt. Father feels that he cannot handle patient medically. Tox screen + for BZ, opiates and cannabinoids. Family History: Noncontributory. Physical Exam: PE: 93 / 115/66 / 94% 6L Gen: NAD, lying supine in bed moving arms HEENT: Clear oropharynx, no LAD, supple neck, no thyroid masses Lungs: Poor inspiratory effort, diffuse rhonchi with end-expiratory wheezing L>R, on insuff/exsuff Heart: RRR, no m/r/g Abd: +BS, soft, ND, NT, scars on abd Sacral ulcers unknown Extr: Paraplegic LE, 2+ pitting edema to knees, L ankle ulcer Pertinent Results: [**2178-11-7**] 10:40PM TYPE-ART TEMP-37.8 RATES-/22 TIDAL VOL-550 PEEP-15 O2-70 PO2-77* PCO2-35 PH-7.46* TOTAL CO2-26 BASE XS-1 -ASSIST/CON INTUBATED-INTUBATED [**2178-11-7**] 07:52PM TYPE-ART TEMP-38.3 RATES-/18 TIDAL VOL-650 PEEP-12 O2-70 PO2-81* PCO2-34* PH-7.44 TOTAL CO2-24 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED [**2178-11-7**] 07:30PM GLUCOSE-105 UREA N-6 CREAT-0.5 SODIUM-144 POTASSIUM-3.2* CHLORIDE-108 TOTAL CO2-22 ANION GAP-17 [**2178-11-7**] 07:30PM ALT(SGPT)-129* AST(SGOT)-116* LD(LDH)-359* ALK PHOS-137* AMYLASE-44 TOT BILI-1.8* [**2178-11-7**] 07:30PM ALBUMIN-2.5* CALCIUM-8.1* PHOSPHATE-2.1*# MAGNESIUM-1.7 [**2178-11-7**] 07:30PM WBC-17.9*# RBC-4.17* HGB-12.1* HCT-35.0* MCV-84# MCH-29.0 MCHC-34.6 RDW-15.4 [**2178-11-7**] 07:30PM NEUTS-73* BANDS-2 LYMPHS-10* MONOS-2 EOS-9* BASOS-1 ATYPS-0 METAS-1* MYELOS-2* [**2178-11-7**] 07:30PM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL TARGET-OCCASIONAL TEARDROP-OCCASIONAL HOW-JOL-OCCASIONAL [**2178-11-7**] 07:30PM PLT COUNT-185# [**2178-11-7**] 07:30PM PT-12.8 PTT-31.0 INR(PT)-1.1 . CXR [**2178-11-7**]: There is poor visualization of the lines and tubes due to body habitus and technique of the exam. An endotracheal tube is present, with the tip terminating in the region of the superior aspect of the clavicles with the neck in apparently flexed position. Nasogastric tube and right subclavian vascular catheters are present, but their tips are not well visualized due to the factors listed above. The heart is mildly enlarged and there is upper zone vascular redistribution as well as widening of the vascular pedicle. This is associated with diffuse perihilar haziness. More confluent opacities are seen at the lung bases, right greater than left. IMPRESSION: 1. Endotracheal tube is slightly proximal in location particularly given flexed position of the patient's neck. This could be advanced several centimeters from more optimal placement as communicated to the clinical service caring for the patient. 2. Findings consistent with volume overload or congestive heart failure. 3. Asymmetrical basilar consolidation raises concern for underlying pneumonia. . CXR [**2178-11-8**]: IMPRESSION: 1. Endotracheal tube tip slightly proximal and could be advanced 1-2 cm for more optimal placement. 2. Persistent perihilar edema. 3. Slight improvement in more confluent basilar opacities, which may reflect dependent edema or other superimposed process such as aspiration or pneumonia. . RUQ US [**2178-11-8**]: LIMITED RIGHT UPPER QUADRANT ULTRASOUND: The study was limited secondary to the patient's large body habitus and inability to turn sideways. The gallbladder wall was not distended, and demonstrated no intraluminal stones or material. There was no gallbladder wall edema or pericholecystic fluid. There is no intrahepatic ductal dilatation. The liver demonstrated no focal mass lesions. The common bile duct and pancreas were obscured by overlying bowel gas, and were not completely visualized. IMPRESSION: The gallbladder was normal in appearance, without any associated intrahepatic ductal dilatation. There is limited evaluation of the CBD secondary to overlying bowel gas. The results were discussed with the covering house staff immediately after the study was performed. . CTA Chest [**2178-11-9**]: IMPRESSION: 1. Findings consistent with a small pulmonary embolism to the artery to the right lower lobe given limitations of this study. 2. Bilateral dependent consolidations. 3. Diffuse ground-glass opacities and thickened interlobular septae consistent with pulmonary edema or ARDS. 4. Mediastinal and hilar lymphadenopathy. . Echo [**2178-11-10**]: Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . EKG [**2178-11-12**]: Baseline artifact. Sinus tachycardia. Diffuse non-specific ST-T wave changes. Compared to the previous tracing tachycardia is new. . CXR [**2178-11-17**]: Right lower lobe atelectasis is minimally improved but still severe. Asymmetric interstitial pulmonary edema, favoring the left lung is unchanged. The heart is top normal size. There is no appreciable pleural effusion. Left PIC catheter tip projects over the superior cavoatrial junction. No pneumothorax. . CTA Chest [**2178-11-17**]: 1. No new areas of embolism identified. Persistent small pulmonary embolism to the artery to the right lower lobe. 2. Bilateral dependent consolidations, which are slightly improved compared to the prior study, particularly in the right lower lobe. 3. Unchanged mediastinal and hilar lymphadenopathy. 4. Retained secretions in the trachea. 4. Fatty infiltration of the liver. . KUB [**2178-11-20**]: FINDINGS: Comparison is made to prior examination dated [**2176-11-16**]. A single supine abdominal examination was obtained. There is no evidence for dilated bowel or obstruction. No significant amount of stool is identified. . CT Head [**2178-11-20**]: FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect, shift of normally midline structures, major vascular territorial infarcts. The [**Doctor Last Name 352**]-white matter differentiation is preserved. The density values of the brain parenchyma are within normal limits. The ventricles are of normal size. The imaging of the posterior fossa is limited due to hardware from occipital cervical fusion. No suspicious lytic bony lesions are seen. The visualized portions of the paranasal sinuses, are normally aerated. There is opacification of mastoid cells bilaterally due to fluid. IMPRESSION: 1. No evidence of acute intracranial pathology. 2. Opacification of bilateral mastoid air cells. Brief Hospital Course: Hospital Course: 20 M with PMH paraplegia s/p MVA [**2176**], being transferred from [**Hospital Unit Name 153**] to floor for resolving septic shock from MRSA bacteremia, ARDS, RLL MRSA/Pseudomonas pna, +influenza B. . ## RLL PNA (MRSA / Pseudomonas / GBS / [**Female First Name (un) 564**]), +influenza B: Patient had been found down and unresponsive and was brought to [**Hospital **] Hospital, where [**11-3**] Urine cx was positive for Klebsiella, [**Female First Name (un) 564**] (not albicans). [**11-4**] sputum cx was positive for MRSA, beta hemolytic Strep B, [**Female First Name (un) 564**] (not albicans). A [**11-4**] blood cx was positive for MRSA. He was antigen positive for influenza B and negative for influenza A. The patient was transferred to [**Hospital1 18**], where in the ED, the patient was intubated, was found to have purulent sputum, was on dopamine briefly for hypotension. The patient was admitted to [**Hospital Unit Name 153**] from [**11-7**] to [**11-16**]. . In the [**Hospital Unit Name 153**], the patient was on Vanc/Unasyn for MRSA pna and bacteremia. It was thought that the Strep and [**Female First Name (un) 564**] were likely colonizing organisms. Antibiotics were changed to Vanc/Levo/Flagyl due to cephalosporin allergy, an increase in serum eosinophils, and to help treat a Klebsiella positive UTI. This regimen was again changed to Vanc/Zosyn/Flagyl for T103.7 spike on hospital day 3, changed again to Vanc/Meropenem for Pseudomonas in bronchial washings on [**11-14**]. Blood cultures at [**Hospital1 18**] were all negative. In the [**Hospital Unit Name 153**], he was maintained on an inexsufflator TID with suctioning. The inexsufflator exerted alternating positive and negative pressure with breathing, to help eject mucus from bronchi. . The patient was extubated on [**11-14**] and did well in the [**Hospital Unit Name 153**]. He was transferred to the floor on [**11-16**]. The patient was continued on Vancomycin 1.5 IV Q8H for MRSA for a total 14 day course (start [**11-10**], end [**11-23**]) and Meropenem 1g Q8H (for ventilator-associated pna for Pseudomonal coverage) for a total 10 day course (start [**11-13**], end [**11-19**]). It was difficult to get the patient therapeutic on Vancomycin. The patient was weaned down to a 6L O2 requirement in the [**Hospital Unit Name 153**], and on the floor was continually weaned down from 6L O2 to room air for the last 2 days before discharge. . On the floor, the patient was triggered for desaturation to the 80's due to mucus plugging. The inexsufflator was the primary aid in recovering his saturations, and after ejection of much mucus, patient's saturations returned to 90s on 6L. As long as patient required > 2L O2, patient was maintained on inexsufflator [**Hospital1 **] to TID. On the last 3 days before discharge, patient no longer required inexsufflator. . CTA Chest showed ARDS, small RLL PE, mediastinal/hilar LAD. Placed on heparin drip for PE, started Coumadin [**11-16**]. Transaminitis was thought to be due to shock liver (hypotension in ED) and followed. Patient was transferred to the floor on [**11-16**] for resolving septic shock. . ## MRSA septic shock: On [**11-4**] at [**Hospital **] Hospital, the patient was found to have a blood culture positive for MRSA. At [**Hospital1 18**], he was hypotensive and required dopamine for proper perfusion. The patient was on Vancomycin 1.5 IV Q8H for MRSA for a total 14 day course (start [**11-10**], end [**11-23**]) and Meropenem 1g Q8H (for ventilator-associated pna for Pseudomonal coverage) for a total 10 day course (start [**11-13**], end [**11-19**]). Meds were administered through a picc in his L arm (placed [**11-15**]). The patient has a history of IV drug use, and could not be discharged with a picc line in place, and was kept in house for the last few days of Vancomycin administration. A TTE was negative for endocarditis, and blood cultures at [**Hospital1 18**] were all negative. . ## Transaminitis: The patient had a transaminitis thought to be due to shock liver from brief hypotension in the ED. A CT showed fatty liver, likely from a combination of alcohol and IVDU. . ## RLE DVT / RLL PE: The patient was found to have a RLL PE and ARDS on CTA Chest while in the [**Hospital Unit Name 153**]. On the floor, the patient was triggered for acute desaturation. CTA Chest at that time did not show another PE, and desaturation and tachycardia was attributed to mucus plugging. Patient was started on heparin gtt in the [**Hospital Unit Name 153**] and once therapeutic to INR 2.0 to 3.0, was maintained on Coumadin 5 mg PO QHS to be followed as an outpatient. Heme recommended a 6 month treatment on Coumadin for this paraplegic patient. . ## Reactive thrombocytosis: On the floor, the patient had plts up to 1130. Heme recommended no treatment, that aspirin was not required, and to continue to treat the cause of inflammation. The patient's plts continued to trend down for the last 2 days before discharge, to the 900's. . ## Sacral skin breakdown and L ankle ulcer: The patient had multiple areas of skin breakdown in the sacral area, and had a L ankle ulcer. He was kept on a [**Doctor First Name **]-air mattress and had dry sterile dressing with saline wash [**Hospital1 **] to TID. The sacral skin breakdown improved greatly during his admission, and the L ankle ulcer remained stable. . ## Insomnia: Patient had episodes of insomnia during admission. He was maintained on Valium and Ambien, but had tried Trazodone, Xanax and Haldol with periodic improvement. . ## Paraplegia: Patient has chronic LE discomfort, and was maintained on Baclofen and Neurontin per his home regimen. He was not given percocet or vicodin during his stay. . ## Illicit drug use: Patient was found to have +tox screen for opiates, benzos, cannabinoids. Patient was not allowed to leave with a picc line in L arm due to history of IVDU. The picc had been placed on [**11-15**]. Patient was counseled on drug addiction and abuse, as well as consequences of using such drugs with overlying pneumonia and paraplegic disposition. . ## Disposition: Family meeting agreement was that patient return to father's basement, where there is no handicap capability. It is an unfinished basement, not humidified, but patient was staunchly insistent on returning there, and refused any rehab facility despite communication over several days. He stated that he had not done well in a rehab in the past, and had had a long stay at rehab, and that he did not wish to return there again for now. Patient was at mother's home which was built to be entirely handicap capable, but patient had gotten into a fight with one of his mother's children, and he was not allowed back into his mother's house. Patient was discharged with inexsufflator therapy, and was told to use when he sensed mucus buildup or if he developed a cough. Medications on Admission: MEDS AT HOME: Macrobid 100 QD Senna tiweek Dulcolax tiweek Lexapro 10 mg po qd Alprazolam 2 mg po bid Ambien 10 mg po QOD (per OSH records) Diazepam 10 mg po qod Neurontin [**Age over 90 **] m gpo [**Hospital1 **] Baclofen 20 mg po tid Protonix 40 mg po qd Ditropan 10 mg po qd Clonidine 0.1 po BID . MEDS ON TRANSFER: Miconazole Nexium 40 q12 Lovenox 100 q12 Unasyn 300 q6 Fluconazole 400 qd Vanc 1500 q12 Bactroban Dry sterile dressings Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*56 Tablet(s)* Refills:*0* 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). Disp:*1 month supply* Refills:*2* 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*15 Tablet(s)* Refills:*0* 7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. Disp:*1 inhaler* Refills:*2* 8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:*1 inhaler* Refills:*2* 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). Disp:*30 Capsule(s)* Refills:*2* 10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 11. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*56 Tablet(s)* Refills:*2* 12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain in legs. Disp:*56 Tablet(s)* Refills:*5* 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal 3X/WEEK (MO,WE,FR). Disp:*90 Suppository(s)* Refills:*2* 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO 3X/WEEK (MO,WE,FR). Disp:*180 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 15. Inexsufflator 4x/day Sig: One (1) inexsufflator four times a day. Disp:*1 machine* Refills:*0* Discharge Disposition: Home With Service Facility: Personal Touch Home Care - [**Location (un) **], NH Discharge Diagnosis: Primary diagnosis: MRSA bacteremia, MRSA/Pseudomonas pneumonia Secondary diagnoses: RLL PE, paraplegia, splenectomy Discharge Condition: Good, no SOB, vitals stable, afebrile. Discharge Instructions: 1. Please return to the emergency room if you experience shortness of breath, fever, chills, chest pain, abdominal pain, nausea, vomiting. 2. Please take all medications as prescribed. Followup Instructions: 1. Make an appointment to see your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 50166**] [**Last Name (un) 50167**], [**Telephone/Fax (1) 50168**], on this Friday or as soon as possible to get your INR checked. Your most recent INR is 2.4 ([**11-23**]). Completed by:[**2178-11-27**]

[ "707.07", "038.11", "596.54", "518.5", "E929.0", "780.52", "112.4", "907.2", "995.92", "V09.0", "707.04", "570", "372.00", "304.70", "289.9", "996.64", "785.52", "415.19", "482.1", "286.7", "344.03", "487.0", "482.41" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

17889, 17971

8564, 8564

341, 394

18133, 18174

2286, 8541

18409, 18773

1854, 1872

15996, 17866

17992, 17992

15533, 15834

8581, 15507

18198, 18386

1887, 2267

18078, 18112

277, 303

422, 1489

18012, 18056

1511, 1617

1633, 1838

15852, 15973

15,720

123,368

25610

Discharge summary

report

Admission Date: [**2113-9-18**] Discharge Date: [**2113-9-23**] Date of Birth: [**2056-4-29**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion/+ETT Major Surgical or Invasive Procedure: CABGx3(LIMA->LAD, SVG->Ramus,SVG to PDA) [**2113-9-18**] History of Present Illness: Mr. [**Known lastname 16471**] states that he has has progressive dyspnea on exertion over the past few months. He denies any chest pain. An exercise tolerance test was positive. A cardiac catheterization was significant for three vessel disease and he was referred for CABG to Dr. [**Last Name (STitle) 1290**]. Past Medical History: Hypercholesterolemia Diabetes Nephrolithiasis HTN Anxiety Social History: Non smoker, no alcohol, cabinet maker. Lives with wife. Family History: Brother w/ CABG at age 56 Physical Exam: GEN: No acute distress CV: RRR, normal S1-S2., no murmur LUNGS: Clear EXT: No edema, no varicosities, warm with peripheral pulses ABD: Soft, NT/ND, NABS Pertinent Results: [**2113-9-20**] 06:55AM BLOOD WBC-11.5* RBC-3.67* Hgb-11.1* Hct-33.0* MCV-90 MCH-30.2 MCHC-33.6 RDW-13.5 Plt Ct-166 [**2113-9-22**] 07:20AM BLOOD PT-13.6* PTT-44.7* INR(PT)-1.2 [**2113-9-22**] 07:20AM BLOOD UreaN-15 Creat-0.8 K-4.4 [**2113-9-23**] 06:15AM BLOOD PT-18.5* PTT-64.9* INR(PT)-2.4 [**2113-9-20**] 06:55AM BLOOD Glucose-227* UreaN-13 Creat-0.9 Na-136 K-4.6 Cl-100 HCO3-26 AnGap-15 [**2113-9-20**] 06:55AM BLOOD Glucose-227* UreaN-13 Creat-0.9 Na-136 K-4.6 Cl-100 HCO3-26 AnGap-15 [**2113-9-23**] 06:15AM BLOOD Mg-1.8 [**2113-9-19**] 03:47AM BLOOD freeCa-1.21 Brief Hospital Course: Mr. [**Known lastname 16471**] was admitted to [**Hospital1 18**] on [**2113-9-18**] for surgical management of his coronary artery disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to three vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname 16471**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Aspirin and lopressor were started. He was then transferred to the cardiac surgical step down unit for further recovery. He was gently diuresed towards his preoperative weight. On postoperative day 2, Mr. [**Known lastname 16471**] developed atrial fibrillation for which amiodarone was started. Although he converted back into normal sinus rhythm, he continued to have episodes of paroxysmal atrial fibrillation and coumadin was started for anticoagulation. The physical therapy service was consulted for assistance with his postoperative strength and mobility. A persistent small, left apical pneumothorax was noted on chest x-ray and a repeat chest x-ray was obtained with his chest tube on water seal. This revealed a small left apical pneumothorax and there was no evidence of an air leak in his chest tube. His left chest tube was subsequently removed. Heparin was started as a bridge to coumadin as his INR was subtherapeutic. He also continued on plavix. Chest tubes were removed on the floor and pacing wires removed before INR was therapeutic. He remained on amiodarone and coumadin and INR on day of discharge was 2.4. He was instructed to take 1 mg of coumadin that evening at home. Discharge exam: 129/77, HR 88, t 99.0, 99% RA sat, RR 18, 91 kg. Discharged to home with VNA services. Medications on Admission: Glucophage 1000 mg [**Hospital1 **] Avandia 8 mg [**Hospital1 **] Glyburide Lantus 17 units qhs Crestor 10 mg daily Aspirin 81 mg daily Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days: Then decrease dose to 400 mg PO daily for 7 days, then decrease to 200 mg PO daily. Disp:*60 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 10. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*2* 11. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Insulin Glargine 100 unit/mL Solution Sig: Seventeen (17) units Subcutaneous at bedtime. Disp:*6 ml* Refills:*2* 13. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime for 2 days: Take as directed by Dr. [**Last Name (STitle) 37063**] for an INR goal of [**2-1**].5. Disp:*90 Tablet(s)* Refills:*0* 14. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO every 4-6 hours. Disp:*50 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: s/p CABG x3(LIMA->LAD,SVG->PDA,SVG->Ramus) hypertension Insulin dependent diabetes mellitus elev. ^chol, Anxiety, Nephrolithiasis, T+A Discharge Condition: good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds [**Last Name (NamePattern4) 2138**]p Instructions: [**Hospital 409**] clinic in 2 weeks Dr [**Last Name (Prefixes) **] in 4 weeks Dr [**Last Name (STitle) 37063**] in [**1-1**] weeks Dr. [**Last Name (STitle) 1295**] 2-3 weeks Completed by:[**2113-10-24**]

[ "300.00", "272.0", "250.00", "427.31", "401.9", "414.01", "997.1" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.11", "39.61" ]

icd9pcs

[ [ [] ] ]

5434, 5483

1684, 3350

303, 362

5662, 5669

1089, 1661

874, 901

3640, 5411

5504, 5641

3480, 3617

5693, 5847

5898, 6106

916, 1070

3366, 3454

239, 265

390, 704

726, 785

801, 858

26,220

196,422

43177

Discharge summary

report

Admission Date: [**2150-4-12**] Discharge Date: [**2150-4-16**] Date of Birth: [**2078-4-30**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 20128**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 93041**] is a 71 year-old woman with a history of COPD (FEV1 35% 03/09), with frequent exacerbations, on 2L home O2 and a history of diastolic dysfunction. She was recently discharged from [**Hospital3 **] on [**2150-4-12**] after treatment for a presumed COPD exacerbation. At one point she indicated that she did not have her medications at home and ran out of O2. (She later denied both of these statements.) She again became dyspneic and presented to the [**Hospital1 18**] ED. . She denies recent fever/chills, no LH/dizziness/CP/+occasional palp/-orthopnea/-URI symptoms, abdominal pain, +nausea/diarrhea this am, -vomiting, -brbpr/melena, -dysuria, -joint pains, -rash, -sick contacts. . In the [**Name (NI) **], pt was not hypoxic. Vital signs T 98.2 77 140/59 15 96% on BIPAP. She was given IV solumedrol, azithromycin, nebulizer treatments, morphine and zofran. Her respiratory status improved. She was considering being DNR. She was admitted to the MICU. Past Medical History: # Asthma ?????? Moderate Persistent - PFTs: [**2148-8-2**] FVC 65%, FEV1 44%, FEV1/FVC 68%, baseline SaO2 low 90s -Followed by Dr. [**Last Name (STitle) 575**] # Diastolic Dysfunction: Echo [**12-17**] showed hyperdynamic LV (80%), impaired relaxation. The pulmonary artery systolic pressure could not be determined, but commented as normal. - Stress [**2-/2138**] no ischemic changes, induced asthma by exercise. # GERD # Cerebral aneurysm repair # migraines # Osteopenia of the lumbar spine and femoral neck regions # Low back pain with bilateral radiculopathy as well as a history of myofascial pain syndrome and cervical radiculopathy Past Surgical History: # Incisional Hernia Repair # Cataract Surgery Social History: Lives with husband in [**Name (NI) 392**]. Has in-laws in area with whom she is close. Brother in [**Name (NI) 531**].15 pkyr smoking history, quit 20 years ago. No EtOH, illicits Family History: No history of cancer, heart disease, DM Physical Exam: gen-On bypap, cooperative, alert, NAD, speaking in [**1-13**] word sentences vitals-BP 145/62, HR 81, RR 23, sat 95% on Bypap 35% 8/6. HEENT-nc/at, PERRLA, EOMI, anicteric, MMM, neck-no JVD, no thyromeg, no LAD chest-b/l ae +diffuse expiratory wheezing b/l, no c/r heart-s1s2 rrr no m/r/g abd-+bs, soft, NT, ND ext-No c/c/e 2+pulses, +slight bluish discoloration b/l shins, without edema/erythema/rash. neuro-aaox3, CN 2-12 intact Pertinent Results: [**2150-4-12**] 12:36PM CK(CPK)-43 [**2150-4-12**] 12:36PM CK-MB-NotDone cTropnT-<0.01 [**2150-4-12**] 07:02AM LACTATE-1.4 [**2150-4-12**] 06:52AM CK(CPK)-57 [**2150-4-12**] 06:52AM CK-MB-NotDone cTropnT-<0.01 [**2150-4-12**] 01:15AM PLT COUNT-404 PLTCLM-1+ [**2150-4-12**] 01:15AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TARGET-1+ STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2150-4-12**] 01:15AM NEUTS-81* BANDS-2 LYMPHS-8* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-1* NUC RBCS-5* Brief Hospital Course: Pt is a 71 y.o female with h.o COPD (FEV1 .5L/35%), h.o diastolic dysfunction, GERD who presents with recurrent dyspnea after discharge from OSH for COPD exacerbation yesterday. . #Dyspnea/hypoxia: Patient has a history of COPD, with FEV1 35%. She was recently admitted and discharged earlier today from [**Hospital3 **] with COPD exacerbation. It was unclear exactly what propmted her respiratory decompensation and re-admission shortly after discharge. (The patient denied having run out of O2 or her medications at home.) Potential etiologies included persistent COPD exacerbation, URI/PNA, or volume overload. Other possible etiologies include PE, however no tachycardia/EKG changes, or [**Name (NI) 93044**] pt w/o CP/palp, so these were thought less likely. She initially required Bipap and was thus admitted to the ICU. . In the ICU, given the possibility of volume overload (elevated BNP, and echo with evidence of diastoic dysfunction) she was diuresed ~2L. For her COPD, she was given a dose of solumedrol followed by prednisone 30 mg daily and azithromycin. She was also given round-the-clock nebulizer treatments. Her O2 Sats were excellent on this regimen, although ABG did reveal significant CO2 retention. She was persistently afebrile. She was transferred from the ICU to the general medicine floor. . On the general medicine floor, her outpatient COPD regimen with the exception of theophylline was restarted (see below). Prednisone was continued at an increased dose of 30 mg daily. Her O2 Sats were 92-95% on 2L NC, which is apparently her baseline. Her volume status was continually evaluated. Given her metabolic alkalosis (which was beyond the compensatory amount expected for her chronic respiratory acidosis) and her physical examination, she was almost certainly dry. She remained net foluid even to slightly negative daily without diuretics. Her home O2 company was contact[**Name (NI) **] and verified that her equipment was working properly at home prior to discharge. She is discharged with another 2 week taper of prednisone back to the 10 mg daily she is on at baseline and an appointment with her pulmonologist later this month to guide further treatment. Calcium and vitamin D were started given prolonged steroid use. . #Leukocytosis: This was likely secondary to steroid use. She was afebrile, without cough, dysuria, fever/chills. Blood and urine cultures were persistantly negative. . #Nausea/LFT abnormalities: She intermittently complained of nausea and had an episode of vomitting. This was thought to be possibly due to theophylline, which was stopped. Concominantly, she developed slight right upper quadrant pain and a mild transaminitis of unclear etiology. RUQ ultrasound showed only fatty infiltration of the liver. Nausea improved, and LFTs trending down near the normal range. . #GERD: PPI was increased to [**Hospital1 **] to help with potential reflux contribution to reactive airway disease, as recommended in a recent note from her pulmonologist. . #Diabetes: Metformin was held initially given the recent contrast study at an outside hospital. She was covered with sliding scale insulin. Fingersticks were frequently elevated as high as 500 in the context of high-dose prednisone (30 mg). Metformin was restarted, with improvement in glucose control. The day of discharge, she was still having values as high as 300. She was encouraged to check her fingersticks twice daily and to call her PCP for values >400. Follow up was arranged with PCP for further titration of her diabetes regimen as the steroids are tapered. . #Hypertension: The patient did not carry a prior diagnosis of hypertension, but systolic BPs were in the 180s (in the context of 30 mg prednisone). Lisinopril was started and uptitrated to 10 mg daily, with SBP falling into the 140-150 range. . . The patient initially stated a desire to be DNR/DNI, but later conveyed clearly that she wished to be FULL CODE. Medications on Admission: Theophylline 300 mg Tab Oral 1 Tablet(s) Once Daily Nexium 40 mg Cap Oral 1 Capsule, Delayed Release(E.C.)(s) Once Daily Singulair 10 mg Tab Oral 1 Tablet(s) Once Daily Gabapentin 300 mg Tab Oral 1 Tablet(s) Once Daily Oxycodone -- Unknown Strength 1 Solution(s) Once Daily Pantoprazole -- Unknown Strength 1 Tablet, Delayed Release (E.C.)(s) Once Daily Prevacid 15 mg Cap Oral 1 Capsule, Delayed Release(E.C.)(s) Once Daily Ondansetron 4 mg Tab, Rapid Dissolve Oral 1 Tablet, Rapid Dissolve(s) Once Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 3. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Metformin 500 mg Tablet Sig: 1-2 Tablets PO asdir: 2 tablets qam, 1 tablet qpm. 8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). Disp:*30 Tablet, Chewable(s)* Refills:*0* 14. Prednisone 10 mg Tablet Sig: 1-3 Tablets PO asdir: Please take 3 tabs for one week, then 2 tabs for one week, then 1 tab daily ongoing. Disp:*60 Tablet(s)* Refills:*0* 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: primary: chronic obstructive pulmonary disease, acute exacerbation of chronic diastolic congestive heart failure secondary: gastroesophageal reflux disease Discharge Condition: stable Discharge Instructions: You came to the hospital because you were short of breath. You were treated for an exacerbation of your chronic obstructive pulmonary disease. You were in the intensive care unit for a day, and then you improved. You also had nausea and abnormal liver tests. These improved prior to discharge. The following medications were changed: lisinopril was started at 10 mg daily omeprazole was increased to 20 mg twice daily prednisone was increased calcium was started vitamin D was started theophylline was stopped Please call your doctor or return to the emergency room if you have worsening shortness of breath, chest pain, fevers, chills, or other symptoms that are concerning to you. Followup Instructions: Appointment #1 MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**] Specialty: Primary Care Date and time: [**4-28**] at 09:20am Location: [**Apartment Address(1) 65264**] Phone number: [**Telephone/Fax (1) 2205**] Appointment #2 MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**] Specialty: Pulmonary Date and time: [**5-6**] at 12:00pm Location: [**Hospital Ward Name 23**] [**Location (un) 436**] Phone number: [**Telephone/Fax (1) 612**] Special instructions if applicable: PFT's at 12pm followed by MD visit at 12:30pm. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 20129**] Completed by:[**2150-4-16**]

[ "428.33", "530.81", "787.02", "288.60", "401.9", "276.3", "493.22", "428.0", "E945.7", "346.90", "E932.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9574, 9631

3352, 7309

281, 287

9832, 9841

2760, 3329

10576, 11306

2252, 2293

7860, 9551

9652, 9811

7335, 7837

9865, 10553

1989, 2036

2308, 2741

234, 243

315, 1305

1327, 1966

2052, 2236

27,716

122,743

54326

Discharge summary

report

Admission Date: [**2196-10-19**] Discharge Date: [**2196-10-22**] Service: ORTHOPAEDICS Allergies: Morphine Attending:[**First Name3 (LF) 8587**] Chief Complaint: R hip pain Major Surgical or Invasive Procedure: [**2196-10-19**] R CMN for subtroch femoral fx [**2196-10-21**] exlap for ischemic bowel History of Present Illness: [**Age over 90 **]F who was living at home ran to answer the phone and fell on her right hip, sustaining a R subtrochanteric femur fx. She presents to [**Hospital1 18**] for surgical treatment. Past Medical History: HTN Afib hypothyroid s/p L hip fx, L THA remote MI PVD carotid bruit h/o 2/6 systolic murmur gout anxiety abdominal hernia Social History: lives alone in apt, takes elevator to 24th floor "very independent" per daughter remote [**Name2 (NI) **], no etoh originally from [**Country 111274**], immigrated to US in [**2148**] used to work at [**Doctor First Name 4049**] Fund - electromicroscopy Family History: unremarkable Physical Exam: ON ADMISSION [**2196-10-19**] VS 97.9 81 172/42 16 GCS 15 R upper thigh with significant lateral swelling, tenderness to palpation RLE shortened, externally rotated neurovascularly intact unable to assess R quad/TA otherwise 5/5 strength throughout palpable pulses bilaterally Pertinent Results: [**2196-10-19**] 01:20PM PLT COUNT-213 [**2196-10-19**] 01:20PM NEUTS-87.8* LYMPHS-7.9* MONOS-2.7 EOS-1.4 BASOS-0.2 [**2196-10-19**] 01:20PM WBC-13.7*# RBC-3.00* HGB-9.0* HCT-28.7* MCV-96 MCH-30.1 MCHC-31.5 RDW-14.7 [**2196-10-19**] 01:20PM estGFR-Using this [**2196-10-19**] 01:20PM GLUCOSE-140* UREA N-60* CREAT-1.5* SODIUM-144 POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-21* ANION GAP-17 [**2196-10-19**] 05:58PM PLT COUNT-207 [**2196-10-19**] 05:58PM WBC-14.0* RBC-2.32* HGB-6.9* HCT-22.6* MCV-97 MCH-29.8 MCHC-30.6* RDW-14.8 [**2196-10-19**] 05:58PM CALCIUM-8.8 PHOSPHATE-5.4*# MAGNESIUM-1.7 [**2196-10-19**] 05:58PM GLUCOSE-189* UREA N-55* CREAT-1.6* SODIUM-148* POTASSIUM-3.7 CHLORIDE-113* TOTAL CO2-20* ANION GAP-19 PELVIS (AP ONLY) [**2196-10-19**] 9:02 PM PELVIS (AP ONLY) Reason: s/p ORIF [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with R hip pain, s/p fall, foreshortened, externally rotated leg. REASON FOR THIS EXAMINATION: s/p ORIF AP VIEW OF THE PELVIS [**2196-10-19**] HISTORY: [**Age over 90 **]-year-old woman with right hip pain, status post fall, and "foreshortened" externally-rotated leg, status post ORIF. FINDINGS: Limited perioperative bedside AP examination with no comparisons on record, demonstrates numerous skin staples and subcutaneous emphysema in the soft tissues overlying the right hip, consistent with recent ORIF of displaced comminuted inter- and subtrochanteric fracture of the right proximal femur. There is an uncemented femoral fixation intramedullary nail (with distal portion not included) and helical blade through the proximal nail, transfixing the femoral head and neck, in grossly satisfactory position. Also noted is a left bipolar hip prosthesis with cemented femoral stem (distal tip, also not included) in overall satisfactory position. Also noted is diffuse osteopenia, apparent lower lumbosacral scoliosis with associated asymmetric degenerative changes, extensive vascular calcification and fecoloaded left colon, with air- filled rectum. LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT [**2196-10-19**] 4:30 PM HIP UNILAT MIN 2 VIEWS IN O.R.; LOWER EXTREMITY FLUORO WITHOUT Reason: IM HIP NAILING] HISTORY: _____ hip nailing. Fluoroscopic assistance provided to the surgeon in the OR, without the radiologist present. Five spot views obtained. These demonstrate portions of an intramedullary rod, with distal interlocking screw, superimposed over the femur, with evidence of a subtrochanteric femoral fracture. Correlation with real-time findings and, when appropriate, conventional radiographs, is recommended for full assessment. HIP UNILAT MIN 2 VIEWS RIGHT [**2196-10-19**] 1:54 PM HIP UNILAT MIN 2 VIEWS RIGHT Reason: assess for fx [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with R hip pain, s/p fall, foreshortened, externally rotated leg. REASON FOR THIS EXAMINATION: assess for fx PELVIS AND RIGHT HIP RADIOGRAPHIC SERIES PERFORMED ON [**2196-10-19**]. Comparison with a prior study from [**2189-1-15**]. CLINICAL HISTORY: [**Age over 90 **]-year-old woman with right hip pain, status post fall with foreshortened and externally rotated leg, evaluate for fracture. FINDINGS: AP view of the pelvis and two views of the right hip are obtained. An acute right proximal femoral fracture is noted with irregular margins, at a subtrochanteric loevel. The lesser trochanter is also fractured. Varus angulation of the femoral shaft is seen. The right femoral head is located. Loss of joint space is noted at the right hip joint. Left hip hemiarthroplasty is noted, with prosthesis appearing intact and in good position. Degenerative changes are noted in the lower lumbar spine, with associated scoliosis. SI joints appear unremarkable. Vascular calcification is noted. IMPRESSION: 1. Subtrochanteric fracture of the right proximal femur. 2. Left hip hemiarthroplasty hardware appears intact, though inferior aspect of the femoral stem is not included. 3. Degenerative changes in the lower lumbar spine. CHEST (PORTABLE AP) [**2196-10-21**] 1:58 PM CHEST (PORTABLE AP) Reason: acute process [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with acute abdomin REASON FOR THIS EXAMINATION: acute process HISTORY: Acute abdomen. COMPARISON: [**2196-10-1**]. FINDINGS: Single portable upright chest radiograph performed at 14:10 p.m. demonstrates increase in left small pleural effusion. A new right apical opacity and increasing left perihilar opacity are present, likely representing aspiration. There is no pneumothorax. Heart cannot be adequately evaluated. S-shaped scoliosis with degenerative changes are unchanged. The stomach is dilated. IMPRESSION: 1. Increase in small left pleural effusion. 2. Increase in left perihilar and new right apical opacities, likely representing aspiration. ABDOMEN (SUPINE & ERECT) PORT [**2196-10-21**] 1:31 PM ABDOMEN (SUPINE & ERECT) PORT Reason: acute process, free air [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with distended tender abdomen REASON FOR THIS EXAMINATION: acute process, free air HISTORY: [**Age over 90 **]-year-old female with distended tender abdomen concerning for acute intra-abdominal process including free intra-abdominal air. COMPARISON: Portable supine radiograph of the pelvis was performed on [**2196-10-19**]. FINDINGS: _____ view of the upper abdomen and a supine radiograph of the abdomen and pelvis show normal bowel gas pattern and no evidence of intra-abdominal free air. Quality of the examination is limited by technique. A moderate amount of stool is seen in the rectum and sigmoid colon. Again seen is a displaced comminuted inter- and sub-trochanteric fracture of the right proximal femur that is status post ORIF. There is subcutaneous emphysema seen in the right hip consistent with history of recent ORIF. Also noted is a left bipolar hip prosthesis. Diffuse vascular calcifications are seen. Scoliosis and degenerative changes are seen throughout the thoracic and lumbar spine. Osteopenia is again noted. IMPRESSION: Nonspecific bowel gas pattern with no evidence of free intraperitoneal air on this technically limited study. Moderate amount of stool is seen in the rectum and sigmoid colon. Brief Hospital Course: Briefly, Ms. [**Known lastname 111275**] was admitted to [**Hospital1 18**] after falling at home, suffering a R subtrochanteric femur fracture. She received a R cephalomedullary nail for this fracture by Dr. [**Last Name (STitle) **] of orthopaedic surgery on [**2196-10-19**]. Her postoperative course was complicated by hypovolemia and a reduced hematocrit for which she was transfused 2u pRBC and she was monitored on tele for Afib. On POD1 she was noted to have decreased urine output with a rising Cr, and geriatric medicine and renal were consulted. On POD2 pt was noted to have decreased mental status, cool extremities, and a distended and exquisitely tender abdomen. Renal and medicine consults were notified, pt was transferred to SICU, and general surgery was consulted for her abdominal pain. Given her constellation of symptoms, general surgery was concerned for mesenteric ischemia. After a cvl was placed, she was emergently taken to the OR with Dr. [**Last Name (STitle) **] of general surgery for an exploratory laparotomy which revealed grossly ischemic bowel with worsening lactate and acidosis. The family decided to make the patient CMO on [**2196-10-21**]. The pt was comfortable and she was pronounced dead by Dr. [**Last Name (STitle) **] on [**2196-10-22**] at 2:31am. The admitting office and the medical examiner were notified, and a report of death was submitted. Medications on Admission: allopurinol asa clonazepam lasix levoxyl lisinopril lovastatin metoprolol pravachol Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a

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icd9cm

[ [ [] ] ]

[ "79.35", "38.91", "38.93", "54.11", "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

9188, 9197

7621, 9025

233, 323

9249, 9259

1306, 2123

9311, 9317

980, 994

9160, 9165

6337, 6401

9218, 9228

9051, 9137

9283, 9288

1009, 1287

183, 195

6430, 7598

351, 547

569, 693

709, 964

22,549

188,535

52740

Discharge summary

report

Admission Date: [**2142-6-4**] Discharge Date: [**2142-6-15**] Service: MEDICINE Allergies: Codeine / Oxycodone Attending:[**First Name3 (LF) 2145**] Chief Complaint: Hypotension, diarrhea Major Surgical or Invasive Procedure: Arterial line History of Present Illness: 89 year old male with HTN, CHF (EF 40%), chronic aspiration, celiac sprue and recently diagnosed IgA nephropathy with hemodialysis initiation in [**3-12**] and subsequent transfer to a nursing home, who presents with a 2 weeks history of diarrhea, found to be hypotensive at rehab. . The patient states that he has been having diarrhea for the last week or so at rehab. He describes the diarrhea as soft stool (not entirely unusual for him given his celiac disease), about 7 or so times per 24 hours. He is not sure whether or not it is bloody. He has become progressively more fatigued over the week, but otherwise has been feeling well. He denies any fevers or chills, dysuria, cough, shortness of breath. . Of note, he had a recent hospitalization at [**Hospital1 18**] in [**3-12**] for acute on chronic renal failure at which time he was diagnosed with IgA nephropathy and started on HD. During this hospitalization he was diagnosed with C. Diff which was treated initially with flagyl, but later changed to PO vancomycin given concern that flagyl was contributing to mental status changes. He completed a course of treatment at this time, extended to last 5 days after completion of concurrent antibiotics for a pneumonia. He reports symptomatic improvement in the interim. . On arrival to the ED, vitals were 98.6, 112, 80/42, RR 20, 100% on RA. His blood pressure subsequently dropped to 69/39. He received 2L IVF while in the ED. A femoral line was attempted unsuccessfully. He received levofloxacin and flagyl. While in the ED he was noted to have 2-3 episodes of ventricular tachycardia on telemetry lasting about 15 seconds during which time he was asymptomatic. An EKG after the episodes demonstrated sinus tachycardia with T wave flattening throughout the precordium, no ST segment changes. 1st set of enzymes with troponin elevation, though normal CK. Patient denied any chest pain currently, or in the past. He was given ASA 325 mg x 1 and transferred to the MICU. Code confirmed as DNR/DNI. Past Medical History: 1) Hypertension 2) Biventricular CHF: Last echo [**3-12**]. LVEF 40%, with RV systolic function mildly depressed as well. Also with signs of diastolic dysfunction. 3) Gout 4) Chronic renal insufficiency with superimposed acute renal failure; renal biopsy in [**3-12**] with IgA nephropathy. Started on HD during hospitalization in [**3-12**]. 5) Celiac Sprue 6) History of aspiration pneumonia 7) History of MRSA pneumonia 8) History of Clostridium Difficile infection [**3-12**] 9) Anemia of chronic inflammation Social History: Patient currently living in a nursing home since last admission. Prior to this he was living at home with his wife and daughter in [**Name (NI) **], who helps take care of them. His wife is 86; they have been married for 59 years, and have 3 children, two of whom are in the area. He used to drink a drink or so per day; denies any heavy drinking, and hasn't drank in about a year. He used to smoke a PPD for many years, but quit 20 years ago. Denies IVDU. Family History: Non-contributory. Physical Exam: T 95.4, BP 60/22, HR 68, RR 15, 100% on RA. I/O: [**2136**]/0 in ED, 450 since arrival to MICU. Gen: Cachectic caucasian male, conversant, resting comfortably in bed. HEENT: Dry mucous membraines. Neck: Strong carotid upstrokes. JVP not elevated. Cor: RR, normal rate, no murmurs, rubs, or gallops, though heart sounds are distant. Lungs: Clear to auscultation bilaterally with decreased breath sounds at L base and dullness to percussion. Abd: Normoactive bowel sounds, soft, non-tender, non-distended. Groin: R groin with bandage in place, no bruit or hematoma. Extr: Extremities warm. No edema. Rectal: Per ED, guaiac negative. Pertinent Results: Admission laboratories: [**2142-6-4**] 06:45PM WBC-29.4*# RBC-3.90*# HGB-12.9*# HCT-42.8# MCV-110* MCH-32.9* MCHC-30.0* RDW-21.2* [**2142-6-4**] 06:45PM NEUTS-68 BANDS-27* LYMPHS-2* MONOS-0 EOS-2 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 . [**2142-6-4**] 06:45PM GLUCOSE-119* UREA N-31* CREAT-4.3*# SODIUM-144 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-26 ANION GAP-20 [**2142-6-4**] 06:45PM CALCIUM-8.3* PHOSPHATE-2.4*# MAGNESIUM-1.9 . [**2142-6-4**] 06:45PM PT-14.1* PTT-27.6 INR(PT)-1.3* . Discharge laboratories: [**2142-6-14**] 05:30AM BLOOD WBC-6.4 RBC-3.21* Hgb-10.5* Hct-33.1* MCV-103* MCH-32.6* MCHC-31.7 RDW-22.9* Plt Ct-134* . [**2142-6-14**] 05:30AM BLOOD Glucose-78 UreaN-35* Creat-3.2* Na-141 K-4.5 Cl-105 HCO3-27 AnGap-14 [**2142-6-12**] 06:10AM BLOOD Albumin-1.7* Calcium-7.5* Phos-3.3 Mg-2.1 . [**2142-6-12**] 06:10AM BLOOD PT-16.3* PTT-35.4* INR(PT)-1.5* . Culture Data: Blood cultures ([**6-4**] and [**6-6**]): negative Stool C Diff ([**6-5**], [**6-7**], and [**6-7**]): negative . [**2142-6-7**] 02:39AM STOOL CLOSTRIDIUM DIFFICILE TOXIN B ASSAY-DETECTED Brief Hospital Course: 1) Hypotension: On admission, there was clinical concern for sepsis given hypotension, leukocytosis, and hypothermia. He was covered empirically with broad spectrum antibiotics (vancomycin, levofloxacin, and metronidazole). However, cultures remained negative, and he responded promptly to aggressive fluid resuscitation. He was given IVF boluses to maintain a MAP > 55. By HD #[**2-9**], he was maintaining adequate blood pressures without fluid boluses. He completed a 7 day course of levofloxacin. Flagyl was changed to vanco po for tx of C diff. A cosyntropin stimulation test was normal. . 2) Diarrhea: Felt most likely from C. Diff colitis. He was started on empiric metronidazole on admission and stool samples sent for C Diff toxin assay. Toxin A assays returned negative x 3, and toxin B assay was sent. His diarrhea improved somewhat with empiric metronidazole therapy, but continued to persist. Despite negative laboratory data, there was high clinical suspicion for C Diff. Oral vancomycin was added for coverage of metronidazole resistant C Diff, with prompt response and near resolution of his diarrhea. C Diff tox B assay returned positive the day prior to discharge. By that time, he was having [**2-9**] semiformed bowel movements per day. . 4) Ventricular tachycardia: He had ventricular tachycardia in the ED, possibly secondary to chronic scar given biventricular failure. He had no signs of active ischemia. Troponin was chronically elevated and unreliable in setting of end stage renal disease, with a normal CK. He had no further ventricular tachycardia on telemetry. . 5) Atrial tachycardia: He had intermittent atrial tachycardia during his hospitalization, with a rate of around 100. He seemed to tolerate this well, without associated hypotension or symptoms. His outpatient regimen of low dose metoprolol was resumed prior to discharge. . 6) IgA nephropathy/ESRD: Dialysis was held for a number of days after admission as his electrolytes continued to remain within normal limits and he was not fluid overloaded even after aggressive fluid resuscitation. Dialysis was eventually resumed, with last session prior to discharge on [**6-14**]. He was continued on epogen 5000 units QHD and nephrocaps. Phosphate binders were held as his phosphate was low. . 7) CHF: He had a history of biventricular heart failure, both systolic and diastolic, therefore fluids were given judiciously initially. He continued to appear hypovolemic by exam, and never had any signs of fluid overload other than mild bipedal edema. . 8) Mixed Respiratory and Metabolic acidosis: He initially had what appeared to be an acute respiratory acidosis based on ABG, with additional metabolic AG acidosis (AG at 16, and expected much lower given last albumin 2.2), in part secondary to lactic acidosis, possibly also contribution of unmeasured anions in renal failure. It is unclear what caused his respiratory acidosis. His metabolic acidosis resolved with treatment of his sepsis and decrease in his lactate. . 9) Eosinophilia: He was noted to have a chronic eosinophilia. A cortisol level was checked to rule out Addison's Disease, which was normal. . 10) Chronic tophaceous gout: Continued on allopurinol. . 11) Celiac sprue: Continued a gluten-free diet and pancreatic enzyme replacement. . 12) Thrombocytopenia: Noted to have thrombocytopenia during the last hospitalization at which time a HIT antibody was negative. His thrombocytopenia was felt secondary to medications (though unclear which ones), and nadired at 51. During this hospitalization his platelets were in the low 100 range. It was noted that he has a concurrent anemia with elevated MCV (with normal B12), and large platelet forms. This could possibly represent myelodysplastic syndrome An outpatient hematology consult is something to consider should his blood counts worsen. . 13) Anemia: See above regarding possibile MDS. He was severely hemoconcentrated on admission with a hematocrit > 40, dropping to 30 the following day after aggressive IVF hydration. His hematocrit subsequently remained at around 33, which is near his baseline. . 14) Corneal ulcerations: Diagnosed with bilateral exposure keratopathy and corneal ulcerations by ophtho during last admission. Continued natural tears in house. . 15) FEN: He was advanced to a pureed, gluten free diet with thickened liquids once clinically stable. After a repeat swallow evaluation with video swallow study, he was advanced to thin liquids, but maintained on pureed solids. . 16) His code status was verified as DNR/DNI. . PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 26735**] ([**Telephone/Fax (1) 26736**]). Medications on Admission: Acetaminophen 500 mg Q6 hours Milk of Magnesia prn, bisacodyl prn Methylphenidate 10 mg PO QAM Pancrease 1 cap PO before meals TID Cyanocobalamin 500 mcg PO daily Allopurinol 100 mg PO QOD folic acid 1 mg PO daily Vitamin C 500 mg PO daily Calcium acetate 667 mg PO TID with meals Cholestyramine 1 packet PO Q 8 hours Chlorhexidine 30 mL? Ophthalmic lubricant 1 application OU daily Nephrocaps 1 tab PO daily metoprolol 12.5 mg PO TID Discharge Medications: 1. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 2. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Polyvinyl Alcohol 1.4 % Drops Sig: Two (2) Drop Ophthalmic DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 14 days. 10. Epoetin Alfa Injection 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Armenian Nursing & Rehabilitation Center - [**Location (un) 538**] Discharge Diagnosis: Clostridium Difficile Collitis Diarrhea Hypotension secondary to dehydration End stage renal disease on hemodialysis Chronic tophaceous gout Celiac sprue Exposure keratopathy Discharge Condition: Stable, resolved diarrhea, stable blood pressure Discharge Instructions: 1) Continue your medications as prescribed. - You were started on an antibiotic called vancomycin for an infection causing your diarrhea. Continue for 2 weeks. 2) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction: 1.5L 3) Follow up as directed below. 4) Call if you have worsened diarrhea, abdominal pain, lightheadedness, chest pain, shortness of breath, nausea, fevers, or any other concerns. Followup Instructions: Follow up with Dr [**Last Name (STitle) 26735**]. Call [**Telephone/Fax (1) 26736**] to schedule. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2142-6-15**]

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icd9cm

[ [ [] ] ]

[ "38.91", "39.95" ]

icd9pcs

[ [ [] ] ]

11209, 11302

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248, 263

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188,282

38459

Discharge summary

report

Admission Date: [**2150-6-13**] [**Month/Day/Year **] Date: [**2150-6-22**] Service: SURGERY Allergies: Levofloxacin / Penicillins Attending:[**First Name3 (LF) 598**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: Paravertebral block History of Present Illness: [**Age over 90 **] yo F s/p motr vehicle crash; was passenger in front seat unrestrained, +LOC, +airbag, patient per EMS rpeort was wedged into dashboard requiring extrication at scene. She was taken to an area hopsital and transferred to [**Hospital1 18**] for further care. Past Medical History: CHF, CAD, Afib, Dislipidemia, Aortic stenosis, Depression, Anxiety, Deverticulosis, GERD, PE, Angina, acute urinary retention Family History: Noncontributory Physical Exam: Upon presentation to [**Hospital1 18**]: CTAB RRR soft, NT, ND well healed midline incision rectal good tone guiac neg 2+ DP and PT pulses with 2+ radial pulses Neurological: MS-Alert and visually attentive to me. Oriented to "[**2150**]," [**Month (only) **] and hospital (not which one). Fluent speech. Names pen and watch. Repeats simple phrases. Follows three step commands. CN-Perrl 3 to 2mm bilaterally. VFF. EOM full. Smile symmetric. Tongue midline. No dysarthria or dysphonia. Motor-Normal tone, no drift. Arms appear to be full strength. Legs are at least 4+/5. There is some giveway weakness in the proximal L leg but this seems very related to pain. Coord-No dysmetria to FNF. DTRs-are slightly brisk, not necessarily pathologic. Toe down right. L toe is equivocal. Pertinent Results: [**2150-6-13**] 09:10PM GLUCOSE-131* UREA N-32* CREAT-1.0 SODIUM-140 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-29 ANION GAP-11 [**2150-6-13**] 09:10PM LIPASE-17 [**2150-6-13**] 09:10PM cTropnT-0.03* [**2150-6-13**] 09:10PM WBC-14.0* RBC-3.26* HGB-9.8* HCT-31.2* MCV-96 MCH-29.9 MCHC-31.3 RDW-13.9 [**2150-6-13**] 09:10PM PLT COUNT-268 [**2150-6-13**] 09:10PM PT-12.3 PTT-25.1 INR(PT)-1.0 IMAGING: CXR [**6-18**]:IMPRESSION: 1. Stable bilateral airspace opacities, in similar distribution and pattern compared to prior, worse at the right upper lobe. 2. Central line remains in place. 3. Improved appearance of the right costophrenic angle, with minimal blunting of the left costophrenic angle, stable, could be scarring. 4. No pneumothorax. 5. Stable bilateral rib fractures and incompletely evaluated sternal fracture. CT C/S [**6-13**]:IMPRESSION: 1. Type 3 dens fracture, essentially nondisplaced, with extension into left superior facet. Small associated hematoma, with no significant canal compromise. 2. Multilevel degenerative changes in the cervical spine. C5-C6 disc osteophyte complex with mild ventral canal encroachment (increased risk for cord injury). 3. Extensive biapical opacities and superior mediastinal lymphadenopathy, incompletely assessed on CT C-spine. For more details, refer to CT torso CT TORSO [**2150-6-13**]:IMPRESSION: 1. Bilateral rib fractures. 2. Bilateral focal opacities in the lungs. Given the distribution, a chronic condition such as sarcoid is suspected. Superimposed foci of contusion cannot be entirely excluded 3. Bilateral small pneumothoraces with signs of tension. 4. Mid-body sternal fracture, with small retrosternal hematoma. No pericardial effusion or CT evidence of cardiac contusion. 5. Superior endplate L4 compression fracture. 6. Possible L3 spinal process fracture. 7. Intramuscular hematoma at the right gluteus muscle with foci of active extravasation. 8. Possible cystic changes at the pancreatic head. Exophytic cyst off the uncinate process could be side branch IPMN. If indicated, finding can be further followed with MRI. Brief Hospital Course: She was admitted to the Trauma service and transferred to the trauma ICU for close monitoring. Neurosurgery was consulted for the Type II dens fracture which was managed non operatively. It is being recommended that she remain in a hard cervical collar for at least 6-8 weeks. She will follow up at that time for a repeat CT scan of her spine. She was also noted with multiple rib fractures requiring close respiratory monitoring. A paravertebral catheter was placed while in the ICU which provided some pain relief. The Acute Pain Service was consulted for assistance with managing her acute pain on top of her chronic pain issues. Several recommendations were made using adjunct therapy. She was evaluated by Speech for dysphagia and underwent a video swallow. She is being recommended for a soft diet with nectar pre-thickened liquids and 1:1 supervision with aspiration precautions. She was eventually transferred to the regular nursing unit where she progressed slowly. She was evaluated by Physical therapy and is being recommended for rehab after her acute hospital stay. Medications on Admission: Norvasc 5mg', ASA 81', Xenaderm 1 appbid, Celebrex 200', Colace 100mg", Lasix 80mg', Imbur 30', Lido patch daily, Toprol XL 25 ', Singulair 10', MVI', Protonix 40', Miralax 17 gram', Crestor19', Albuterol 1 pudd, Remeron 30mg', Oxycodone 10 "". Acetaminophen 325 q 4h, MOM 30 ml PRN, bisacodyl 10', Xanax 0.25bid, Prednisone 5 mg daily?, Mucinex 600mg', Ferrous sulfate 325bid, Duonebs [**Year (4 digits) **] Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation every six (6) hours. 3. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's Injection [**Hospital1 **] (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) Gram PO DAILY (Daily). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to affected areas. 14. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 15. Oxycodone 5 mg Tablet Sig: 2.5 Tablets PO Q4H (every 4 hours) as needed for pain. 16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). [**Hospital1 **] Disposition: Extended Care Facility: [**Male First Name (un) 4542**] of [**Location (un) 6981**] - [**Location (un) 6981**] [**Location (un) **] Diagnosis: s/p Motor vehicle crash Type III dens fracture Sternal fracture Small bilateral pneumothoraces Multiple right and left sided rib fractures L4 compression fracture L3 spinous process fracture Secondary diagnosis: Chronic pain syndrome [**Location (un) **] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. [**Location (un) **] Instructions: You were hospitalized following an auto crash where you sustained fractures of your spine and multiple rib fractures. Your injuries did not require any operations; you did however have a special catheter placed to deliver medications to help control your pain from your rib fractures. Cervical collar must be worn at all times until follow up with Dr. [**First Name (STitle) **]. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery for your rib fractures; call [**Telephone/Fax (1) 1669**] for an appointment. You will need an upright end expiratory xray for this appointment. Please call/or have the patient call ([**Telephone/Fax (1) 88**] to schedule a follow- up appointment in 6 weeks with Dr. [**First Name (STitle) **], Neruosurgery, with a Non-contrast CT scan of the cervical spine. Our office is located in the [**Hospital **] Medical Building, [**Last Name (NamePattern1) **], [**Location (un) 86**], [**Numeric Identifier 718**] [**Hospital Unit Name 12193**]. Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab; you or your family will need to call for an appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2150-7-15**]

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icd9cm

[ [ [] ] ]

[ "38.93", "05.31", "99.61" ]

icd9pcs

[ [ [] ] ]

3724, 4807

268, 289

1598, 3701

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761, 778

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205, 230

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44,214

145,522

1310

Discharge summary

report

Admission Date: [**2135-1-20**] Discharge Date: [**2135-1-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1936**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: none History of Present Illness: This is a 88 year-old male with a history of CAD s/p CABG [**2121**], CHF (EF: 25%), DM2, HTN, HL, a-fib who presents with dyspnea. . The patient was in his normal state of health until today when he complaned of SOB. He was at rehab and was given a neb, but continued to have worsening dyspnea. He denied any fevers, chills, cough, sputum, or abdominal pain, EMS was called to take the patient to the ED and O2 sats were in the high 80's per EMS. In the ED he was placed on NRB with initial vital signs 97.1 HR:64 BP:142/81 RR:36 O2:99%. He was then placed on BiPAP and vitals signs improved to HR:63 BP:120/64 RR:20 O2:100%. Labs were significant for a BNP: [**Numeric Identifier 8068**], trop:0.04, CK:36, WBC: 15.5, lactate 2.4 creatinine 1.4. The CXR showed mild vascular congestion, large left pleural effusion and ?opacity in the left base, likely atelectasis. He was given Vanco/levoflox/CTX for presumed pneumonia and albuterol/ipratropium nebs. He only received 150ml IVF and no lasix. . In the ICU the patient was continued on bipap and comfortable. He denied any fevers, chills, cough. He did report improved SOB. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: - CHF (EF 25% [**2132**]) - [**Company 1543**] Thera DDD pacer for sick sinus syndrome - Coronary artery disease s/p CABG '[**21**] w/ SVG-RCA-PDA, SVG-OM1, LIMA-LAD, and status post MI - Status post DDD pacer placement in [**2122-1-17**] for sinus arrest and bradycardia - History of prostate cancer status post XRT in [**2121**], status post prostatectomy. - Radiation cystitis with hematuria. - Hypertension. - Hypercholesterolemia. - Type II diabetes. - A.fib - Appendectomy Social History: The patient lives with his wife in [**Location (un) **] and has five sons and four daughters, who are extremely attentive. He retired at 68 years after working in textiles as an executive. He reports 6mo hx of tobacco, denies alcohol history recently. Family History: The patient has a brother who died of a myocardial infarction at age 63 years, and a mother with diabetes mellitus. Brother died of EtOH abuse. Physical Exam: Tcurrent: 36 ??????C (96.8 ??????F) HR: 60 (60 - 69) bpm BP: 127/65(81) {126/64(78) - 127/65(81)} mmHg RR: 29 (17 - 29) insp/min SpO2: 96% Heart rhythm: V Paced General Appearance: Well nourished, No acute distress, Anxious, on bipap Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic, dry MM Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : b/l , Bronchial: , Diminished: L>R) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, No(t) Tender: , Obese Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): x3, Movement: Purposeful, No(t) Sedated, Tone: Normal Pertinent Results: ================== ADMISSION LABS ================== [**2135-1-20**] 01:00AM BLOOD WBC-15.5*# RBC-3.82* Hgb-9.8* Hct-31.6* MCV-83 MCH-25.6* MCHC-30.9* RDW-18.4* Plt Ct-295 [**2135-1-20**] 01:00AM BLOOD Neuts-90.9* Lymphs-4.3* Monos-4.3 Eos-0.5 Baso-0.2 [**2135-1-20**] 01:00AM BLOOD PT-24.1* PTT-30.6 INR(PT)-2.3* [**2135-1-20**] 01:00AM BLOOD Glucose-190* UreaN-29* Creat-1.4* Na-142 K-4.3 Cl-100 HCO3-31 AnGap-15 [**2135-1-20**] 01:00AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 8068**]* [**2135-1-20**] 01:00AM BLOOD cTropnT-0.04* [**2135-1-20**] 01:00AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.0 [**2135-1-20**] 01:04AM BLOOD Lactate-2.4* K-4.4 ECHO ([**2135-1-20**]) The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 20-30 %) secondary to extensive severe inferior and posterior wall hypokinesis/akinesis, apical dyskinesis, and hypokinesis of all other segments with relatively preserved function of the basal segments. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with depressed free wall contractility. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The ascending aorta is moderately dilated. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) 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. CHEST X-RAY ([**2135-1-21**]) IMPRESSION: Mild pulmonary interstitial edema. Worsened, now large left pleural effusion and left basilar opacification with component of atelectasis, though pneumonia is not excluded. Read in conjunction with CT examination from [**2128**] which demonstrated concern possible left lower lobe lung mass, current radiograph is insensitive for confirmation, and correlation with interval imaging or a repeat CT examination can be performed as appropriate. [**2135-1-22**] CXR: FINDINGS As compared to the previous radiograph, the pre-existing basal opacity has completely cleared. The left basal opacity, however, is more dense than on the previous examination. There seems to be an element of volume loss, leading to slight displacement of the heart towards the left. The presence of a left pleural effusion cannot be excluded. The cardiac silhouette is of unchanged size. Unchanged position of sternal wires and pacemaker leads. Brief Hospital Course: Please see attending d/c letter for further details: below is summary by resident: . . This is a 88 year-old male with a history of CAD s/p CABG [**2121**], CHF (EF: 25%), DM2, HTN, HL, a-fib who presents with dyspnea. . #. ACUTE SYSTOLIC HEART FAILURE / DYSPNES: Pt with extensive cardiac history and last EF 25% likely secondary to ischemia. The patient has a markedly elevated BNP of [**Numeric Identifier 8068**] (prior value ~5000). Given his extensive cardiac history most likely etiology is CHF exacerbation, and during admission able to elucidate recent discontinuation of metolazone and drastic dose reductions in home furosemide, carvedilol and ACE-I. CXR showed large left pleural effusion and atelectasis vs consolidation in the left base. He does have leukcytosis and elevated lactate and received vanco/levo/CTX while more data was obtained, however all cultures remained negative and urine legionella antigen was negative; no leukocytosis or fever was observed. Patient was given BIPAP initially and diuresed gently to avoid acute kidney injury. Able to transition to supplemental oxygen without difficulty in MICU and patient was transferred to the floor for further management of his CHF exacerbation. Antibiotics were discontinued with exception of azithromycin (5 day course). He did well on the floor, tolerated physical therapy. He was continually diuresed and improved in O2 requirement. He was discharged in stable condition. . # DYSPHAGIA / ASPIRATION: After contacting [**Hospital1 **], it was communicated that there was high concern for aspiration and esophageal disorder. Speech therapy was consulted and video swallow with esophageal barium study were ordered. Patient was noted to have some aspiration however esophageal motility seemed grossly appropiate. Given aspiration unable to complete barium study, but aspiration precautions were intitated (chin tuck / multiple chews per bite / honey thickened fluids / pureed solids). . #. CAD s/p CABG [**2121**]: Pt with no evidence of active ischemia. Slightly elevated trop of 0.04 with flat CK. No ECG changes. Patient continued on ASA 81mg QD, lisinopril, and carvedilol / cont isosorbide mononitrate. Ruled out by enzymes for acute event. . #. CHF: Last ECHO showed EF 25% with severe hypokinesis. Pt likely volume overloaded as above. We adjusted medications of his diurietics and added metalozone. . #. A-fib: Patient with chronic atrial fibrillation, ? tachy/brady syndrome requiring permanent pace maker. Rate control achieved with carvedilol, we continued coumadin in house at a lower dose than his outpatient dose (as per daily INR value with a INR goal between [**1-19**]) . #. CKD: Pt creatinine 1.4 and at recent baseline (1.3-1.4). - cont to trend - avoid nephrotoxins and renally dose meds . # FEN: NPO while on BiPAP . # Access: PIV . # PPx: bowel regimen, H2, coumadin . # Code: DNR/DNI -confirmed with HCP . # Dispo: ICU . # Comm: [**First Name4 (NamePattern1) **] [**Name (NI) 8069**] (Son) [**Telephone/Fax (1) 8070**] Medications on Admission: LISINOPRIL 5mg daily CARVEDILOL - 3.125 mg [**Hospital1 **] FUROSEMIDE - 80mg daily GLYBURIDE - 10mg qam 7.5mg qpm ISOSORBIDE MONONITRATE - 10 mg daily PANTOPRAZOLE 20mg [**Hospital1 **] SIMVASTATIN - 10 mg daily WARFARIN SODIUM - 2.5MG/3MG alternating ASPIRIN - 81MG Tablet QOD LEXAPRO 10mg daily MULTIVITAMIN daily SENNA Percocet prn pain Lidoderm patch Reglan 5 mg PO 3x daily with meals ISS Trazodone 50mg Tab PO QHS PRN Ativan 0.5min 1 tab PO Q 8 H PRN Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO Q12 (). 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-18**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 16. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 17. insulin Insulin SC (per Insulin Flowsheet) Sliding Scale 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Dyspnea CAD s/p CABG [**2121**] CHF A-fib CKD DMII Hyperlipidemia Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You came to the hospital with shortness of breath. We found that you had diastolic congestive heart failure due to your recent medication changes. You were placed back on your medications to help with diuresis. You responded well to the medications and recovered appropriately. You were discharged in stable condition. Please note we made the following changes to your medications. STOPPED: Percocet prn pain - you were not in pain Lidoderm patch - you were not in pain GLYBURIDE - 10mg qam 7.5mg qpm - did not require in house ISOSORBIDE MONONITRATE - 10 mg daily - defer to restart in the future, you were placed on Metalozone for further diuresis, as your blood pressure is already within normal range, we did not feel that Isosorbide Mononitrate should be restarted at the time of your discharge. Reglan 5 mg PO 3x daily with meals - did not require in house ISS - due to blood glucose changes Trazodone 50mg Tab PO QHS PRN - did not require in house Ativan 0.5min 1 tab PO Q 8 H PRN - due to sedation effects WARFARIN SODIUM - 2.5MG/3MG alternating - due to supertherapeutic INR STARTED: 1. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. Please note you need to follow up with the following doctors. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2135-5-31**] 12:30

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

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283, 290

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195,600

30896

Discharge summary

report

Admission Date: [**2105-10-7**] Discharge Date: [**2105-10-15**] Date of Birth: [**2062-9-27**] Sex: F Service: MEDICINE Allergies: Penicillins / Vaccine/Toxoid Preps,Combo. Classifier / Morphine / Tegaderm / Keflex Attending:[**First Name3 (LF) 10323**] Chief Complaint: infection of L port site Major Surgical or Invasive Procedure: surgical drianage of fluid collection History of Present Illness: 43 yo with hx of breast CA s/p right mastectomy, met to liver s/p extended right hepatic lobectomy, hx left portacath infection s/p removal [**10-2**], presents with erythema at old port site, fevers, and left shoulder pain. Pt reports problems with original left port for quite some time. Was put on keflex 8 days ago but developed a rash on face and hands. Keflex d/c'd and port subsequently removed [**10-2**]. Rash on hands and face has not changed in the last week. Of note, she also had right sided port placed on [**10-2**]. Over last weekend, noted erythema at left site and left shoulder pain. This was evaluated yesterday at chemo infusion and was felt to be infected. She was given RX for cipro. However, today, erythema continued to extend, left shoulder pain worsened, and pt was hot/cold all day long. Of note, swab of old port site and port from [**10-2**] growing MSSA. She thus presented to ED. CXR unremarkable. Labs with WBC 1.1 with 85% polys. Given cefepime, tylenol, and dilaudid. Vitals stable but temp 100. She reports no acute reaction in ED to cefepime. Past Medical History: hypertension, cardiomyopathy secondary to chemotherapy, hypothyroidism, guillain-[**Location (un) **] syndrome at age 14 invasive ductal carcinoma s/p modified left radical mastectomy ([**5-18**]) with chemo and radiation [**3-20**]: right mastectomy (risk reducing) [**2105-7-10**]: extended right hepatic lobectomy for metastatic breast CA Social History: works as occupational therapist in the [**Location (un) 686**] Program for frail elders Family History: n/a Physical Exam: on admission: Vitals: 98.2, 117/80, 90, 20, 98% RA. Gen: Pleasant NAD. HEENT: No OP erythema or exudate. CV: RRR. No m/r/g. Chest: Left port site with erythema and warmth. Right port site c/d/i. Left shoulder very tender to touch, but no associated erythema. Pulm: Clear bilaterally. Abd: +BS. NTND. Ext: No c/c/e. Skin: Maculopapular rash on hands bilaterally and right side of face. Pertinent Results: [**2105-10-7**] 03:36AM GLUCOSE-112* UREA N-14 CREAT-0.6 SODIUM-138 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-26 ANION GAP-9 [**2105-10-7**] 03:36AM ALT(SGPT)-46* AST(SGOT)-45* ALK PHOS-136* TOT BILI-0.9 [**2105-10-7**] 03:36AM PHOSPHATE-2.5* MAGNESIUM-1.9 [**2105-10-7**] 03:36AM WBC-1.3* RBC-2.98* HGB-8.5* HCT-24.8* MCV-83 MCH-28.6 MCHC-34.4 RDW-17.5* [**2105-10-7**] 03:36AM NEUTS-72* BANDS-8* LYMPHS-14* MONOS-0 EOS-5* BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2105-10-7**] 03:36AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2105-10-7**] 03:36AM PLT SMR-NORMAL PLT COUNT-201 [**2105-10-6**] 10:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2105-10-6**] 10:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2105-10-6**] 10:35PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2105-10-6**] 10:25PM GLUCOSE-134* UREA N-16 CREAT-0.6 SODIUM-136 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-11 [**2105-10-6**] 10:25PM estGFR-Using this [**2105-10-6**] 10:25PM WBC-1.1*# RBC-3.07* HGB-8.7* HCT-25.4* MCV-83 MCH-28.4 MCHC-34.4 RDW-18.0* [**2105-10-6**] 10:25PM NEUTS-85* BANDS-1 LYMPHS-11* MONOS-2 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2105-10-6**] 10:25PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL BITE-OCCASIONAL [**2105-10-6**] 10:25PM PLT COUNT-207 Brief Hospital Course: 43 yo with hx of breast CA s/p right mastectomy, met to liver s/p extended right hepatic lobectomy, hx left portacath infection s/p removal [**10-2**], presents with erythema at old port site, fevers, and left shoulder pain. # L Port infection - Evidence on exam of infection at old port site. Pt had grown MSSA from swab of old port site on prior visit. US showed small fluid collection s/p surgical drainage with myositis but no obvious osteomyelitis. Echo: poor image quality but no evidence for endocarditis. Ortho attempted tap of left shoulder but was dry. MRI shoulder showed 1. Edema of the left pectoralis major and subclavius muscles subjacent to the site of portal removal, in keeping with myositis. 2. Edema in the medial clavicle is felt to be reactive in the setting of myositis. No drainable fluid collection. 3. Long head of the biceps tenosynovitis. 4. Mild infraspinatus tendinopathy. 5. Mild AC joint arthropathy. Wound cx from left port site showed coag + staph. Pt with allergy to PCN and keflex. Initially treated with vancomycin ([**Date range (1) 15975**]) but was spiking. Naficillin started on [**10-11**] after desensitization in [**Hospital Unit Name 153**] but stopped [**10-13**] due to suspicion for AIN. Started on daptomycin [**10-13**]. Erythema around port site resolved during hospital stay and patient was afebrile on daptomycin. Plan to continue IV daptomycin for 4 wks (continue until [**2105-11-5**]), repeat MRI shoulder at 3 weeks (approximately [**2105-10-29**]). Blood cultures pending at time of discharge. - . #Elevated Cr: Baseline 0.5-0.6; elevated up to 1.8 after naficillin desensitization. FeNa 0.7% Urine eos negative. Renal US: No evidence of hydronephrosis or renal vein thrombosis. Renal consulted and believe ARF due to AIN, recommend stopping naficillin and all other penicillins. Naficillin was stopped and Cr started to trend down. Will arrange for f/u of Cr after discharge . #Neutropenia: neutropenic on admission, likely secondary to chemotherapy. Neupogen started [**10-8**], stopped [**10-13**]. White count elevated secondary to neupogen at time of discharge. . #Breast Cancer: Abraxane Cycle #: 1 Day 1: [**2105-10-5**] Cycle end: [**2105-11-15**] Continued herceptin. . # Rash - Erythematous maculopapular rash on dorsum of hands bilaterally. Present on admission and resolved by time of discharge. Dermatology consulted and did biopsy. Per path, rash is reaction to Taxol. . # anemia: Transfused 1 unit. Likely secondary to chemotherapy. . # HTN - continued metoprolol. Held lisinopril given change in renal function . # Hypothyroid - continue dsynthroid. . Medications on Admission: Tylenol prn calcium cipfro 250 [**Hospital1 **] colace 100 [**Hospital1 **] vicodin 1-2 tabs q 4-6 hours levothyroxine 137 mcg qd lisinopril 40 qd lorazepam 0.5 - 1.0 q 8 hours metoprolol 100 qd mvi zofran prn sertraline 200 qd zocor 40 qd vitamin d statin Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 3. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 4. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for nausea/anxiety. 6. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**12-13**] Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. 8. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. daptomycin 500 mg Recon Soln Sig: Five [**Age over 90 11578**]y (580) mg Intravenous Q24H (every 24 hours) for 4 weeks: Continue until [**11-5**]. Disp:*[**Numeric Identifier 73089**] mg* Refills:*0* 10. Outpatient Lab Work Please check CK and Chem 10 once a week for 4 weeks while on Daptomycin. Please send results to: 1. [**Name6 (MD) 26**] [**Name8 (MD) 28**], RN [**Telephone/Fax (1) 22**] 2. [**Last Name (LF) **],[**First Name3 (LF) **] E. phone [**Telephone/Fax (1) 250**] Fax: [**Telephone/Fax (1) 4004**] [**University/College 73090**] 3. Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary: Infection of L port site Secondary: metastatic breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 73087**], It was a pleasure participating in your healthcare. You were admitted to [**Hospital1 69**] for infection of your old left port site. You were treated with antibiotics and pain control. You underwent surgical drainage of a small fluid collection. You were desensitized to naficillin in the ICU, but you developed a renal condition called acute interstitial nephritis so this antibiotic was discontinued. You were started on a different antibiotic called daptomycin. Please make the following changes to your medications: START Daptomycin 580 mg intravenous through your port once a day until [**11-5**] STOP Lisinopril (please discuss restarting this medication with your primary care physician in several weeks because your kidney function has not yet come back to normal) STOP Simvastatin Please continue your other home medications. Followup Instructions: The following appointments have been made for you: Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2105-10-19**] at 3:00 PM With: [**Name6 (MD) 26**] [**Name8 (MD) 28**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2105-10-26**] at 3:00 PM With: [**Name6 (MD) 26**] [**Name8 (MD) 28**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: INFECTIOUS DISEASE When: WEDNESDAY [**2105-10-28**] at 10:30 AM With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] Please also call and arrange to see your primary care physician in several weeks.

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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51482

Discharge summary

report

Admission Date: [**2100-11-2**] Discharge Date: [**2100-11-17**] Date of Birth: [**2044-8-21**] Sex: M Service: MEDICINE - [**Company 191**] firm CHIEF COMPLAINT: The patient was found down. HISTORY OF PRESENT ILLNESS: This is a 56 year old white male with a past medical history of seizure disorder on Tegretol and mental retardation among others. The patient was found down at home today by EMS. Per the patient's brother, the patient lives alone and the family periodically "checks in with him". No one has heard from the patient for three days so the EMS broke the door down. The patient was found down unconscious, covered in emesis as well as blood (question nosebleed). The patient was noted to have multiple abrasions over his body. Little is known about the patient's other history. He was admitted to [**Hospital1 336**] last week with a change in mental status. His mental status there was described as awake, alert, but minimally attentive. His course was complicated by an upper gastrointestinal bleed. Esophagogastroduodenoscopy showed severe erosive esophagitis, question of [**Female First Name (un) 564**], and small gastric polyps. The patient was discharged on Fluconazole, Tegretol, Prilosec, and Loperamide. Apparently, the patient's father died on [**Holiday 1451**] one year ago and the patient was depressed related to this. Many empty pill bottles were found next to him. The patient was brought to [**Hospital1 69**] Emergency Department where his GCS was 6 with oxygen saturation in the 80s. The patient was intubated. He was hemodynamically stable with blood pressure in the 120s and heart rate in the 90s. Left groin line was placed. Chest x-ray showed a right lower lobe pneumonia and bilateral apical opacities. CT of the head was negative. CT of the spine was negative for any cervical spine fractures. The patient was transferred to the Medical Intensive Care Unit for further evaluation and treatment. PAST MEDICAL HISTORY: 1. Mental retardation. 2. Hypertension. 3. Seizure disorder secondary to meningitis as a child. 4. Hypercholesterolemia. 5. Fecal incontinence. 6. Recent upper gastrointestinal bleed secondary to erosive esophagitis. 7. Status post coronary artery bypass graft in [**2094**]. 8. Atrial fibrillation. MEDICATIONS ON ADMISSION: 1. Tegretol. 2. Pravachol. 3. Atenolol. 4. Zantac. 5. Fluconazole ALLERGIES: No known drug allergies. FAMILY HISTORY: Non contributory. SOCIAL HISTORY: The patient denies alcohol or tobacco use. He lives alone in an apartment in [**Hospital1 8**], [**State 350**] and is able to care for himself. Once awake, he described how he takes the subway to see his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 102851**], at [**Hospital 14852**], and described how he gets there. He also reports that he walks to the grocery store and buys his own groceries. He keeps in close contact with a social worker, [**Name (NI) **] [**Name (NI) 12130**], that works in his building. His brother, [**Name (NI) **] [**Name (NI) 13304**], lives in [**Name (NI) 3844**] and checks in with the patient periodically. REVIEW OF SYSTEMS: Unknown. PHYSICAL EXAMINATION: Vital signs revealed blood pressure of 90/45, temperature maximum 102.4, heart rate 96 to 110, respiratory rate 16 to 21, oxygen saturation 95 to 98% on "many" liters of oxygen. General - The patient is not responsive but moving in athetotic pattern. Skin - multiple abrasions on bilateral lower extremities (DIP of all toes, lateral malleoli and dorsum of feet). No petechiae. No jaundice. Head, eyes, ears, nose and throat examination - The pupils are 2.0 millimeters and reactive bilaterally. Unable to assess extraocular movements. Bilateral periorbital erythema and edema. Right eye with subconjunctival hemorrhage superior to pupil. No Battle sign. Respiratory is clear to auscultation anteriorly. Examination limited due to the patient's unresponsiveness. Cardiovascular - regular rate and rhythm, no murmurs, rubs or gallops. Abdomen is soft, normoactive bowel sounds, nontender, nondistended, no organomegaly. Extremities - no cyanosis, clubbing or edema, pulses 2+ bilaterally. Abrasions on lateral malleoli bilaterally and dorsum of feet. Rectal is guaiac negative. Neurologically, the patient is moving all four extremities, withdraws to pain, no posturing, no corneal or gag reflex (but on Propofol). Toes downgoing. LABORATORY DATA: White blood cell count 17.6, hematocrit 34.3, platelets 364,000, neutrophils 71%, bands 18%, lymphocytes 6%. Urinalysis is nitrite positive, protein trace, bilirubin small, pH 5.0, blood negative, red blood cells 0 per high power field, white blood cells 0-2 per high power field, bacteria rare. Chem7 revealed sodium 141, potassium 4.4, chloride 105, bicarbonate 13, blood urea nitrogen 56, creatinine 4.2, glucose 100, anion gap 23. CPK [**Numeric Identifier 40281**], MB 91, index 0.8. Toxicology screen - Aspirin negative, ETOH negative, Tylenol negative, benzodiazepines negative, barbiturates negative, TCAs negative. Carbamazepine 33 ([**3-18**]). Electrocardiogram revealed normal sinus rhythm, PR interval 204 consistent with first degree AV block, left atrial enlargement, QRS 140, Q-Tc 450, peaked T waves, 1.0 to 2.[**Street Address(2) 27948**] elevation in V1, V2, but pattern is left bundle branch block, no T wave inversions, Q wave only in lead III. IMAGING STUDIES: CT of the head revealed cerebellar atrophy, mucosal thickening of maxillary and ethmoid sinus. CT spine revealed normal alignment of vertebra, no fractures, no subluxation, positive degenerative changes in C4-C5, C5-C6, C6-C7. Chest x-ray revealed hazy opacities in the bilateral apices and right lower lobe - ? aspiration. HOSPITAL COURSE: 1. Toxicology - The patient was noted to have elevated Carbamazepine levels. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from toxicology recommended charcoal for absorption of the toxin. Carbamazepine levels were monitored q3hours. Activated charcoal 30 grams were given at the time of arrival to the Medical Intensive Care Unit and three hours afterwards and need for further doses was evaluated in the a.m. after admission. The patient most likely had a Carbamazepine overdose (question intentional or confused or due to interaction with fluconazole, recently begun for candidiasis). The levels were reduced to therapeutic range with charcoal treatment and intravenous hydration. They were monitored for a couple days after that, however, remained in normal limits for the duration of the hospital course. 2. Cardiology - The patient had a new widening of the QRS on initial electrocardiogram and this was likely related to sodium channel blocking activity of Tegretol. One amp of bicarbonate was pushed and the electrocardiogram was rechecked. QRS prolongation resolved rapidly after the bicarbonate and resolution of the patient's acidemia. 3. Pulmonary - Due to the patient's findings on chest x-ray of right lower lobe and bilateral apical opacities, he was assumed to have suffered an aspiration event causing aspiration pneumonia. He was started on Levofloxacin 500 mg intravenously q.d. and Clindamycin 300 mg t.i.d. intravenously which was continued for fourteen days. While in the Medical Intensive Care Unit, he was kept on the ventilator with full support, however, once he improved, on [**2100-11-8**], he was extubated. No complications after extubation. The Levofloxacin and Clindamycin were continued for a fourteen day course and discontinued starting on [**2100-11-17**]. The patient's lung findings improved rapidly over the course of the stay and for the last six days he was clear to auscultation bilaterally with normal oxygen saturation and no signs or symptoms, i.e., cough. 4. Renal - Initially the patient's creatinine was increased to 4.2. He also had elevated creatinine kinase enzyme levels around 10,000. This was most likely rhabdomyolysis and resolved with hydration and bicarbonate and eventually the CKs trended downward. The elevated creatinine normalized within the first couple of days around [**2100-11-4**], and was postulated to be due to acute renal failure secondary to severe hydration. His decreased potassium was also suspected to be secondary to diarrhea, gastrointestinal losses. 5. Gastrointestinal - His recent gastrointestinal bleed at [**Hospital 14852**] secondary to erosive esophagitis prompted nasogastric tube lavage on admission in the Emergency Department which was clear. He was treated with intravenous Protonix for the duration of his hospital course up until discharge. Multiple Clostridium difficile toxin assays were sent which were negative. His abdominal examination continued to appear benign. 6. Neurology - The patient's altered mental status was likely secondary to the Tegretol overdose. His CT of the head was negative for any acute process. Cerebrospinal fluid cultures for HSV and urine toxicology screens were negative, not consistent with these as possible etiologies of altered mental status. The patient was also while intubated on Propofol and thus not allowing assessment of his current mental status. A few days later, a CT was done of the head again which showed minimal intraventricular and subarachnoid blood. Neurology recommendations included electroencephalogram and magnetic resonance scan to further workup altered mental status. Two lumbar punctures were also done, one at admission and one later on. Both were bloody with increased protein, however, CT of the head initially did not reveal an acute bleed. The repeat CT on [**2100-11-4**], is stated above. Neurology did not feel that these were large enough to be treated and thus would resolve on their own. Follow-up CT will need to be obtained one week after discharge. 7. Hematology - The patient's hematocrit was 34.3 on admission and dropped to 26.7 on hospital day number one. He was transfused with two units after which his hematocrit remained stable for the duration of the admission. 8. Trauma - He was seen by trauma surgery to be evaluated for cervical spine instability; they recommended that he be kept in a cervical collar even though he had no fracture, since ligamentous injury was not ruled out at the time. Later on in the course of the hospitalization when he was moved to the floor, flexion and extension spine films were done and approved by neurosurgery as clear and thus the collar was removed. He will follow-up with neurosurgery a week or two after discharge when he will be reevaluated with flexion and extension films as well as a head CT to follow his subarachnoid blood and intraventricular blood seen on CT of the head on [**2100-11-4**]. 9. Dermatology - The patient was also seen by dermatology while in the Medical Intensive Care Unit for his multiple abrasions on bilateral malleoli and forehead. Initially, it was felt that these may be trauma induced erosions versus herpetic erosions. DFA for HSV type I and type II as well as ZBZ were negative except for an HSV type I DFA which was positive. All other cultures of the wound were negative and Acyclovir, which was started empirically when dermatology first saw him for HSV, was discontinued when these cultures and DFA came back negative. These abrasions were treated with Bacitracin Ointment and wound dressing changes b.i.d. 10. Psychiatry - While in the Medical Intensive Care Unit, the patient was also seen by psychiatry who was unable to fully evaluate him while he was sedated. They recommended an electroencephalogram and magnetic resonance scan to evaluate mental status if this did not improve once he was extubated. They also were questioning the fact that his Carbamazepine level of 33 implied overingestion, suggesting possible assault or possible suicide attempt. The hypothesis that was generated was that perhaps the patient had a seizure and overdosed with Tegretol during postictal confusion. Later on in the hospitalization, they revisited the patient when he was alert, awake and oriented. The patient disclosed that he had had a seizure on the day of admission. He did not know anything about the overingestion of the Tegretol, however, he did deny assault or suicidal attempts. At the time of discharge, the patient was not considered to have any psychiatric issues as he was cheerful and responsive to questions. The psychiatry team felt that it was reasonable that he was going to be discharged to a temporary rehabilitation facility prior to returning home to care for himself. 11. Hospital floor course - The patient was extubated on [**2100-11-8**], and moved to the floor on [**2100-11-9**]. His respiratory status was stable and oxygen was in the process of being weaned. His issues of Tegretol overdose as well as rhabdomyolysis were resolved and levels of Tegretol as well as CKs were trending downward towards normal limits. As aspiration pneumonia continued to be treated with Levofloxacin and Clindamycin for a fourteen day course. The patient continued to improve respiratory wise with good oxygen saturation, good respiratory rate and clear lung examination. Neurology: he had a repeat head CT done on the day of transfer from the Medical Intensive Care Unit to the floor which was not different from the [**2100-11-4**] study and was notable for perhaps a slightly larger bleed ("subdural fluid collection"). It was decided that a repeat CT would be done one to two weeks after discharge when following up with neurosurgery unless there was significant clinical deterioration. During his continued hospital course, he had no neurological deficits, no signs of central nervous system infection. Magnetic resonance scan and electroencephalogram were postponed as the patient's mental status continued to improve progressively and once he was awake, was alert and oriented times three. Eventually as stated previously, his cervical collar was removed once he was clinically cleared with extension and flexion cervical spine films. He was continued on Lopresor 100 mg b.i.d. for his hypertension and was switched to Atenolol 100 mg q.d. on discharge. Nutrition - The patient had a nasogastric tube in since the Medical Intensive Care Unit stay and due to aspiration pneumonia history as well as neck instability, tube feeds were started on this patient two days after he reached the floor in efforts to give him nutrition. Swallow specialist was consulted. For the first couple of days, he failed the swallow studies with signs and symptoms of aspiration upon taking thin liquids. Eventually, he did better with liquids and was started on soft solids and thick liquids. This continued to be his diet upon discharge. He remains on aspiration precautions. His hematocrit remained stable during his hospital floor course and his abrasions on his extremities continued to be treated with Bacitracin Ointment application to the wounds with dressing changes twice a day. Of note, the patient's brother visited him once during his Medical Intensive Care Unit stay at which time he was unable to talk to the patient. His brother visited one more time while he was on the floor. He described the patient was slowly returning to his baseline and at baseline the patient talks and is fully functional, transports himself around the city, and is very meticulous about his medication regimen by taking the right amount at the right time, never over or under. DISPOSITION: To subacute/acute rehabilitation facility until function returns to baseline. [**Hospital **] [**Hospital **] Rehab - [**Telephone/Fax (1) 106748**]. PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. [**Last Name (STitle) 102851**] ([**Hospital1 336**]) [**Telephone/Fax (1) 106749**] CONDITION ON DISCHARGE: Stable. MEDICATIONS ON DISCHARGE: 1. Tegretol 200 mg p.o. t.i.d. 2. Atenolol 100 mg p.o. q.d. 3. Bacitracin Ointment apply b.i.d. to wounds. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 4814**] Dictated By:[**Name8 (MD) 106750**] MEDQUIST36 D: [**2100-11-16**] 16:36 T: [**2100-11-16**] 16:49 JOB#: [**Job Number 40852**]

[ "966.3", "319", "E980.4", "401.9", "V45.81", "272.0", "780.39", "728.89", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "03.31", "96.72" ]

icd9pcs

[ [ [] ] ]

2463, 2482

15914, 16258

2336, 2446

5826, 15854

3232, 5464

3199, 3209

184, 213

242, 1979

2001, 2310

2498, 3179

15879, 15888

5482, 5809

60,234

195,850

37116

Discharge summary

report

Admission Date: [**2141-2-22**] Discharge Date: [**2141-3-3**] Date of Birth: [**2087-5-23**] Sex: F Service: SURGERY Allergies: Bee Sting Kit / Percocet Attending:[**First Name3 (LF) 1481**] Chief Complaint: esophageal high-grade dysphagia Major Surgical or Invasive Procedure: [**2141-2-22**] minimally invasive esophagectomy History of Present Illness: Patient has a history of Barrett's esophagus with dysplasia, treated with three rounds of ablative therapy. She has had a recent endoscopy in [**Month (only) 404**] after an ablation in [**Month (only) 359**]. At this time, Barrett's ulcers were seen. Biopsies were done. Multifocal high-grade dysplasia was seen at 28 cm. Other biopsies did show Barrett's esophagus with either no dysplasia or low-grade dysplasia. Otherwise, she has been feeling the same and still has some reflux-type symptoms. Past Medical History: PMHx: GERD, Hypothyroidism PSHx: tonsillectomy, hysterectomy, wisdom teeth removal, and dental implants. Social History: She drinks alcohol occasionally. She has smoked approximately half a pack of cigarettes a day for over 20 years. Family History: Family History is notable for father with heart disease and paternal grandmother with diabetes and a maternal aunt with ovarian cancer. Physical Exam: Post-op Pertinent Results: [**2141-2-27**] UGI study: Barium passes freely through the proximal anastomotic site without evidence of hold up or leak. There is slight hold up of contrast at the distal end, just below the diaphragm, without evidence of leak. [**2141-2-27**] CXR: No evidence of pneumothorax status post chest tube removal. Stable small bilateral pleural effusions. [**2141-2-22**] 06:19PM BLOOD Hct-34.4* [**2141-2-23**] 01:25AM BLOOD WBC-12.8* RBC-3.47* Hgb-10.9* Hct-32.0* MCV-92 MCH-31.5 MCHC-34.2 RDW-13.4 Plt Ct-218 [**2141-2-24**] 01:04AM BLOOD WBC-12.6* RBC-3.17* Hgb-10.7* Hct-30.0* MCV-95 MCH-33.6* MCHC-35.5* RDW-13.8 Plt Ct-176 [**2141-2-25**] 07:05AM BLOOD WBC-10.0 RBC-3.17* Hgb-10.0* Hct-29.8* MCV-94 MCH-31.4 MCHC-33.5 RDW-13.3 Plt Ct-173 [**2141-2-27**] 06:29AM BLOOD WBC-8.7 RBC-3.33* Hgb-10.4* Hct-30.6* MCV-92 MCH-31.2 MCHC-34.0 RDW-13.2 Plt Ct-238 [**2141-2-27**] 01:05PM BLOOD TSH-7.0* [**2141-2-27**] 01:05PM BLOOD T4-7.3 T3-50* [**2141-2-22**] pathology: 1. Barrett's esophagus with multifocal high grade dysplasia. No invasive carcinoma seen. 2. Proximal and distal margins free of dysplasia. Proximal epithelial margin is squamous type, distal epithelial margin is gastric body type. 3. 6 lymph nodes with no evidence of malignancy. Brief Hospital Course: Patient was admitted [**2141-2-22**] for surgery by Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **]. Please refer to their respective operative notes for details of the surgery. Bilateral chest tubes, a neck JP drain, and an NGT were placed in the OR. She was extubated in the OR and transferred to the TICU. Pain was significant, interfering with respiration and patient needed to be reintubated. The morning of [**2141-2-23**] she was successfully weaned from her ventilator and extubated. Pain was well-controlled on IV Dilaudid. On [**2141-2-24**] chest tubes were placed to water seal, tube feeds were started, and patient was transferred from the TICU to the floor. On [**2141-2-26**] the left chest tube and NG tube were removed and tube feeds were advanced to goal. On [**2-27**], patient underwent UGI which showed no leak. She was started on sips. She was evaluated by ENT for hoarseness and underwent flexible endoscopy, showing normal vocal cord movement and post-intubation swelling. The right chest tube and Foley were removed. There was no pneumothorax on subsequent CXR. Patient was noted to be tired, and thyroid function tests were obtained, showing a TSH of 7.0. Levothyroxine dose was increased. On [**2-28**] patient was started on clears. Tube feeds were subsequently cycled. On [**3-2**] the JP drain was removed. Patient was advanced to fulls but felt nauseated and had multiple episodes of small amounts of emesis. After decreasing oral intake, nausea resolved. On [**3-3**] patient was taking a full diet without nausea, was ambulating, and received good pain control with oral medication. She was discharged to home with services for management of her tube feeding. Dr. [**Last Name (STitle) **], patient's PCP, [**Name10 (NameIs) **] manage thyroid supplementation titration as an outpatient. Medications on Admission: Nexium 80", Levothyroxine 0.112', carafate"" Discharge Medications: 1. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*20 Tablet(s)* Refills:*1* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for consipation. 3. levothyroxine 112 mcg 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. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*35 Tablet(s)* Refills:*0* 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: refractory high grade esophageal dysplasia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the West3 surgery service for a minimally invasive esophagectomy for high-grade dysphagia. Please call your doctor or go to the emergency department if: *You experience new chest pain, pressure, squeezing or tightness. *You develop new or worsening cough, shortness of breath, or wheeze. *You are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. *Your pain is not improving within 12 hours or is not under control within 24 hours. *Your pain worsens or changes location. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *You develop any concerning symptoms. General Discharge Instructions: Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. Tube feeds: Continue tube feeding (Replete with fiber) at 80 ml per hour for 14 hours (6 PM to 8 AM). Flush with 10 mL water before and after tube feedings. Change dressing around feeding tube site as needed. Tube feeding will be re-evaluated at clinic follow-up. Followup Instructions: Call Dr.[**Name (NI) 1482**] office at ([**Telephone/Fax (1) 1483**] to schedule and appointment to be seen 10-14 days following discharge. Call Dr.[**Name (NI) 2347**] office at ([**Telephone/Fax (1) 17398**] to schedule an appointment to be seen 10-14 days following discharge. Call Dr. [**Last Name (STitle) **] (PCP) at [**Telephone/Fax (1) 53156**] to discuss your thyroid function tests and the need to adjust your thyroid supplementation.

[ "530.89", "V70.7", "784.42", "530.85", "787.01", "244.9", "530.81", "518.5", "496" ]

icd9cm

[ [ [] ] ]

[ "42.41", "96.04", "46.39", "96.6", "96.71", "31.42", "42.52" ]

icd9pcs

[ [ [] ] ]

5228, 5291

2634, 4465

315, 366

5378, 5378

1356, 2611

7751, 8202

1174, 1312

4561, 5205

5312, 5357

4491, 4538

5529, 6531

7168, 7728

1327, 1337

6563, 7153

244, 277

394, 897

5393, 5505

919, 1027

1043, 1158

24,266

115,892

46665

Discharge summary

report

Admission Date: [**2138-1-2**] Discharge Date: [**2138-1-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2932**] Chief Complaint: hypotension following right hip arthroplasty Major Surgical or Invasive Procedure: right hip arthroplasty History of Present Illness: 85 year old man admitted to the medical ICU from the post-operative care unit for persistent hypotension post-op. He was initially admitted [**2138-1-2**] with avascular necrosis/osteoarthritis of the right femoral head s/p ORIF intertrochanteric femur fracture. He underwent conversion of prior right hip fracture to total hip replacement. Post opeartively, he was agitated and hypotensive (sbp 90s). In PACU he received 1.5mg haldol over several hours, and a total of 10mg IV of morphine for agitation and pain control. Past Medical History: 1. Early dementia. 2. Back pain/Vertebral compression fractures/kyphosis. MRI L-dpine [**5-1**] - Diffuse disc bulge at L3-L4 asymmetric to the right causing mild canal stenosis and mild right neural foraminal narrowing. Vertebroplasty cement adjacent to L5 nerve root resulting in mild narrowing of the right neural foramen. 3. [**Doctor First Name **] on clarithromycin followed by Dr. [**Last Name (STitle) **] 4. Abdominal aortic aneurysm. 5. Coronary artery disease. 6. Chronic obstructive pulmonary disease/emphysema home oxygen (4L at night, 2L during day). FEV1/FVC 59% pred ([**3-3**]). 7. Bronchiectasis. 8. Retinal vein occlusion. 9. R hip fracture/surgery [**2130**]/[**2136**] s/p hardware removal in '[**37**]. 10. Seizures 11. Osteoporosis - bone density [**2135**] 12. Anemia - chronic Social History: Patient lives at home with his wife, who also uses home O2. Patient ambulates with cane/walker at home. Despite dementia, he was independent in his ADL's until his recent fracture/surgery Family History: Non-contributory Physical Exam: Physical Exam on admission: PE: T:98.1 BP:91/42 HR:94 O2:100%RA Gen: Alert, not oriented HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL , ruS1, S2. No murmursbs or [**Last Name (un) 549**] LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL, post-op NEURO: A, not oriented. CN 2-12 grossly intact. Preserved sensation throughout. Gait assessment deferred Pertinent Results: Laboratory studies on admission [**2138-1-2**] WBC-11.1 HGB-9.1 HCT-26.6 MCV-104 RDW-17.3 PLT COUNT-233 GLUCOSE-207* UREA N-13 CREAT-0.5 SODIUM-137 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-28 7.5* Phos-2.1* Mg-2.1 Recent Laboratory studies [**2138-1-15**] WBC-7.5 Hgb-11.7 Hct-34.4 MCV-95 RDW-18.8 Plt Ct-371 Glucose-143 UreaN-11 Creat-0.5 Na-145 K-3.6 Cl-108 HCO3-34 AnGap-7 [**1-3**] EKG: Baseline artifact. Probable sinus rhythm with a single. Vertical axis. Right bundle-branch block. Since the previous tracing of [**2137-12-30**] decreased QRS voltage in leads VI-V2 may be related to lead position Radiology [**1-2**] right hip plain films: The distal femoral component of the THA is excluded from intraoperative frontal film. There has been placement of a right total hip arthroplasty with a cemented acetabular and femoral component. On this single AP view, components are aligned. [**1-3**] CXR: No pneumonia or CHF. Subtle increased interstitial markings at the bases are unchanged [**1-7**] CT Abdomen: Moderate-sized hematoma with residual air pockets from recent surgery adjacent to right hip prosthesis. No extension with into the retroperitoneum or more inferiorly into the thigh. Bilateral small pleural effusions, mild subcutaneous edema diffusely and some collection of fluid within the perirectal fat. Findings consistent with mild anasarca. Stable bilateral adrenal adenomas [**1-8**] CT Chest: The heart size is normal. Extensive aortic and coronary calcifications are identified. There is no axillary, mediastinal or hilar lymphadenopathy. Evaluation of the lung parenchyma is somewhat limited by respiratory motion. Again seen are numerous small pulmonary nodules which are stable back to [**2134**]. Scattered tree-in-[**Male First Name (un) 239**] opacities are also unchanged. There are moderate bilateral pleural effusions. Visualized portions of the upper abdomen are stable with fullness of the adrenal glands again noted. There are no suspicious lytic or sclerotic osseous lesions. Degenerative changes of the thoracic spine are noted. Right proximal humeral enchondroma or bone infarct is again noted. [**1-13**] KUB/upright: There is no evidence of free intra-abdominal air. Normal bowel gas [**Doctor Last Name 5926**] seen. Mild bibasilar atelectasis is identified. There is unchanged appearance of a right prosthetic hip. High-density material overlying the L5 vertebral body unchanged and likely represents a prior history of vertebroplasty. [**1-13**] CXR: No evidence of pneumonia. Stable small bilateral pleural effusions. Pathology [**1-2**] right hip: The articular surface of the bone appears focally eburnated with small osteophyte formation of which representative sections are submitted in A-B. Decalcified. Transthoracic echochardiogram [**2138-1-7**]: EF 50%. Mid inferior (and probable inferolateral) hypokinesis. Trace aortic regurgitation is seen, [**1-28**]+ MR. Brief Hospital Course: 85 year old male initially admitted to the medical ICU with hypotenstion following a right total hip replacement. He was stabilized and transferred to the general medical floor [**2138-1-6**]. His hospital course was notable for NSTEMI, right hip/left groin hematomas, atrial fibrillation, and diarrhea (likely C. diff). 1) Hypotension: The patient's post-op hypotension was most likely secondary to NSTEMI (see below) and peri-op blood loss. His blood pressure stabilized and, at time of discharge, his sbp was 120s. 2) Coronary artery disease with NSTEMI: The patient's troponin peaked at 0.27 on [**2138-1-5**]. An echocardiogram was obtained, which showed an EF 50% (down from pre-op PMIBI 66%) with mid inferior and probable inferolateral hypokinesis. The cardiology service was consulted, who recommended medical management. He was started on high dose statin, continued on beta-blocker (sotolol), and aspirin. He will follow-up with his cardiologist as an outpatient. 3) Supraventricular tachycardia: The patients telemetry monitoring showed a predominantly sinus rhythm with PVCs and occasional runs of atrial fibrillation/flutter along with rare 4-5 beats of NSVT. His sotalol dose was increased to 80 mg daily with improved rate control. 4) Mental status change: The cause of the patient's poor mental status, which was clearing by time of discharge, was likely multifactorial - delirium due to multiple acute illnesses (diarrhea, recent surgery/anesthesia, pain) superimposed on his underlying dementia. The patient was restarted on Namenda and Donepezil. Vitamin B12, RPR, and TSH were within normal limites. The patient was very sensitive to narcotics, and, on the evening of [**2138-1-9**] required multiple doses of Narcan for depressed mental status. At time of discharge, his pain was controlled on standing tylenol with tramadol as needed. 5) Right hip and left groin hematomas: These developed while the patient had a supratherapeutic INR. He required 2 tranfusions of PRBC (last [**1-10**]), and his INR was reversed with vitamin K and FFP. His hematocrit remained stable (34.4 on discharge), and he was restarted on coumadin. His hematocrit will need to be closely monitored as an outpatient, particularly while he is anticoagulated. 6) Anemia: This was likely due to peri-operative bleeding as well as to the hematomas mentioned above. The patient was transfused 6 units of blood in the immediate post-op period, followed by 2 units of blood (the last [**1-10**]) when he developed the above hematomas. Further work-up included iron studies (not consistent with deficiency, vitamin B12/folate (not deficient), haptoglobin (not consistent with hemolysis), SPEP/UPEP (negative), and fibrinogen (not consistent with DIC). His hematocrit on discharge was stable at 34.4. He will need to have his hematocrit monitored closely (especially while he is anticoagulated). 7) Right total hip replacement: The patient was followed by the orthopedics service throughout his hospital stay. He will be maintained on coumadin (goal INR 2-2.5) for a total of 6 weeks from surgery (4 additional weeks following discharge). He was briefly on Keflex given serosanguinous drainage from the right hip incision site, which was discontinued once the incision was dry. He will follow-up 1 week following discharge for staple removal. 8) Diarrhea: The patient developed copious diarrhea while in-house. He was started on empiric metronidazole for suspected C. diff with good effect, although C. diff A toxin was negative X 5. C. diff toxin B is pending at discharge. Given clinical improvement, he will continue metronidazole for a 14 day course for presumed C. difficile colitis. 9) COPD: The patient was continued on albuterol/atrovent and flovent. He remained stable on his home O2 (2 liters). 10) Chronic [**Doctor First Name **]: The patient was continued on azithromycin. 11) Urinary retention: The patient failed multiple voiding trials while in-house (most recent Foley placed [**2138-1-15**]). He was started on Flomax and should have a repeat voiding trial at rehab. Medications on Admission: Acetaminophen Oxycodone 20 mg Tablet Sustained Release 12HR Sig Oxycodone 5 mg Tablet Sig Calcium Carbonate 500 mg Tablet Cholecalciferol (Vitamin D3) 400 unit Tablet Phenobarbital 30 mg Tablet Sotalol 80 mg 0.5 tablet daily Aspirin 81 mg Tablet Donepezil 5 mg Tablet Gabapentin 300 mg Capsule Docusate Sodium 100 mg Capsule Fluticasone 110 mcg/Actuation Aerosol Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Memantine 5 mg [**Hospital1 **] Senna Enoxaparin 30 mg/0.3 mL Pantoprazole 40 mg Tablet Lidocaine 5 %(700 mg/patch) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO once a day. 4. Phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Sotalol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)): at 9 p.m. 10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 13. Memantine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for dementia. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). 17. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 18. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days: through [**2138-1-20**]. Tablet(s) 20. Tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pain: hold for oversedation. 21. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) for 4 weeks: to complete 6 weeks of anticoagulation from surgery. 22. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed: to groin. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: total hip replacement for avascular necrosis Secondary: hypotension, coronary artery disease, NSTEMI, congestive heart failure, atrial fibrillation, right thigh/left groin hematoma, anemia, myocbacterium avium complex, diarrhea Discharge Condition: Stable Discharge Instructions: 1) Please take all medications as prescribed. - you have been started on atorvastatin - you will complete a 14 day course of metronidazole for C. diff colitis; it is important that you not drink alochol while taking this medication. - Flomax was added to your regimen for benign prostatic hypertrophy - you have been started on anticoagulation to prevent clots following surgery; you will continue this for 4 weeks following discharge. 2) Please follow-up as indicated below. 2) Please come to the emergency room if you develop chest pain, shortness of breath, increased pain, or other symptoms that concern you. Followup Instructions: 1) Orthopedics Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2138-1-24**] 3:00 - plan for staple removal at that time 2) Primary Care: Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3393**]) within 1-2 weeks following discharge. 3) Pulmonary: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2138-4-10**] 12:00 Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2138-4-10**] 11:40 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**] Completed by:[**2138-1-15**]

[ "788.20", "715.15", "410.71", "905.3", "294.8", "428.20", "427.31", "733.00", "731.3", "998.12", "414.01", "E989", "458.29", "008.45", "285.1", "293.0", "733.42", "496" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.07", "81.51" ]

icd9pcs

[ [ [] ] ]

12059, 12129

5349, 9434

306, 330

12410, 12419

2403, 5326

13081, 13955

1931, 1949

10015, 12036

12150, 12389

9460, 9992

12443, 13058

1964, 1978

222, 268

358, 882

1992, 2384

904, 1709

1725, 1915

74,448

187,621

35833

Discharge summary

report

Admission Date: [**2144-2-22**] Discharge Date: [**2144-3-2**] Date of Birth: [**2087-7-7**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Right SDH Major Surgical or Invasive Procedure: Intubation PICC History of Present Illness: The patient is a 56 year-old male with a history of alcohol abuse, HTN and GERD who was admitted to [**Hospital **] Hospital on [**2144-2-17**] after a fall. The patient was apparently escorting his mother to a doctors [**Name5 (PTitle) 648**] when [**Name5 (PTitle) **] became acutely lightheaded and dizzy. EMS was called after he had a witnessed fall and he was found to be markedly jaundiced, hypotensive and orthostatic. In the ER, he was in renal failure with hepatitis. Review of the OSH notes indicates that the patient noticed he was jaundiced 3-4 days before presentation. He reported [**Name5 (PTitle) 5283**] pain on and off for about 1 month and also endorsed intermittent black stools without hematemesis. He had apparently been binge drinking for about 10 days before admission with limited PO intake other than alcohol. A [**Name (NI) 5283**] sono was performed on admission and revealed hepatomegaly and probable diffuse fatty infiltration. He also had a large right exophytic cortical renal cyst. He did not have evidence of cholecystitis or biliary obstruction. An EGD was performed on [**2-19**] and was notable only for mild portal hypertensive gastropathy. He had no esophageal varices, ulcers or AVMs to the second portion of the duodenum. On [**2-20**] he was found to have fallen in the bathroom of his hospital room. Initial non-contrast CT head was normal. The following day ([**2-21**]) he was noted to be acutely confused. A CT A/P was performed and revealed a heterogeneously enlarged liver with small ascites. A repeat head CT on [**2-22**] revealed a large 18mm acute subdural hematoma along the right convexity with 16mm of right to left midline shift. He was intubated and transferred to [**Hospital1 18**] for further neurosurgical management last night. According to the d/c summary, the patient was on broad spectrum Abx for a possible UTI while at the OSH. Blood cultures were reportedly negative. On questioning this morning, the patient denies any toxic ingestions or Tylenol use together with his excessive alcohol ingestion. He has never been jaundiced before and was unaware of any underlying liver problems. I see no toxicology report from the OSH. Past Medical History: Past Medical History: HTN GERD Alcohol abuse Depression Social History: Social History: Smokes 1ppd. Drinks [**2-14**] pints of whiskey per day. No IVDU. Marries but ?separated from his wife. Lives with his elderly mother. Family History: Family History: Denies Physical Exam: ON ARRIVAL: Physical Exam: VS: 96/42 85 93% on RA GEN: Deeply jaundiced and somewhat diaphoretic but in NAD HEENT: Dry MM, icteric CVS: RRR, nl s1s2, no m/r/g LUNGS: CTA b/l ABD: Obese soft, NT and ND with NABS and hepatomegaly Ext: Palmar erythema, no LE edema NEURO: AAOx2-3, tremulous but no asterixis Pertinent Results: [**2144-2-22**] 08:57PM SODIUM-131* [**2144-2-22**] 08:57PM OSMOLAL-326* [**2144-2-22**] 08:57PM PT-17.8* PTT-39.2* INR(PT)-1.6* [**2144-2-22**] 04:32PM SODIUM-131* [**2144-2-22**] 04:32PM OSMOLAL-301 [**2144-2-22**] 01:00PM SODIUM-134 [**2144-2-22**] 01:00PM OSMOLAL-298 [**2144-2-22**] 01:00PM PT-17.7* PTT-40.2* INR(PT)-1.6* [**2144-2-22**] 09:17AM SODIUM-132* [**2144-2-22**] 09:17AM OSMOLAL-298 [**2144-2-22**] 05:15AM GLUCOSE-141* UREA N-32* CREAT-1.5* SODIUM-133 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-18* ANION GAP-18 [**2144-2-22**] 05:15AM estGFR-Using this [**2144-2-22**] 05:15AM ALT(SGPT)-115* AST(SGOT)-208* LD(LDH)-424* ALK PHOS-468* AMYLASE-91 TOT BILI-25.5* [**2144-2-22**] 05:15AM LIPASE-23 [**2144-2-22**] 05:15AM cTropnT-0.02* [**2144-2-22**] 05:15AM ALBUMIN-2.5* CALCIUM-7.5* PHOSPHATE-1.9* MAGNESIUM-1.8 IRON-81 [**2144-2-22**] 05:15AM calTIBC-125* FERRITIN-GREATER TH TRF-96* [**2144-2-22**] 05:15AM TSH-2.1 [**2144-2-22**] 05:15AM WBC-22.1* RBC-2.46* HGB-10.3* HCT-28.1* MCV-114* MCH-41.9* MCHC-36.7* RDW-15.3 [**2144-2-22**] 05:15AM NEUTS-89* BANDS-1 LYMPHS-4* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2144-2-22**] 05:15AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL TARGET-OCCASIONAL [**2144-2-22**] 05:15AM PLT SMR-NORMAL PLT COUNT-255 [**2144-2-22**] 05:15AM PT-18.7* PTT-36.0* INR(PT)-1.7* Brief Hospital Course: This 56 year old male was admitted to TICU after transfer in from OSH s/p fall with Right SDH. He was intubated for the transfer. He received vitamin K and FFP for ICH w/ coagulopathy prior to transfer. A CT scan of the torso was performed after large L sided bruising was noted. This showed multiple rib fractures , spinous process fractures and hepatomegaly with Right lobe hypoperfusion. He was pre-medicated for this CT [**3-16**] elevated Cr. S/P recieving 4u FFP his INR went from 1.7->1.6. The pt was extubated on hosp day #2 and hepatology was consulted for input. MICU service was consulted for transfer and pt was not deemed a candidate for transfer at that time. Medicine was consulted for their input however they felt that he was not appropriate for transfer to the floor with Acute SDH. Rifaximin was started and CIWA scale protocol initiated for agitation. Mannitol was given for approx 24 hours. Vit K 10mg IV x 3days started and repeat head CT shows mild improvement. His exam has remianed stable thus far. ABD US showed ********** Renal Consult was called for ARF on HD#3 and recs were followed. MICU service was recontacted and the patient was transferred to their serivce. During the MICU course, the patient's renal function continued to decline, likely from a pre-renal source. CVVH was not initiated. The patient's mental status continued to wax and wane and subsequently decline. The patient was intubated for airway protection. The next morning the patient self extubated, and he was able to maintain his airway. He was not reintubated. His hepato-renal function continued to worsen and his mental status declined to the point where he was not responsive. Per discussion with family patient was made CMO and dobhoff tube feeds were held. The patient then sustained 12 hours on his own before his heart slowed and he passed away 1038 AM [**2144-3-2**]. . Medications on Admission: Medications (home): Clonazepam prn Nexium 40 mg daily Citalopram 20 mg daily Neurontin 300 mg TID K-Dur 10 meq daily Enalapril 20 mg daily HCTZ 25 mg daily Atenolol 50 mg daily Ecotrin 325 mg daily Medications (at OSH): MVI, thiamine and folate Prilosec 40 mg daily Neutraphos 1 packet QID Zosyn Levaquin 250 mg daily (d/c'd [**2-21**]) SQ heparin Lactulose Ativan by CIWA scale Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure failure secondary to end stage liver disease and acute renal failure Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: NA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2144-3-2**]

[ "276.0", "403.90", "305.1", "V66.7", "276.1", "E888.9", "276.2", "518.81", "852.20", "286.9", "305.01", "571.1", "571.2", "782.4", "584.9", "585.9", "578.1", "530.81", "311", "789.59" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "38.93", "96.71", "54.91", "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

6975, 6984

4642, 6544

293, 310

7116, 7125

3178, 4619

7176, 7344

2823, 2832

7005, 7095

6570, 6952

7149, 7153

2875, 3159

238, 255

338, 2542

2586, 2622

2654, 2791

54,643

189,860

6475

Discharge summary

report

Admission Date: [**2167-9-1**] Discharge Date: [**2167-9-8**] Date of Birth: [**2085-1-14**] Sex: F Service: NEUROLOGY Allergies: Lisinopril Attending:[**First Name3 (LF) 618**] Chief Complaint: headache and bumping into things on the left Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname 2152**] is an 82 yo RH woman with a PMH of Diabetes, Dyslipidemia and Hypertension p/w CNS bleed. She was at her baseline till yesterday in the morning. Her headache started at 11:00 am yesterday. The pain was of throbbing quality, constant, localized on her forehead bilaterally and radiated to her temples. It improved a little bit, yet not completely. She had nausea, but there was no vomiting. It was not modified by positional changes. There are no thunderclap features. It started with an intensity of [**2-11**] an dbuilt up to [**10-11**] at 3:00 am. At this point her daughter gave her tylenol 500 mg. The onset of her headache was not related to strenuous physical exercise or sexual activity. She is not on anticoagulation. No hx of recent trauma. According to her daughter, she has been bumping into objects on her left side. Sh ewas looking for her meds in the bathroom counter and could not find them (they were on her left side). In addition, her daughter placed her meds on her left hand) and she did not know where they were. They became concerned and brought her to the ED. She was recently admitted at [**Hospital1 18**] ([**2167-6-22**]) due to dizziness in the context of a sinus bradyarrhythmia (secondary to atenolol) with PR after holding her meds. She improved and never developed a type 2 AV block, hence she did not receive a PPM. Past Medical History: PMH: 1. Diabetes 2. Dyslipidemia 3. Hypertension 4. Sinus bradicardia in the context of high atenolol doses 5. Bl cataracts Social History: [**Location 7972**] speaking. Denies any tobacco, Etoh or recreational drug use. Lives in [**Country 3587**] for much of the year. When in the US, she lives with one of her daughters; has 9 children total. Traveled to [**Country 3587**] most recently with husband. [**Name (NI) **] organizes and takes her own medications without help. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: PE: 98.4 64 136/40 16 97 GCS 15. Gen: Lying in bed, NAD. HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Soft, nontender, non-distended. No masses or megalies. Percussion within normal limits. +BS. Ext: no edema, no DVT data. Pulses ++ and symmetric. . MS: General: alert, awake, normal affect Orientation: oriented to person, place, date, situation. . DOW backwards +: in less than 20 seconds. Follows simple axial and appendicular commands: closes and opens his eyes, shows me the tongue. Gives me a thumb or provides and releases a grip at command. Follows three step commands: "take this piece of paper with your right hand, fold it into two parts and return it to me with the left hand". . Memory: *Auditory memory: [**3-4**] and Recalls [**3-4**] when given choices at 5 min. *Recalls major events: 9/ 11 [**Location (un) 7349**] attack and also the earthquake in [**Country 2045**]. *Spatial memory: does not remember where is the clock in the room. . Speech/Language: fluent w/o paraphasic (phonemic or semantic) errors; comprehension, repetition, naming (high and low frequency objects): normal. Prosody: normal. . Praxis/ agnosia: Able to brush teeth. Able to recognize I am brusing my teeth. Able to mimic me brushing my teeth. . She does not really understand the task when I show her the red pin to assess field cuts. Howerver, she does not blink to threat on her LEFT. When shown the stroke card picture in the kitchen, she does not see the girl and focuses on the right side of the picture (window an the woman drying dishes). Copies the right-sided tree and sun, not the samples on her left. The bisection task shows the same pattern (added to chart) with compensation when the lines are smaller. No extinction to visual or tactile stimuli or to a combination of both. . No extinction: *To simultaneous tactile stimuli. *No Motor neglect: When crossing hands or with hands uncrossed. I gave her a coin on her left hand and she thought it was a pen. There is a mild agraphestesia in her left hand. She can tell I am writing "0 or 1", not "6 or 3", though. Able to read (only the last word and a half in the right end of the page, though)and write (on the right end of the page). No other right parietal deficits. CN: I: not tested II,III: Baseline deviated to the right, but she crosses the midleine. PERRL 3mm to 2mm, fundus w/o papilledema. No red desaturation. OD and OS with her glasses on 20/ 20. Pin hole exam/ Madox-Rod exam: not required. III,IV,VI: EOMI, no ptosis. No pathological nystagmus. Normal pursuit. Optokinetic nystagmus: intact V: sensation intact V1-V3 to LT. VII: Facial strength intact/symmetrical VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [**Doctor First Name 81**]: SCM/trapezeii [**5-6**] bilaterally XII: tongue moves properly in both directions (no asymmetry seen), no dysarthria . Rinne: R ear: AC>BC, LEFT ear AC> BC [**Doctor Last Name 15716**]: central. Motor: Normal bulk. Tone: normal. No tremor, no asterixis or myoclonus. No pronator drift: . Delt;C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7 Left 5 5 5 5 5 Right 5 5 5 5 5 . IP: Quad: Hamst: Dorsiflex: [**Last Name (un) 938**]:Pl.flex Left 5 5 5 5 5 5 Right 5 5 5 5 5 5 . Deep tendon Reflexes: . Bicip: Tric: Brachial: Patellar: Achilles Toes: Right 2 2 2 2 2 DOWNGOING Left 2 2 2 2 2 DOWNGOING . Sensation: Decreased to light touch, and PP on her left face arm and leg. Coordination: *Finger-nose-finger normal. *Rapid Arm Movements normal. *Fine finger tapping: normal. *Heal to shin: normal. Pertinent Results: [**2167-8-31**] 10:30AM PLT COUNT-165 [**2167-8-31**] 10:30AM WBC-6.0 RBC-5.04 HGB-15.2 HCT-44.2 MCV-88 MCH-30.1 MCHC-34.3 RDW-14.0 [**2167-9-1**] 10:00AM PT-13.3 PTT-24.8 INR(PT)-1.1 Brief Hospital Course: Ms [**Known lastname 2152**] is an 82 year old right handed woman with a history of newly diagnosed diabetes, dyslipidemia and hypertension who presented with headaches and bumping into things on her left. Her examination was remarkable for right parietal findings. She did not blink to threat on her LEFT. When shown the stroke card picture in the kitchen, she did not see the girl and focuses on the right side of the picture (window and the woman drying dishes). She copied the right-sided tree and sun, but not the samples on her left. The bisection task showed the same pattern with compensation when the lines are smaller. She could not recognize a coin in her left hand and she thought it was a pen. There was a mild agraphesthesia in her left hand (could tell "0 or 1", not "6 or 3", though.) She was able to read only the last word and a half in the right end of the page. She was able to write on the right end of the page. In drawing a clock, she wrote all of the numbers on the right side of the circle. There was some sensory extinction on the left with simultaneous tactile stimuli and no motor neglect. There were no other right parietal deficits. She had a head CT scan and MRI which confirmed a right parietal hemorrhage. Her MRI showed the following: 1. Right parietal subdural hematoma without definite evidence of an underlying mass-like enhancement. 2. Subarachnoid hemorrhage as well as a small right subdural hematoma. 3. The MRA images are limited due to motion artifact. Within these limitations, the intracranial course of the internal carotid, vertebral, basilar artery and their branches do not show any stenosis or occlusion. The assessment for an aneurysm is limited. Etiology of bleeding is not entirely clear, but is likely due to amyloid angiography. MRI with and without gadolinium, and MRA did not show other causes of hemorrhage. Mrs. [**Known lastname 2152**] was initially monitored in the ICU and was stable without evidence of increased intracranial pressure. She had a swallow evaluation which she passed. On the neurology floor, her blood pressure was monitored and her systolic blood pressure remained less than 160, and mean arterial pressures <110. She was given Amlodipine 5mg daily for blood pressure control. She also received pravastatin. On the neurology floor, she had bradycardia to the 50s, with telemetry showing AV nodal Wenkebach in a variable pattern. She was asymptomatic. She was seen by cardiology, who noted that this was mostly occurring in sleep, a time of heightened parasympathetic tone. Cardiology recommended continued avoidance of nodal blocking agents and follow up with her primary cardiologist. We believe that Mrs.[**Known lastname 24868**] hemorrhage was possibly secondary to amyloid angiography. Additionally, she now has significant left sided neglect, and is now at high risk of injury and falls. Therefore, we have elected to discontinue her home Aspirin therapy at this time. Mrs.[**Doctor First Name 24868**] family has decided that they would like her to go home, instead of to a facility for rehab at this time. They have been able to arrange schedules such that Mrs. [**Known lastname 2152**] will have 24 hours of care and supervision from the family to prevent injury. She will also have home nursing and PT/OT services. Medications on Admission: 1. Aspirin 81 mg qd 2. Amlodipine 5 mg qd 3. Pravastatin 40 mg qhs 4. Artificial Tears 1 drop Ophthalmic q6h Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 6. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: 1. Right parietal hemorrhage with left sided neglect Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). (neglect of left side - danger for fall or accident) Discharge Instructions: You were admitted to [**Hospital1 18**] because you were found to have bleding on the right side of your brain. You were initially admitted to the ICU for monitoring, and then were transferred to the neuromedicine floor. Your blood pressure was controlled well with amlodipine, your home blood pressure medication. You were continued on your cholesterol medicine. You were started on a new medication, Glyburide, to control your blood sugars. We have stopped your aspirin medication because you have had bleeding, and you now have an increased risk of injury and new bleeding. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2167-9-11**] 9:30 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2167-9-28**] 10:00 Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2167-11-10**] 9:00 Please call to schedule follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **], neurology stroke service in [**4-7**] weeks. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "277.39", "781.8", "431", "272.4", "455.6", "426.13", "348.5", "250.00", "342.92", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10511, 10584

6508, 9837

314, 320

10681, 10681

6294, 6485

11522, 12162

2256, 2338

10000, 10488

10605, 10660

9863, 9977

10917, 11499

2353, 6275

230, 276

348, 1734

10696, 10893

1756, 1882

1898, 2240

5,579

113,698

3154

Discharge summary

report

Admission Date: [**2109-11-13**] Discharge Date: [**2109-11-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4052**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a [**Age over 90 **] yo Asian male from NH with multiple medical problems who presents with shortness of breath and hypoxia. Per NH records and family patient had developed cold-like symptoms [**2-22**] days ago. He had a nasal/sinus congestion, cough with yellow sputum, and increasing lethargy. Today at NH he was noted to have PNA on CXR. He was started on Levo/Flagyl but had not received any dosages. He was then seen in the afternoon by his family who found him SOB, gurgling, and disoriented. At this time his O2 sats were noted to be in the 60-70 range. Therefore family asked that the patient be sent to the hospital. . Pt is currently pain free, denies any abd pain, chest pain, diarrhea, nausea, vomiting. . In the ED he was found to be hypoxic with O2 sat of 79% on RA. He was given combivent with minimal improvement and placed on NRB. His lactate was found to be 7.4 and after 3L of fluid came down to 2.4. He was given levofloxacin and clindamycin in the ED. Past Medical History: PMH: Hypothyroid Dementia A.fib h/o CVA BPH Depression Dysphagia CHF- EF 30% CRI- Baseline cr 1.7 Anemia h/o bilateral renal stones(uric acid) h/o GIB (duodenal/gastric ulcers) Social History: Currently lives in a NH. Per old records no ETOH/tobacco use. Family History: NC Physical Exam: PE T 97 BP 97/50 [**Last Name (un) **] 69 HR 88 RR 20 O2sats 96% 70% Shovel Gen: Awake, following commands, A&O times 2(did not know date) HEENT: Unequal pupils, both reactive to light Lt 5mm Rt 3mm, EOMI, dry mm, anicteric Neck: no JVD Lungs: Signficant upper airway sounds, gurgling, bilateral basilar crackles Heart: Irregularly, irregular Abd: Soft, NT, ND hypoactive BS, + abd scar Ext: No edema, cyanosis Neuro: A& O times 2, CN 2-12 intact, strength 5/5 bilaterally in UE/LE Pertinent Results: SPUTUM GRAM STAIN (Final [**2109-11-14**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. RESPIRATORY CULTURE (Final [**2109-11-16**]): SPARSE GROWTH OROPHARYNGEAL FLORA. YEAST. SPARSE GROWTH. . CXR: [**2109-11-13**]: IMPRESSION: Development of bilateral pulmonary opacities. The differential includes multifocal pneumonia versus atypical pattern of CHF, given underlying emphysema. . ECG: Afib at 81, LAD, no ST/T wave changes . ECHO '[**06**]- Conclusions: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate global left ventricular hypokinesis. No masses or thrombi are seen in the left ventricle. The right ventricular cavity is dilated with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but not stenotic. Mild to moderate ([**12-23**]+) 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. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is no pericardial effusion. IMPRESSION: Biventricular hypokinesis. Moderate-severe mitral regurgitation. Pulmonary artery systolic hypertension. Moderate-severe tricuspid regurgitation. . [**2109-11-13**] 05:30PM CK-MB-4 cTropnT-0.04* proBNP-[**Numeric Identifier 14891**]* [**2109-11-13**] 11:39PM ART PO2-299* PCO2-40 PH-7.34* TOTAL CO2-23 BASE XS--3 [**2109-11-13**] 11:39PM LACTATE-4.7* [**2109-11-13**] 06:06PM LACTATE-7.4* [**2109-11-13**] 05:30PM GLUCOSE-94 UREA N-44* CREAT-2.3* SODIUM-145 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-21* ANION GAP-23* [**2109-11-13**] 05:30PM WBC-10.5 RBC-4.60 HGB-12.7* HCT-40.5 MCV-88 MCH-27.6 . [**2109-11-18**] Video Swallowing Study: FINDINGS: Oral and pharyngeal swallowing videofluoroscopy was performed in collaboration with the speech therapist. Two teaspoons of nectar thick liquid barium were administered. The patient aspirated both times without spontaneous coughing. Cued cough was ineffective in clearing the aspirated material. [**Known lastname **] tuck position did not prevent aspiration. The exam was subsequently discontinued given the patient's tenuous respiratory status. Brief Hospital Course: In the ED the pt was found to be hypoxic with O2 sat of 79% on RA. He was given Combivent with minimal improvement and placed on NRB. CXR on admission showed bilateral lower lung field infiltrates, and he was given levofloxacin and clindamycin in the ED. On admission, his lactate was also found to be 7.4 and after 3L of fluid came down to 2.4. . The patient was admitted to the MICU, where Levo/Flagyl were started for tx of presumptive aspiration pneumonia; Vancomycin was also started for empiric coverage for MRSA as pt is a nursing home resident. The pt received aggressive chest physiotherapy, albuterol/atrovent nebulizers PRN, O2 by face tent (pt is a mouth breather). Sputum was sent for culture [**11-14**]. Speech and swallow consult was obtained, and pt was deemed to be at high risk for aspiration, and pt was made NPO with NGT recommended for nutrition/hydration. . The pt's hypoxia was also thought to be also due in part to CHF, as pt's EF 30% per [**9-23**] Echo, and BNP [**Numeric Identifier 14892**]. However, pt appeared intravascularly depleted, with reported poor PO's and thirst; diuresis was also held given h/o CRI, with increased Cr on admission thought to be secondary to pre-renal azotemia. Pt received gentle boluses of NS, then LR (given low bicarbonate) for intravascular fluid repletion as well as for tx of low UOP. . The patient was called out of the ICU to regular inpatient floor [**11-15**], as his O2 saturation had improved greatly to 95-96% with blow-by O2 (face tent not on face, lying on chest). . HOSPITALIZATION COURSE - REGULAR INPATIENT FLOOR: 1) ID/ PNA: Pt with initial hypoxia, has transitioned from face tent to O2 by NC, with improved O2 sats on NC to 99-100% on 2L, 93-95%RA; productive cough improved and ultimately resolved, pt appears much more comfortable with respiration. Pt was continued on Vancomycin, Levo, Flagyl until sputum culture came back; as no evidence of MRSA, Vancomycin was discontinued. He ultimately completed a 2 week total course of Levaquin and Flagyl, ending with doses given on [**11-28**]. The patient was never febrile; his WBC increased transiently to 18, but quickly decreased to WNL. He was maintained on aspiration precautions, daily chest physiotherapy for loosening of secretions, and daily albuterol/atrovent nebulizers. He had negative blood cultures, UCx negative [**11-18**], [**11-20**], C. diff negative [**11-17**] . 2) CHF: Pt has EF of 30%, BNP [**Numeric Identifier 14892**]. Pt had evidence of pulmonary edema on exam with lung crackles and LE edema. He was started on Lasix 10 mg IV given [**11-18**], pt responded with good diuresis; he was transitioned to 10 mg per G/J tube on [**11-27**]. His Cr was monitored cloesly and actually normalized while on diuresis, as he was simultaneously hydrated and given gentle free water repletion IV for dehydration and intravascular depletion and hypernatremia, then per G/J tube when placed. He is not on an ACEI, but one was not started at this time given ARF. . 3) ARF: Pt with baseline creatinine of 1.7 from [**2106**], increased up to 2.3 on admission. Likely pre-renal, as the patient had had poor PO intake prior to admission, and the pt consistently complained of thirst and requested water. Urine Na 19, also sign of sodium avidity. With gentle hydration, the pt's Cr gradually improved to 1.3 . 4) Afib: Rate controlled on metoprolol IV - then per G/J tube for rate control. Metoprolol given w/ holding parameters given low BP. Pt has not been on anti-coagulation, per NH. Had been on coumadin in the past, but discontinued [**1-23**] GI bleed . 5) FEN- NPO given aspiration risk. Pt failed both bedside and video speech and swallow, and was found to have no gag reflex and silent aspiration. The patient was NPO w/ aspiration precautions, then given PPN for a short course prior to receiving G/J tube placement by IR [**11-26**]. He was started on tube feeds, Probalance 15 cc-> 55 cc/hr, with 150 cc H20 boluses. This was increased to 200 cc boluses as UOP slightly decreased and concentrated on day of discharge. He tolerated tube feeds with low residuals and no leakage. **NOTE**: G/J tube held in place w/ T- fasteners sutured to skin - will need these d/c'd in [**6-30**] days, can be done by RN in NH, just need to cut sutures holding fasteners in place (NOT sutures holding PEG in place) The patient also required care for oral hygiene, slightly wet sponges for oral comfort given thirst. . 6) Coagulopathy: - The pt was found to have increased INR from baseline of 1.3-1.6, up to 2.0. The pt had not been on coumadin, per NH. LFT's normal, no evidence of DIC, normal platelets, possible nutritional deficiency. He received 3 day courses of Vitamin K x 2 during admission. INR on discharge was 1.6 . 7) Anemia: - Uncertain etiology, normal MCV so B12/Folate deficiency unlikely, pt has h/o GI bleeds, guaiac negative. Hcts were stable during admission, Hct on day of discharge 34.8. . 8) Lactate - Lactate initially elevated on admission, likely due to dehydration/hypoperfusion, hypoxia, subsequently improved w/ hydration. . 9) Hypothyroidism - Levothyroxine per home regimen . 10) BPH - Possible traumatic foley placement, with hematuria (now resolved). 11) Dementia: - Initially on Doxepin; Zyprexa PRN/HS, however, pt never demonstrated any agitation or confusion, and did not receive these medications, and they were discontinued. 12) Peripheral neuropathy: - Pt seen by neurology consult, initially for evaluation of limited speech. Found to be able to verbalize with no focal deficits and normal cranial nerve exam - and that pt does not like to speak secondary to oral dryness and discomfort. However, pt found to have a distal sensory polyneuropathy, for which he had a negative work-up, with negative ESR, A1C, RPR; only abnormal TSH given hypothyroidism. - Pt followed by PT during admission, and deemed to be safe to be discharged. Able to ambulate with assist. Only requires further PT for mobility. 13) Code- DNR/DNI; confirmed by Dr. [**Last Name (STitle) 1266**] and son [**Name (NI) **] [**Name (NI) **]. Medications on Admission: Meds: Furosemide 10mg qday, metoprolol 12.5mg [**Hospital1 **], MVI, synthroid 50 mcg qday, Vit C, zyrtec 10mg qday, colace, ranitidine 150mg [**Hospital1 **], doxepin 10mg qhs, tylenol prn, albuterol nebs, Urocit-K 5meQ qday . All: NKDA Discharge Medications: 1. NURSING ORDER To RN: PLEASE D/C FASTENER'S HOLDING G/J TUBE TO SKIN IN 7 DAYS - these are the barrel shaped pieces of cotton with protruding wires. Please cut wires, they will recede into abdomen and will be resorbed. Please do not cut sutures tied directly around G/J tube! Thank you 2. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). 3. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). 4. Furosemide 40 mg/5 mL Solution [**Hospital1 **]: Ten (10) mg PO DAILY (Daily). 5. Levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. Senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed. 8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a day). 9. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). 10. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 11. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6 hours) as needed. 12. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 13. Docusate Sodium 150 mg/15 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day) as needed. 14. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal HS (at bedtime) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] - [**Location (un) **] Discharge Diagnosis: Presumed aspiration pneumonia, chronic renal insufficiency/acute renal failure, dehydration, anemia, atrial fibrillation, congestive heart failure Discharge Condition: Stable Discharge Instructions: Please take your medications as written. Call your primary care physician with worsening cough, chest pain, fever, shortness of breath, confusion, any other worrisome symptoms Followup Instructions: Please call for an appointment to follow up with Dr. [**Last Name (STitle) 1266**] in [**12-23**] weeks ([**Telephone/Fax (1) 8417**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**] Completed by:[**2109-11-28**]

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icd9cm

[ [ [] ] ]

[ "44.32", "99.15", "96.6" ]

icd9pcs

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9506

Discharge summary

report

Admission Date: [**2113-9-29**] Discharge Date: [**2113-10-9**] Service: CCU Medicine CHIEF COMPLAINT: This is an 87 year old female, resident-[**Hospital3 **] with ischemic cardiomyopathy, with severe diastolic dysfunction, right ventricular systolic dysfunction, with an ejection fraction of 45 to 50%, severe pulmonary artery systolic hypertension and severe tricuspid and mitral regurgitation (not a surgical candidate) who presented with a heart failure exacerbation, and admitted to the CCU for inotropic support and tailored diuresis. PAST MEDICAL HISTORY: The past medical history is significant for coronary artery disease, status post a coronary artery bypass graft times four in [**2102**], chronic atrial fibrillation, first diagnosed two years ago on Coumadin (presents with INR of 4.0 on admission), chronic renal insufficiency, (baseline creatinine of 1.7), chronic hypoxia on 2 liters of home oxygen, restricted lung disease, lung cancer, status post wedge resection, breast cancer, status post mastectomy, gout, anemia, cholelithiasis, history of recurrent urinary tract infections and frequent pyuria, dysuria, Do-Not-Resuscitate/Do-Not-Intubate code status. The patient's dry weight is 149 lbs. HISTORY OF PRESENT ILLNESS: The patient had recent worsening of heart failure over the past two months prior to admission. She was seen in the Heart Failure Clinic by Dr. [**First Name (STitle) 2031**] on [**2113-9-25**] with worsening shortness of breath, increased weight gain, decreased ability to carry on activities of daily living where she was treated medically at the time. The day prior to admission she had a three pound weight gain, dyspnea with dressing, walking at a normal pace and increased ankle edema. Her supplemental oxygen requirement was unchanged. She denied lightheadedness, weakness, fevers, chills, dysuria. She did have a dry cough, though. At baseline she is alert and oriented times three with mild amnesia. She performs activities of daily living independently at her [**Hospital3 **] home. In the Emergency Room she presented short of breath. She dropped her systolic blood pressure to the 60s, requiring Dopamine via peripheral intravenous line (INR at 4.0 precluded central access) with an increase in her systolic blood pressure to the 100s. Her oxygen saturation dropped to 75 to 80% range and she was placed on 100% nonrebreather. She was noted to have mental status changes at the time. Her arterial blood gas was 7.21/71/93 and improved to 7.30/53/66 on 6 liters of oxygen with improvement of her mental status (carbon dioxide retainer at baseline, difficult to oxygenate). Also she was noted to have a urinary tract infection, acute and chronic renal failure. She was admitted to the CCU for inotropic support/aggressive/tailored diuresis. PHYSICAL EXAMINATION: Physical examination on admission revealed temperature 98.8, blood pressure 108/46 on 2.5 of Dopamine, heartrate 90 to 110, sating at 98% on 6 liters of oxygen, respiratory rate 18 to 24. In general she was an elderly female, in mild respiratory distress, somewhat somnolent. Her mucous membranes were moist. Her oropharynx was clear without exudate. Her jugulovenous pressure was elevated to her chin. She had no carotid bruits. Her heart was irregular/irregular with III/VI holosystolic murmur at the right lower sternal border, radiating to the axilla with a positive S3. Her lungs had bibasilar crackles halfway up. Her abdomen was mildly distended, nontender. She was alert and oriented times three. Her cranial nerves II through XII were intact. She had nonfocal neurological examination. LABORATORY DATA: Significant laboratory data on admission revealed sodium 135, potassium 5.3, chloride 98, bicarbonate 24, BUN 102, creatinine 3.0, glucose 135, white blood cell count 8.5, hematocrit 30.4, platelets 143. Liver function tests were within normal limits. Urinalysis showed greater than 50 white blood cells, positive leukocyte esterase and trace protein. Coagulation screen on admission were PT 24, PTT 37.2, INR 4.0. Electrocardiogram on admission, atrial fibrillation at 69 beats/minute with left axis deviation, T wave inversions in leads 1, AVL (old T wave inversions), premature ventricular contractions, no ST changes, question of Q in 3. Digoxin level on admission 1.3, creatinine kinase on admission 27, troponin 1.1. FAMILY HISTORY: No cardiac history. SOCIAL HISTORY: Independent activities of daily living, [**Hospital3 **], no tobacco use. No drugs and no alcohol. ALLERGIES: No known drug allergies, however, there is a question of an allergy to Spironolactone which may induce hyperkalemia, so use with caution. MEDICATIONS ON ADMISSION: Toprol XL 25 mg p.o. q.d., Zocor 20 mg p.o. q.d., Coumadin 2.5 mg p.o. q.d., Digoxin 0.125 mg p.o. q.d., Lasix 160 mg p.o. b.i.d., Zestril 5 mg p.o. q.d., Allopurinol 200 mg p.o. q.d. HOSPITAL COURSE: 1. Cardiac - A. Pump; the patient was admitted to the Coronary Care Unit for inotropic support plus tailored diuresis. Initially, she was on a Dopamine drip at 5 mcg/kg/min. She was given Metolazone dose, and started on Natrecor drip. She was given 160 mg intravenous bolus of Lasix (had an additional 100 mg intravenously of Lasix in the Emergency Department), followed by a Lasix drip at 20 mg/hr. Swan-Ganz monitoring was not obtained on this admission secondary to difficult access. The patient responded well to the aforementioned regimen, was weaned off of Dopamine and diuresed to her dry weight of 149 lbs. Her usual ACE inhibitor, Beta blocker, and Digoxin were slowly reinstituted as her blood pressure tolerated. Her Lasix was reinstituted at 20 mg p.o. b.i.d. to be titrated up at rehabilitation (her usual dose was 160 p.o. b.i.d.). Transthoracic echocardiogram was obtained on [**2113-10-2**]. The ejection fraction was 45 to 50%. She had a markedly dilated LA and a moderately dilated RA. The left ventricular systolic function was mildly depressed. Inferior akinesis was present. Right ventricle was mildly dilated, there was mild aortic stenosis. 3+ mitral regurgitation, 3+ tricuspid regurgitation, severe PA systolic hypertension. These findings were unchanged since her echocardiogram on [**2113-6-13**]. Of note, while her heart failure exacerbation this admission was enlarged in part due to the fine balance between diastolic dysfunction and end stage valvular disease, the high salt diet at her [**Hospital3 **] facility may also be a precipitant. B. Valves; 3+ tricuspid regurgitation, 3+ mitral regurgitation. The patient refuses surgery. C. Rhythm; the patient has chronic paroxysmal atrial fibrillation for at least two years. Coumadin was held initially secondary to a supratherapeutic INR, then secondary to a gastrointestinal bleed (see below). Telemetry was notable for a sinus rhythm with paroxysmal atrial fibrillation, and several runs of supraventricular tachycardias with aberrancy. The patient was treated shortly with Amiodarone, however, it was not continued secondary to fear of pulmonary and renal consequences in a patient with our baseline deficits regarding those organs. Digoxin was continued this admission. Cardioversion was deferred as the patient was Do-Not-Resuscitate/Do-Not-Intubate and a transesophageal echocardiogram was not an option and deferred. D. Ischemia; Creatinine kinases on admission were 77. The patient has a known coronary artery disease, status post coronary artery bypass graft. There was no evidence of ischemia on this admission. Aspirin was held secondary to gastrointestinal bleeding (see below); Lipitor was continued on this admission. 2. Pulmonary - The patient has chronic hypoxemia (likely baseline pAO2 in the 60s), on 2 liters of home oxygen, restricted lung defect, and lung carcinoma, status post lung resection. She is likely a carbon dioxide retainer as well and worsened mental status was noted in the setting of carbon dioxide retention. Oxygen saturations were roughly maintained at 90 to 94% which should be her baseline on 2 liters of nasal cannula. 3. Renal - The patient presented with a creatinine of 3.0 and left with a creatinine of 1.9 which is slightly higher than her baseline of 1.7. 4. Gastrointestinal - The patient had melena during this admission and was evaluated by the Gastroenterology Consult Service who elected not to pursue endoscopy given the Do-Not-Resuscitate/Do-Not-Intubate status. It was likely an upper gastrointestinal source. The patient was maintained on Protonix and her hematocrits stabilized once her anticoagulation was discontinued. On discharge she was guaiac negative. 5. Genitourinary - The patient has a long history of pyuria/dysuria and recurrent urinary tract infections. She was treated with Levofloxacin at 250 mg p.o. q.d. for a urinary tract infection on admission and on the day of discharge will be day #9 of 14 of Levofloxacin. She was also treated with Pyridium during this admission as well. CODE STATUS: The patient is Do-Not-Resuscitate/ Do-Not-Intubate. The patient's primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] visited the patient during this admission to discuss a contingency plan if the patient were to decompensate similarly in the future. As documented in his [**Hospital 16730**] medical record note dated [**2113-10-6**]; the patient wants a repeat visit to the Intensive Care Unit if further decompensation was to occur. She does not desire intubation, however. She does not feel hospitalization or Intensive Care Unit admission is undue suffering. The patient's proxy is her [**Last Name (LF) 802**], [**Name (NI) **] [**Name (NI) 32330**]. DISCHARGE MEDICATIONS: 1. Lisinopril 2.5 mg p.o. q.d. hold for systolic blood pressure less than 90 2. Lasix 20 mg p.o. q.d., hold for systolic blood pressure less than 95 (titrate up as tolerated, the patient's usual dose was 160 mg p.o. b.i.d. prior to this admission) 3. Metoprolol 12.5 mg p.o. b.i.d., hold for systolic blood pressure less than 100 4. Digoxin 0.125 mg p.o. q.d. 5. Protonix 40 mg p.o. q.d. 6. Zocor 20 mg p.o. q.d. 7. Levofloxacin 250 mg p.o. q.d., date of discharge [**10-9**], is day #9 of a 14 day course. 8. Allopurinol 200 mg p.o. q.d. 9. Sodium chloride nasal spray 1 to 2 sprays n.u. b.i.d. 10. Acetaminophen 325 to 650 mg p.o. q. 4-6 hours prn pain 11. Ambien 5-10 mg p.o. h.s. prn insomnia 12. Ativan 0.5 to 1 mg p.o. q.d. prn anxiety 13. Senna 1 tablet p.o. b.i.d. prn constipation FOLLOW UP: The patient will be discharged to an acute rehabilitation center. Follow up at the rehabilitation should include - 1. Daily weights the patient's dry weight is 149 lbs. The patient will reaccumulate fluid if left to her own diuresis. Therefore, Lasix should be titrated up accordingly as the patient's weight exceeds her dry weight. 2. The patient should have a chem-10 checked approximately two times per week to monitor her sodium, potassium and electrolytes. 3. The patient will be sent to rehabilitation on 2 liters of nasal cannula of oxygen which is her baseline. The patient should also continue incentive spirometry. Appointments - The patient will have a follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to be scheduled by his office. The patient will also follow up with Dr. [**First Name (STitle) 2031**] at the Heart Failure Clinic and will be scheduled for an appointment in approximately one week after discharge. The patient should also follow up with Urology given her long history of pyuria and dysuria and recurrent urinary tract infections. This matter will be addressed with her primary care physician. [**Name10 (NameIs) **] patient will be contact[**Name (NI) **] with an appointment. The patient should also follow up with physical therapy at rehabilitation, please refer to patient history. CONDITION ON DISCHARGE: Stable. PRINCIPAL DIAGNOSIS: 1. Heart failure [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Name8 (MD) 17844**] MEDQUIST36 D: [**2113-10-8**] 16:42 T: [**2113-10-8**] 17:13 JOB#: [**Job Number 32331**]

[ "599.0", "428.33", "396.3", "585", "998.12", "427.31", "E870.5", "578.9", "584.9" ]

icd9cm

[ [ [] ] ]

[ "00.13" ]

icd9pcs

[ [ [] ] ]

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152,998

13167+56433

Discharge summary

report+addendum

Admission Date: [**2173-7-29**] Discharge Date: [**2173-8-16**] Date of Birth: [**2092-4-29**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor Last Name 1350**] Chief Complaint: low back pain Major Surgical or Invasive Procedure: [**2173-7-30**]: I&D of posterior spine wound infection with removal of hardware (T2-L3) and VAC placement. [**2173-8-1**]: repeat I&D of spine wound infection with VAC placement. [**2173-8-3**]: repeat I&D of spine wound infection with re-instrumentation of T3-L5 posterior spinal fusion and incisional VAC placement. History of Present Illness: 81yoM s/p T3-L3 fusion by Dr. [**Last Name (STitle) 1007**] with T4/5 and L1 laminectomies, L2 laminotomy with allograft placed on [**2173-6-5**] for T5 and L1 fracture-dislocations after fall from roof, now with increased pain at lumbar spine. Has had progressive pullout of screws at L2 and L3. denies fevers, but does have 3cm wound dehiscence at superior portion of wound, but no purulence seen. ESR: 138. WBC 11. CRP 300. based on symptoms and lab values, decision was made to perform I&D of wound. Past Medical History: PMH: GERD, HTN, ankylosing spondylitis, hyperlipidemia. Social History: currently at rehab. Physical Exam: elderly male, mild distress, pleasantly conversant. mildly TTP over lumbar spine. about 3cm area of wound dehiscence near superior end of incision, but no expressible purulence. good strength and sensation in BLE. Pertinent Results: [**2173-7-29**] 01:15PM GLUCOSE-113* UREA N-17 CREAT-0.7 SODIUM-134 POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-28 ANION GAP-15 [**2173-7-29**] 01:15PM CRP-GREATER THAN 300 [**2173-7-29**] 01:15PM WBC-11.7* RBC-3.38* HGB-9.0* HCT-29.0* MCV-86 MCH-26.7*# MCHC-31.1 RDW-13.6 [**2173-7-29**] 01:15PM NEUTS-75.9* LYMPHS-14.1* MONOS-5.6 EOS-4.0 BASOS-0.4 [**2173-7-29**] 01:15PM PLT COUNT-787*# [**2173-7-29**] 01:15PM SED RATE-138* Brief Hospital Course: admitted to the [**Hospital1 18**] spine surgery service on [**2173-7-29**] from the ER. seen by Medicine Consult service for preop eval. due to recent DOE they suggested having a chest CT done. this was negative for a pulmonary embolism and he was ready for the OR on [**7-30**]. he underwent I&D with removal of hardware and VAC placement on [**7-30**]. he was extubated and transferred to the floor after a PACU stay. he had tachycardia despite IVF boluses on [**7-31**] and was transferred to the TICU for closer monitoring. started on vanco/cipro/ceftazidime pending culture results. this was narrowed to vanco when cx's showed MRSA from OR samples. no growth in blood or urine cx's. he had repeat I&D with VAC placement on [**8-1**]. he was transferred back to the TICU intubated after this surgery. he was extubated but required several transfusions due to high VAC output. on [**8-3**] he had repeat I&D with reinstrumention from T3-L5 posterior spine fusion hardware. he was transferred to the TICU postop and subsequently extubated and transferred to the floor on [**8-5**]. he has now remained afebrile and his white count has normalized. he has slowly mobilized with PT/OT using his TLSO brace when upright. his brace was adjusted by NOPCO. he was initially on TEDs/SCDs for DVT prophylaxis and started on subq heparin following his final surgery. his vanco dose has been titrated based upon trough levels and ID recommended starting rifampin in combination with vanco on [**8-10**]. he had a left arm PICC placed on [**8-9**]. his pain is controlled with PO analgesia and he is tolerating a regular diet. he continued to have some serosanguinous drainage from his incision after the incisional VAC dressing was removed on [**8-7**], but this is lessening and he is undergoing daily dressing changes. VAC was replaced on [**2173-8-14**] to a 2cm portion near the inferior portion of the wound that is still with mild drainage. otherwise he is getting out of bed to the chair with his brace on and his labs are normalizing. he is ready for discharge to rehab. he will continue with VAC therapy for now and wean to daily DSD as the wound heals. he will continue on IV and PO abx for about 6 weeks and then likely continue with PO suppressive abx for lifetime. Medications on Admission: NKDA. Meds: alubterol, lipitor, metoprolol, oxycodone, protonix, apap, colace, senna, MOM, bisacodyl. Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for constipation. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD () as needed for pain. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): plan for 6-wk duration. 11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 12. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous Q 24H (Every 24 Hours): plan for 6-wk duration. 13. lab checks weekly lab checks while on antibiotics. cbc with diff, chem 8, LFTs, ESR, CRP, vanco trough. fax results to [**Hospital 18**] [**Hospital **] clinic: ([**Telephone/Fax (1) 1353**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: infection of T3-L3 posterior spine fusion Discharge Condition: stable Discharge Instructions: You have undergone the following operation: irrigation and debridement with revision of posterior thoracolumbar fusion hardware for infection. Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Limit any kind of lifting. - Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. - Brace: You may have been given a brace. This brace is to be worn when you are upright (sitting/walking). You may take it off while lying in bed. - Wound Care: place a dry, sterile dressing daily until it has completely healed. If it is dry then you can leave the incision open to the air. Once the incision is completely dry you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. o We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: TLSO brace when upright. no heavy lifting. WBAT BLE. Treatments Frequency: daily DSD until there is no drainage from posterior spine incision. Followup Instructions: call [**Telephone/Fax (1) 3736**] to schedule a follow-up appt with dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in about 10-14 days. call ([**Telephone/Fax (1) 4170**] to schedule a follow-up appt with the Infectious Disease clinic in about 1-2 weeks. continue weekly lab checks with results faxed to [**Hospital 18**] [**Hospital **] clinic. Completed by:[**2173-8-16**] Name: [**Known lastname 7232**],[**Known firstname 7233**] Unit No: [**Numeric Identifier 7234**] Admission Date: [**2173-7-29**] Discharge Date: [**2173-8-16**] Date of Birth: [**2092-4-29**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor Last Name 147**] Addendum: patient had sepsis without organ dysfunction requiring intensive care in the ICU from [**8-1**] through [**2173-8-5**]. Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 148**] MD [**MD Number(2) 149**] Completed by:[**2173-8-24**]

[ "785.0", "238.71", "720.0", "458.29", "998.32", "041.12", "V15.82", "276.52", "285.1", "730.28", "996.67", "038.9", "530.81", "995.91", "E878.1", "401.9", "996.49", "272.4" ]

icd9cm

[ [ [] ] ]

[ "77.49", "86.28", "38.93", "83.21", "81.08", "77.69", "81.35", "81.64", "84.52", "78.69" ]

icd9pcs

[ [ [] ] ]

9535, 9771

2009, 4283

333, 654

6092, 6101

1553, 1986

8596, 9512

4435, 5904

6027, 6071

4309, 4412

6125, 6269

1319, 1534

8429, 8482

8504, 8573

7927, 8411

6303, 6513

280, 295

6992, 7915

682, 1188

1210, 1267

1283, 1304

7,599

186,433

11277

Discharge summary

report

Admission Date: [**2193-4-15**] Discharge Date: [**2193-4-19**] Date of Birth: [**2121-2-13**] Sex: M Service: MEDICINE Allergies: Ampicillin Attending:[**First Name3 (LF) 443**] Chief Complaint: Chest pain. Major Surgical or Invasive Procedure: Cardiac cath with Cypher stent placement ([**2193-4-15**]). History of Present Illness: 72 year old male with known CAD s/p CABG in [**2175**] (see below) and MI/PCI in [**2187**], chronic chest wall pain, who presented to [**Hospital 24356**] Hospital with complaints of worsening chest pain radiating to left arm and back, associated with diaphoresis and presyncopal symptoms. Given ASA, NTG, heparin, plavix load, zofran, morphine, lopressor 50 mg at OSH. Trop I up to 20; EKG showed antero-lateral ST depressions. Guaiac negative at the OSH. Of note, there was a question of pulmonary infiltrate on CXR, so patient was given CTX and azithromycin for CAP. Past Medical History: 1. Coronary artery disease: a. Anterior STEMI / CABG ([**2175**]) - LIMA to LAD - SVG to OM - SVG to PDA - SVG to D2 b. Percutaneous coronary intervention ([**2177**]) - No intervention with one occluded SVG c. NQWMI / Percutaneous coronary intervention ([**2187**]) - LAD total occlusion proximally - LCx 90% occluded prox --> s/p stenting (3.0 x 18mm BX Velocity) - RCA total occusion proximally - SVG --> PDA patent - SVG --> OM total occlusion - SVG --> D2 90% distal stenosis --> s/p stenting (4.0 x 18mm BX velocity) 2. Hypertension 3. Chronic obstructive pulmonary disease 4. Gastroesophageal reflux disease: s/p Billroth II gastrectomy 5. Bipolar disorder 6. s/p diskectomy 7. s/p carotid endarterectomy 8. Chronic chest wall pain, followed at the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] management center 9. Splanchnic neuropathy s/p spinal cord stimulator implantation [**2191**]-removed in [**2192**] 10. s/p right hernia repair Social History: Social history is significant for current tobacco use (1 pack every other day). There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death. Family History: Non-contributory. Physical Exam: Blood pressure was 94/65 mm Hg while supine, intubated/sedated. Pulse was 64 beats/min and regular, respiratory rate was 15 breaths/min. Generally the patient was well developed, well nourished. There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of 7 cm. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There were no rubs, murmurs, clicks or gallops. The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, clubbing or edema. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral no bruit, hematoma, bleeding at cath site Popliteal 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Pertinent Results: ADMIT LABS: ([**2193-4-15**]): CBC: WBC-17.6* RBC-3.86* Hgb-12.8* Hct-37.7* MCV-98 MCH-33.1* MCHC-33.9 RDW-15.0 Plt Ct-420 Neuts-82.9* Lymphs-11.8* Monos-4.1 Eos-1.0 Baso-0.2 COAGS: PT-12.7 PTT-71.8* INR(PT)-1.1 CHEMISTRIES: Glucose-113* UreaN-8 Creat-0.7 Na-137 K-3.9 Cl-105 HCO3-26 AnGap-10 Calcium-8.0* Phos-2.8 Mg-2.5 CARDIAC ENZYMES: [**2193-4-15**] 11:56PM BLOOD CK(CPK)-737* CK-MB-86* MB Indx-11.7* [**2193-4-16**] 03:14AM BLOOD CK(CPK)-699* CK-MB-70* MB Indx-10.0* ABG: [**2193-4-15**] 08:01PM BLOOD Type-ART Temp-37.0 Rates-14/ Tidal V-600 FiO2-60 pO2-213* pCO2-47* pH-7.40 calTCO2-30 Base XS-3 Intubat-INTUBATED ECG ([**2193-4-15**]): Sinus rhythm Consider left atrial abnormality Consider left ventricular hypertrophy and possible biventricular hypertrophy Nonspecific intraventricular conduction delay ST-T wave abnormalities with probable QT interval prolonged although is difficult to measure - cannot exclude in part ischemia or drug/metabolic/electrolyte effect Since previous tracing of [**2192-9-18**], inferior myocardial infarction less evident CXR ([**2193-4-15**]): Irregular opacification at the base of the right lung could represent pneumonia. There is also a linear opacity more laterally in the right mid lung, likely atelectasis or scar. Upper lungs are clear. The patient has had median sternotomy and coronary bypass grafting. The right hilus is enlarged but has a vascular appearance. There is no evidence elsewhere of central adenopathy. Heart size is normal, and there is no pleural effusion. Endotracheal tube is in standard placement. CARDIAC CATH ([**2193-4-15**]): 1. Coronary angiography of this right dominant system demonstrated 3 vessel coronary artery disease. The LMCA had no angiographically apparent flow-limiting disease. The LAD was occluded at the ostium. The LCx had an OM with a 40% mid-vessel stenosis. The RCA was occluded proximally and filled distally by left to right collaterals. 2. Graft angiography demonstrated a SVG-Diagonal with a thrombotic occlusion in the proximal segment. The SVG-OM and SVG-PDA had stump occlusions. 3. Arterial conduit angiography demonstrated a patent LIMA-LAD. 4. Limited resting hemodynamics revealed normal systemic arterial pressure with a BP of 108/60 mmHg. 5. The lesion in the SVG-Diagonal was treated with thrombectomy, stenting using a 3.5 mm Cypher stent and post dilation with a 4.0 mm balloon. Final angiogram showed TIMI III flow with no residual stenosis, no residual thrombus, no dissection and no embolization. (See PTCA comments) FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Thrombotic occlusion of the SVG-Diagonal. 3. Occluded SVG-OM and SVG-PDA. 4. Patent LIMA-LAD. 5. Succesful stenting of the SVG-Diagonal lesion with Cypher stent. ECHO ([**2193-4-16**]): The left atrium is markedly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the septum, and anterior wall. Tissue Doppler imaging suggests 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 (?#) are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2) and trivial aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Regional left ventricular dysfunction consistent with coronary disease. Mild aortic stenosis. Mild mitral regurgitation. Brief Hospital Course: 1. NSTEMI: Patient presented with chest pain that was worse than his usual chest wall pain and was refractory to percocet. EKG and cardiac enzymes were consistent with a NSTEMI. He presented on heparin and ASA/Plavix; integrillin was added and he was taken to the cath lab. Cardiac cath showed the SVG-Diagonal graft with a thrombotic occlusion in the proximal segment - this was stented using a 3.5 mm Cypher stent and post dilation with a 4.0 mm balloon. Final angiogram showed TIMI III flow with no residual stenosis, no residual thrombus, no dissection and no embolization. Of note the patient became very combative prior to the intervention and asked to terminate the case. Consent to intubate was obtained from the daughter and the patient was sedated and intubated. Post-cath, the patient was monitored in the CCU and remained intubated overnight. His pressures were in the 80s systolic and he was given IVF boluses; he did not require pressors. He was extubated the morning after admission without incident Echo showed an EF of 35% with antero-septal and apical wall motion abnormalities. The integrillin was continues for 18 hours. ASA and Plavix (initially daily, increased to [**Hospital1 **] on HD#2) were also continued. Metoprolol and captopril were written, but note dosed early on, given his low blood pressures. He did not present on a statin; high dose atorvastatin was added. Given the patient's depressed EF and CAD, outpatient referral for possible ICD was recommended. 2. Pneumonia: At the OSH, the patient had a CXR which showed a possible pneumonia. On presentaiton, his WBC was elevated and he had low grade fevers. The CXR showed a possible RLL infilitrate. Given this, he was continued on antibiotics for community acquired pneumonia (azithromycin and ceftriaxone with plan for seven day course. Cultures (sputum and blood) did not show any growth. 3. Hypertension: Antihypertensives were used, as above. 4. GERD: Continued PPI. 5. COPD: Nebs were given PRN. 6. Bipolar disorder: Monitored; did not required any medications. 7. Chronic pain: Morphine, the percocet were used PRN. 8. Constipation: Bowel regimen Medications on Admission: Atenolol 25mg daily Captopril 12.5mg TID Percocet PRN ASA 81mg daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*6* 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*6* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 7. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 1 days. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary: 1. Non ST-elevation myocardial infarction Secondary: 1. Pneumonia (community acquired) 2. Coronary artery disease 3. Hypertension 4. Gastroesophageal reflux disease 5. Chronic obstructive pulmonary disease 6. Bipolar disorder Discharge Condition: Hemodynamically stable. Discharge Instructions: You were admitted after having a heart attack. A stent was placed in one of the bypass vessels. In order to help keep this and the other vessels open you must taken Aspirin and Plavix EVERY DAY. If you experience any chest pains, shortness of breath or have any questions or concerns, please be sure to call your PCP or your cardiologist. There have been multiple medications added to your regimen. These are all important to take given that you had a heart attack. ADDED: 1. Plavix: This helps aspirin to thin the blood and is especially important given that you had a stent placed. You should be sure to take this TWICE A DAY for a minimum of one year. Do not skip any doses and do NOT stop this medication unless instructed by a cardiologist. 2. Aspirin: This is not a new medication, but you should be sure to take a full 325mg dose, daily. 3. Atorvastatin: This is a cholesterol medication that is important for you to take, given that you had a heart attack. 4. Lisinopril: This is a blood pressure medication that also helps in patients who have had heart attacks. 5. Toprol XL: This is similar to the atenolol you had been on previously. It should be taken once daily. As we have mentioned during your stay, there is nothing you can do to improve your health more than QUITTING SMOKING. Followup Instructions: Please be sure to follow-up with your PCP and your cardiologist. 1. Dr. [**Last Name (STitle) **]: [**2193-4-26**] at 9:15am. Please discuss with your doctor regarding cardiac rehabiliation.

[ "E849.7", "E849.8", "496", "458.29", "E879.0", "414.01", "530.81", "414.02", "410.71", "564.00", "296.80", "305.1", "486" ]

icd9cm

[ [ [] ] ]

[ "00.45", "00.66", "88.56", "36.07", "96.71", "96.04", "00.40", "37.22", "99.20" ]

icd9pcs

[ [ [] ] ]

10634, 10705

7517, 9683

282, 344

10985, 11011

3709, 4035

12372, 12570

2219, 2238

9802, 10611

10726, 10964

9709, 9779

6272, 7494

11035, 12349

2253, 3690

4052, 6255

231, 244

372, 947

969, 1987

2003, 2203

5,619

169,918

45216

Discharge summary

report

Admission Date: [**2181-7-25**] Discharge Date: [**2181-8-10**] Date of Birth: [**2104-1-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 49939**] Chief Complaint: SOB and cough Major Surgical or Invasive Procedure: None History of Present Illness: In brief, 77yo M w/ non-ischemia CMP, CHF (EF=15%, [**12-14**]), AF, DM, and CKD p/w intermittent SOB and exacerbation of non-productive cough. . He was discharged 2 days PTA for FTT to rehab. Pt admits to chronic intermittent non-productive cough, which has been exacerbated for last 2 days and now associated with increased SOB. Patient has a history of DOE, stable 1-pillow ONP, and no SOB lying on 2 pillow. . He has no CP, diaphoresis, palpitations. He denies F/C/S. No URI symptoms of sore-throat or nasal congestion. No hemoptysis. No abdominal pain/N/V/D, but complains of constipation on admission. No melena/BRBPR. No symptoms of GERD. Pt explains that he was unsatisfied with his experience at [**Last Name (un) 2299**] house, and requested return to the [**Hospital1 **] ED. . In the ED, his vitals were 97.7, HR68, BP92/63, RR26, 91% on RA. He spiked a fever of 101.4, demonstrated leukocytosis 12.5, elevated D-dimer, and RLL patchy opacity on CXR. . Past Medical History: Past Medical History: non ischemic restrictive cardiomyopathy EF 15% Afib Chronic Kidney Disease Pulmonary Hypertension Diabetes PSH: Prostate Cancer s/p resction Multiple Abdominal Hernias s/p repair s/p repair bil. carpal tunnel syndrome s/p bil knee replacement s/p repair rectal prolapse Social History: Patient currently at rehab s/p recent hospital admission. Usually lives with wife and daughter in [**Location (un) 686**]. Used to be the navy as a cook. Quit smoking 25 yrs ago. He drinks 4-5 beers per week. Family History: Mother with congestive heart failure. Physical Exam: Vitals - T97, BP88/60, HR64, RR18, 99% on 2LO2, FS 126 General - sleeping comfortably, well appearing, able to finish full sentences, no labored breathing HEENT - EOMI, anicteric, OP wnl Neck - supple, JVD 7cm CVS - RRR, nl s1/s2, +s3 Lungs - mildly decreased breath sounds on right side, no egophony. Abdomen - soft, NT/ND, +bowel sounds, liver border 1cm below costal margin, no ascites Extremities - No C/C/E bilaterally, 2+ DP/PT Skin - no rashes or lesions noted. neuro - sleeping but arouseable, A+Ox3, CNII-XII grossly intact, marked decreased bulk with preseverd strength and tone. Sensation intact to light touch in periphery, no asterixis. Pertinent Results: CHEST (PA & LAT) [**2181-7-24**]: Congestive failure. Asymmetric opacity of right lower lung may represent superimposed pneumonia. . ABDOMEN U.S. [**2181-7-25**]: 1. Cholelithiasis and gallbladder sludge without evidence of cholecystitis or biliary tract dilatation. 2. Minimal ascites and small right pleural effusion. 3. Mildly ectatic pancreatic duct with no obstructing lesions seen. This may not be of clinical consequence as similar slight prominence of the pancreatic duct can be seen on a CT from [**2180-7-5**]. . HEMATOLOGY [**2181-7-26**] 06:50AM BLOOD WBC-11.3* RBC-4.82 Hgb-11.7* Hct-35.9* MCV-74* MCH-24.2* MCHC-32.6 RDW-19.7* Plt Ct-412 [**2181-7-24**] 09:30PM BLOOD Neuts-84.5* Lymphs-10.1* Monos-4.0 Eos-0.4 Baso-0.9 [**2181-7-24**] 09:30PM BLOOD WBC-12.5* RBC-5.32 Hgb-12.8* Hct-38.6* MCV-73* MCH-24.1* MCHC-33.1 RDW-19.9* Plt Ct-428 . COAGS [**2181-7-26**] 06:50AM BLOOD PT-33.4* PTT-33.1 INR(PT)-3.6* [**2181-7-25**] 07:05AM BLOOD PT-33.1* PTT-36.0* INR(PT)-3.6* . ELECTROLYTES [**2181-7-26**] 06:50AM BLOOD Glucose-109* UreaN-50* Creat-1.8* Na-135 K-4.0 Cl-100 HCO3-25 [**2181-7-24**] 09:30PM BLOOD Glucose-157* UreaN-59* Creat-2.1* Na-132* K-4.0 Cl-94* HCO3-26 AnGap-16 . HEPATIC [**2181-7-26**] 06:50AM BLOOD ALT-22 AST-38 AlkPhos-365* TotBili-1.3 [**2181-7-26**] 06:50AM BLOOD Albumin-2.9* Calcium-8.7 Phos-3.4 Mg-2.4 . MISCELL [**2181-7-24**] 10:38PM BLOOD D-Dimer-1197* [**2181-7-25**] 07:05AM BLOOD CEA-7.3* . ECHO [**2181-8-9**] 1. The right atrium is moderately dilated. 2. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. These findings are consistent with but not diagnostic of amyloid. 3. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 4. The aortic root is moderately dilated. 5. There is moderate pulmonary artery systolic hypertension. 6. Compared to the previous study of [**2177-12-1**], the LVH has increased. Brief Hospital Course: Assessment/Plan: 77yo M w/ non-ischemia CMP, CHF (EF=15%, [**12-14**]), AF, DM, and CKD p/w intermittent SOB and exacerbation of non-productive cough. He was transferred to the MICU for closer monitoring after admission due to an increase in his oxygen requirement. He was clearly DNR/DNI, but a trial of CPAP was thought to be reasonable. . 1) Respiratory distress: When transferred to the MICU, the shortness of breath was thought to be most likely due to cardiac pulmonary edema. He was also started on empiric antibiotics to cover a possible pneumonia or bronchitis. His studies were most consistent with CHF; a diuresis was begun. Given the large doses of lasix that he is on, as well as a SBP in the 90s at baseline, a lasix drip was started. He was also tried on CPAP over his first night in the ICU, which he did not tolerate. His lasix drip was continued, with a I/O goal of 1-2L / day during his first few days. He met this goal, and on two occassions he required diuril in addition to the lasix drip. His O2 sats were initally in the high 80s on 100 NRB and 5L nc; on discharge from the MICU, his O2 sats are 98-100% on 5L nc. It is likely that he will require home oxygen. He is net a total 7L negative. He is currently on his home dose of lasix (160mg PO bid). He was also started on digoxin to aid in his forward flow; he has been therapeutic. His diuretics were changed to Lasix 120mg PO bid and HCTZ 12.5mg qd to reduce toxicity of Lasix. He was kept about 300-500cc negative per day. A work-up for potential amiodarone toxicity with a Chest CT scan revealed a pneumomediastinum. Pulmonary services were consulted and did not feel an intervention was indicated. The patient did not develop respiratory distress. During the course on the floor we were able to reduce his O2 to three litres. Since he still has some pulmonary edema, cautious diuresis can be continued. Regarding a potential amiodarone toxicity we consulted the CHF service. The recommendation was that amiodarone was initially started for atrial flutter in the history of the patient.But the patient was in sinus rhythm on the floor with no signs of palpitations. CHF service felt comfortable that amiodarone could be discontinued since there was no indication to use it at this point. Since it was also the recommendation of the pulmonary service not to use amiodarone anymore if not necessary, we discontinued amiodarone before discharge. The patient is discharged to rehab requiring oxygen at three litres and O2 saturations of 98-100%. . Cardiomyopathy/Heart failure: TTE [[**12-14**]] and repeated again [[**8-9**]]demonstrated EF 15%-20%. He is followed closely by Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] as an outpatient. Given his acute decompensation (no clear etiology), his coreg was held. His hydralazine was also held as his SBP would dip to the mid 80s. On the last two days of ICU stay, his hydralazine was restarted, and he was placed back on his home dose of lasix. His coreg will most likely need to be restarted as an outpatient. On the floor the patient maintained baseline systolic pressures around 90mmHG, so we discontinued hydralazine. . 2) Atrial fibrillation: Patient has defibrillator, and was rate controlled with BB and amiodarone. He remained in NSR during most of the stay in the ICU. His rate was well controlled with amiodarone. Pt had INR of 6.9 2days PTA, and instructed to hold coumadin. His INR was 4.6 on admission, and his coumadin was held until INR<3.0. He was restarted on [**2181-8-4**]. EKG remained stable without any acute changes. Cardias service felt that amiodarone was not necessary for rate control so it was discontinued because of potential pulmonary toxicity. . 3) CKD: His creatinine was near his baseline on admission. On [**2181-8-4**] his creatinine began to rise, as did his BUN and HCO3, indicating most likely that he was intravascularly dry, which was the goal. His urine output was adequate. During the stay on the floor his creatinine was stable and declined from 2.2 to 1.6 on discharge day. . 4) DM: Well-controlled; he was only covered with a RISS and a diabetic diet. . 5) Hypothyroid: Patient was continued on synthroid, with no concerning si/sx of hypothyroidism. He had recent TFTs that were reasonable, and were not checked during this admission. . 6) Anemia: Pt had h/o anemia with a baseline hct 33-37. No active issues this admission. . Medications on Admission: Amiodarone 200 mg PO DAILY Cholecalciferol 400 unit PO BID Levothyroxine 25 mcg PO DAILY Carvedilol 12.5 mg PO BID Lactulose 30ml PO q8hr PRN constipation Furosemide 160 mg PO BID Insulin sliding scale Discharge Medications: 1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*30 Tablet, Chewable(s)* Refills:*0* 4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*30 Tablet, Chewable(s)* Refills:*2* 10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 11. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 17. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 20. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). 21. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 22. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 23. Insulin Sliding Scale Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: 1. Pneumonia 2. Congestive heart failure 3. Non-ischemic cardiomyopathy 4. Atrial fibrillation 5. Diabetes mellitus 6. Chronic kidney disease 7. Pulmonary hypertension 8. Pneumomediastinum Discharge Condition: Afebrile. Requiring 3L O2 at home. Discharge Instructions: 1. Patient was admitted to [**Hospital1 18**] with diagnosis of pneumonia and exacerbation of congestive heart failure 2. Please take medications as prescribed. 3. Please keep appointments as described. 4. Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases more than 3 lbs. 5. Adhere to 2 gm sodium diet and restrict fluids to 1500ml. 6. Patient was diagnosed with pneumomediatinum that could be complicated by pneumothorax. If patient develops acute respiratory distress, please immediatly evaluate if insertion of achest tube is indicated (should be at patient's bedside) Followup Instructions: 1. Weekly appointment with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2181-8-28**] 10:00 Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2181-8-28**] 10:00 Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2181-8-28**] 9:40 Completed by:[**2181-8-10**]

[ "425.7", "V45.02", "518.82", "E879.8", "486", "250.00", "585.9", "427.31", "790.4", "V10.46", "285.9", "428.40", "244.9", "998.81", "277.3" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

11673, 11770

4712, 9164

330, 337

12003, 12040

2614, 4689

12692, 13252

1890, 1929

9416, 11650

11791, 11982

9190, 9393

12064, 12669

1944, 2595

277, 292

365, 1332

1376, 1648

1664, 1874

76,800

182,372

46573

Discharge summary

report

Admission Date: [**2110-9-8**] Discharge Date: [**2110-9-17**] Date of Birth: [**2028-5-1**] Sex: F Service: CARDIOTHORACIC Allergies: Diltiazem Attending:[**First Name3 (LF) 922**] Chief Complaint: Fatigue/Dyspnea/Heart failure Major Surgical or Invasive Procedure: [**2110-9-11**] Exploration of R brachial artery, embolectomy [**2110-9-9**] L thorc, lead placement, BiV pacer History of Present Illness: 82 year old female status post CABG x 3 in [**2108**] who now is quite symptomatic secondary to heart failure with a reduced left ventricular ejection fraction and complete left bundle-branch block. She also has a very long atrioventricular conduction time, which is also detrimental to optimal hemodynamics. An attempt was made to place a lead transvenously however this was not possible due to technical issues having to do with coronary sinus anatomy. Her functional status continues to decline and she currently complains of fatigue and dyspnea on exertion after approximately 1 block of walking. In addition, she complains of orthopnea. As she is likely to benefit from cardiac resynchronization therapy, she has been referred to Dr. [**Last Name (STitle) 914**] for placement of an LV lead. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia 2. CARDIAC HISTORY: - Paroxysmal atrial fibrillation since [**2098**] treated in the past with sotalol and dronedarone, both of which were discontinued due to inefficacy as well as post-cardioversion bradycardia. - Persistent atrial fibrillation since [**2108-11-27**] despite two cardioversions attempts, maintained in sinus rhythm now on amiodarone 200 mg a day. - Mixed cardiomyopathy with an LV ejection fraction in the range of 32% since [**2109-4-27**]. - Coronary artery disease bypass grafting x3 with a LIMA to the LAD and reverse saphenous vein graft to the RCA and marginal branches (Left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the right coronary artery and the marginal branch.) - Chronic left bundle-branch block with mild-to-moderate AR and trivial MR. - Status post St. [**Male First Name (un) 923**] and Anthem RF dual-chamber pacemaker implantation in [**2109-12-28**] with capping of the LV port given the absence of satisfactory CS anatomy. 3. OTHER PAST MEDICAL HISTORY: - hypercholesterolemia - osteoporosis - multifocal papillary thyroid cancer, small cell variant, s/p 150 mCi I-131 in [**2103**] - basal cell carcinoma - [**Last Name (un) 8061**] syndrome - s/p cataract extraction OU - macular degeneration - R lung nodule - s/p TAH Social History: She is a retired dental office administrator. Lives alone, son had been staying with her. -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: hyperthyroidism, colon cancer father died of MI in 50s, younger brother had CABG and cath at age 76. no hx of arrhythmia, cardiomyopathies Physical Exam: Pulse: 72 Resp: 16 O2 sat: 98% B/P Right: 95/60 Left: 97/59 Height: 4'[**09**]" Weight: 95 lbs General: Well-developed frail elderly female in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Mostly clear lungs bilaterally with some scattered rales at base, Healed sternotomy incision Heart: RRR [X] Irregular [] Murmur [X] soft holosystolic Abdomen: Soft [X] non-distended [X] non-tender [X] +BS [X] Extremities: Warm [X], well-perfused [X] Edema-none, healed EVH incision LLE Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: Admission labs: [**2110-9-8**] 11:14AM PT-14.4* PTT-19.5* INR(PT)-1.2* [**2110-9-8**] 05:30PM WBC-4.6 RBC-2.82* HGB-9.5* HCT-27.5* MCV-98 MCH-33.7* MCHC-34.5 RDW-18.4* [**2110-9-8**] 05:30PM PT-15.3* PTT-25.5 INR(PT)-1.3* [**2110-9-8**] 05:30PM UREA N-40* CREAT-1.3* SODIUM-140 POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-24 ANION GAP-11 Discharge labs: [**2110-9-17**] 05:21AM BLOOD WBC-6.7 RBC-2.96* Hgb-9.6* Hct-28.9* MCV-98 MCH-32.4* MCHC-33.2 RDW-18.2* Plt Ct-259 [**2110-9-17**] 05:21AM BLOOD Plt Ct-259 [**2110-9-17**] 05:21AM BLOOD PT-28.6* INR(PT)-2.8* [**2110-9-17**] 05:21AM BLOOD Glucose-86 UreaN-34* Creat-1.2* Na-136 K-3.6 Cl-97 HCO3-32 AnGap-11 Radiology Report CHEST (PA & LAT) Study Date of [**2110-9-16**] 9:40 AM Final Report: In comparison to prior examination, the pleural effusions are stable to mildly increased in size. They are bilateral. The remainder of the lungs are unchanged from prior examination and the biventricular pacer along with a new epicardial lead are in unchanged correct position. IMPRESSION: 1. Stable-to-slightly increased moderate bilateral pleural effusions. Brief Hospital Course: Ms [**Known lastname 98804**] is well known to cardiac surgery. She was a direct admission to the operating room for LV lead placement via left thoracotomy, please see operative report for details. She tolerated the operation well and was transferred from the operating room to the cardiac surgery ICU in stable condition on Propofol and Neosynephrine infusions. She remained hemodynamically stable in the immediate post-op period, woke neurologically intact and was extubated. On POD1 the patient continued to require Neosynephrine to support blood pressure, it was weaned to off on POD1. She had an epidural catheter for pain control and this was removed on POD2. On POD3 the patients axillary arterial line was removed, and she was then noted to have numbness and loss of pulse on right hand, she was seen by vascular surgery and ultimately brought to the operating room for brachial artery exploration and embolectomy, see operative note for details. Following this procedure the patient was fully anticoagulated. Her numbness resolved and she had doplerable ulnar pulse. The patient remained hemodynamically stable throughout this process but remained in the ICU to monitor her vascular progress. She was transferred to the stepdown floor on POD7. Once on the floor her hospital course was uneventful. She worked with nursing, physical therapy and occupational therapy to increase her mobility, strength and endurance. On POD [**8-2**] she was transferredd to rehabilitation at [**Last Name (un) 1687**] House in [**Location (un) 95809**] Medications on Admission: AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth daily ATORVASTATIN - 10 mg Tablet once a day CALCITONIN (SALMON) - 200 unit/dose Aerosol, Spray - 1 spray each nostril daily CARVEDILOL - 6.25 mg Tablet - Tablet(s) 2 tabs QAM and 1 tab QPM FUROSEMIDE - 20 mg Tablet - 0.5 (One half) Tablet(s) once a day LEVOTHYROXINE - 112 mcg Tablet -1 Tablet(s) by mouth once daily LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth daily RANITIDINE HCL -150 mg Capsule by mouth once a day WARFARIN - 1 mg Tablet - 1.5 Tablet(s) by mouth daily ASPIRIN - 81 mg Tablet(E.C.) - 1 Tablet(s) by mouth once a day CALCIUM CITRATE-VITAMIN D3 -315mg-200 unit Tablet - one Tablet(s) twice daily MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - one Tablet(s) once daily VIT C-VIT E-COPPER-ZNOX-LUTEIN [PRESERVISION] 226 mg-200 unit-[**Unit Number **] mg-0.8 mg-34.8 mg Capsule - 1 Capsule(s) by mouth once a day Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol Sig: One (1) spray Nasal DAILY (Daily). 7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 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. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) package PO DAILY (Daily). 14. PreserVision AREDS 14,[**Telephone/Fax (3) 24725**] unit-mg-unit Capsule Sig: One (1) Capsule PO once a day. 15. furosemide 20 mg Tablet Sig: [**12-29**] Tablet PO once a day. 16. warfarin 1 mg Tablet Sig: 1.5 Tablets PO once a day: adjust dose to target INR 2.0-2.5. 17. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Last Name (un) 1687**] - [**Location (un) 745**] Discharge Diagnosis: [**2110-9-11**] Exploration of R brachial artery, embolectomy [**2110-9-9**] L thorc, lead placement, BiV pacer PMH: Hypertension, Dyslipidemia, Paroxysmal atrial fibrillation since [**2098**] tx w/sotalol & dronedarone, both discontinued d/t inefficacy and post-cardioversion bradycardia, Persistent atrial fibrillation since [**2108-11-27**] two cardioversions attempts, maintained in sinus rhythm now on amiodarone 200', Mixed cardiomyopathy w/LVEF 32% since [**2109-4-27**], Coronary artery disease s/p Coronary artery bypass graft x 3 [**2108**], Chronic LBBB w/mild-to-mod AR and trivial MR, Papillary thyroid Carcinoma s/p total thyroidectomy with lymph node resection s/p oral chemotherapy and radiation s/p radioactive iodine, Osteoporosis, lumbar compression fracture [**2109-3-16**], s/p Pelvic fracture 5 years ago, Lumbar degeneration s/p injections, [**Last Name (un) 8061**] syndrome, Basal Cell Cancer s/p excisions, Rotator cuff injury without repair, Hiatal Hernia, Gastroesophageal reflux disease, Pelvic organ prolapse s/p hysterectomy, Macular degeneration, Right lung nodule followed by Dr. [**Last Name (STitle) **], Coronary artery disease bypass grafting x 3 with a LIMA to the LAD and reverse saphenous vein graft to the RCA and marginal branches, s/p [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] and Anthem RF dual-chamber pacemaker implantation [**2109-12-28**] with capping of the LV port given the absence of satisfactory CS anatomy, s/p Total thyroidectomy [**2103**], Hysterectomy w/anterior/posterior olporrhaphy, Bilateral cataract surgery, Tonsillectomy, Excision of skin cancer lesions Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram/Tylenol Incisions: Left thoracotomy - healing well, no erythema or drainage Right hand remains eccymotic-ulnar pulse present/no radial pulse Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** call for: Weight gain more than 3 lbs Followup Instructions: You are scheduled for the following appointments Surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2110-10-14**] Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**11-5**] @1:30[**Hospital 98881**] clinic [**Hospital Ward Name 23**] [**Location (un) 436**] Vascular Surgeon: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] [**2110-10-1**] @12:45P [**Hospital Unit Name **] [**Hospital Unit Name **] Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) 20**] R. [**Telephone/Fax (1) 1408**] on [**10-10**] at 1:30pm **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication brachial thrombus/Atrial fibrillation Goal INR 2.0-2.5 First draw [**9-18**] Completed by:[**2110-9-17**]

[ "401.9", "425.4", "V45.81", "996.74", "V45.01", "444.21", "244.0", "V10.87", "428.0", "427.31", "E878.2", "426.3", "414.01", "272.4", "443.0", "428.23" ]

icd9cm

[ [ [] ] ]

[ "37.87", "37.74", "38.03" ]

icd9pcs

[ [ [] ] ]

8939, 9017

4896, 6442

304, 418

10704, 10942

3759, 3759

11904, 12883

2798, 2939

7378, 8916

9038, 10683

6468, 7355

10966, 11881

4116, 4873

2954, 3740

1326, 2318

234, 266

446, 1246

3775, 4099

2349, 2617

1268, 1306

2633, 2782

13,033

157,973

58570

Discharge summary

addendum

Name: [**Known lastname 400**], [**Known firstname 749**] JR Unit [**Name2 (NI) **]: [**Numeric Identifier 14564**] Admission Date: [**2182-11-30**] Discharge Date: [**2182-12-2**] Date of Birth: [**2148-4-23**] Sex: M Service: ADDENDUM: After the patient's MICU course, the patient was transferred to the medical team. HOSPITAL COURSE: The patient did well the day following his transfer from the MICU. His blood pressure remained well controlled on his current regimen and he no longer had any nausea, vomiting or other complaints. The patient tolerated p.o. diet well. He was felt to be stable on his current regimen and was discharged with close follow-up. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Gastroparesis. 2. Diabetes mellitus type 1. 3. Hypertensive urgency. MEDICATIONS ON DISCHARGE: The patient was told to continue all previous medications as prescribed. FOLLOW-UP PLANS: The patient was told to follow-up with Dr. [**First Name8 (NamePattern2) 302**] [**Last Name (NamePattern1) **], [**2182-12-3**], at 8:30 p.m. The patient was told to follow-up with cardiology [**2182-12-13**], at 9:00 a.m. as well as with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] on [**2182-12-18**], at 3:00 p.m. The patient was told to continue taking all medications as prescribed. If he developed any worsening nausea, vomiting, fevers, chills, headache, visual symptoms or any concerning symptoms whatsoever, he should immediately contact his primary care physician or return to the Emergency Department. [**First Name8 (NamePattern2) 46**] [**Doctor First Name 258**], M.D. [**MD Number(1) 259**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2182-12-9**] 18:01 T: [**2182-12-9**] 20:44 JOB#: [**Job Number **]

[ "593.9", "414.01", "337.1", "250.61", "536.3", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

786, 862

889, 963

376, 704

981, 1923

729, 765

23,231

126,944

19722

Discharge summary

report

Admission Date: [**2162-9-26**] Discharge Date: [**2162-10-8**] Date of Birth: [**2109-11-23**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 613**] Chief Complaint: hypotension/fever Major Surgical or Invasive Procedure: None History of Present Illness: This is a 52 y/o male with h/o active HIV and HCV, ascites, h/o hepatic encephalopathy, who presented to the ED tonight with c/o abdominal pain x one day. He reports sharp, diffuse epigastric pain that is worsened with movement, no radiation. +nausea, one episode of emesis tonight. Last BM earlier today and normal. No BRBPR/melena per patient, no hematemesis. In the ED, the patient's VS were Tm 101.5, BP 80-92/30-38, HR 70-99, RR 24, SaO2 97%/RA. He received Levo/Vanc/Flagyl and 4 L NS with marginal response in BP, requiring initiation of levophed. Labs were notable for an initial lactate of 7, WBC of 3.3 with a left shift and bandemia of 50%. . Of note, the patient was just admitted at [**Hospital1 18**] from [**Date range (3) 53326**] with shortness of breath and lactate of 4.6. His dyspnea resolved spontaneously without any intervention and had negative imaging at the time, including an abd u/s demonstrating only mild ascites not amenable for non-u/s guided tap. His lactate was 2.3 on discharge; however it was unclear what the etiology of his elevated lactate was as no obvious source of infection. Prior to this admission, he was here for one day on [**2162-9-15**], admitted for SOB NOS, which resolved and allowed pt to be d/c'd the same day. He was also admitted to [**Hospital1 18**] on [**2162-9-9**] for dyspnea, felt to be [**3-18**] ascites. He had a therapeutic paracentesis that day, received aldactone/albumin/laisx, and was discharged that same day with planned follow-up in liver [**Month/Day (2) **]. His tap was negative for any SBP with negative cultures. Past Medical History: HIV ([**7-20**] CD4 325) Hepatitis C cirrhosis Ascites since [**2156**], controlled with diuretics initially, but has required 3 paracenteses over past [**7-21**] mo Hepatic encephalopathy - 1 episode in [**2161**], has been intermittently confused, on lactulose Grade 1 varices - on [**2159**] EGD IVDU - from age 17 to [**2153**] HTN since [**2157**] Last colonoscopy 1 yr ago PPD positive in past; treated for 9 months with INH Pulmonary HTN Social History: Lives alone, has 7 children. Smokes 1 pack of cigarettes over 2 weeks for 20 yrs, social etoh and IVDA (stopped in [**2153**]). Family History: His family history is notable for positive tuberculosis in an uncle and his father had cancer of undetermined etiology. He has seven siblings who are all alive and well. He has seven children who are not aware of his HIV disease. Physical Exam: VS: Tc 98.1, BP 107/51, HR 72, RR 22, SaO2 97%/3LNC General: Fatigued appearing male in distress with labored breathing HEENT: NC/AT, PERRL, EOMI. +scleral icterus. MM dry, OP clear Neck: supple, right IJ in place Chest: CTA-B, no w/r/r CV: RRR s1 s2 normal, no m/g/r Abd: distended, diffusely tender throughout with voluntary guarding; +fluid wave and shifting Ext: slightly cool, no c/c/e, pulses 1+ b/l Neuro: lethargic, AO x 3, moving all four extremities; no asterixis Brief Hospital Course: ASSESSMENT/PLAN - This is a 52 y/o male with HIV, Hep C who was admitted with abdominal pain and septic shock secondary to SBP and E.coli bacteremia. During this admission, patient was made comfort measures only and expired soon after. Medications on Admission: 1. Furosemide 40 mg qd 2. Spironolactone 100 mg qd 3. Lactulose 30 ml tid 4. Nadolol 20 mg qd 5. Pantoprazole 40 mg qd 6. Lamivudine 150 mg [**Hospital1 **] 7. Lopinavir-Ritonavir 200-50 mg [**Hospital1 **] 8. Abacavir 100 mg [**Hospital1 **] Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Shock Discharge Condition: Patient Expired Discharge Instructions: Patient Expired Followup Instructions: Patient expired [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "795.5", "286.7", "571.2", "276.2", "E934.2", "305.60", "567.29", "287.4", "038.42", "456.21", "584.9", "V08", "789.5", "585.9", "518.81", "452", "070.71", "305.1", "486", "560.1", "416.8", "995.92", "570", "785.52", "276.7" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "96.72", "99.05", "00.17", "99.07", "54.91", "99.04" ]

icd9pcs

[ [ [] ] ]

3872, 3881

3300, 3538

293, 299

3930, 3947

4011, 4150

2554, 2787

3831, 3849

3902, 3909

3564, 3808

3971, 3988

2802, 3277

236, 255

327, 1921

1943, 2391

2407, 2538

29,801

188,410

34723

Discharge summary

report

Admission Date: [**2145-7-15**] Discharge Date: [**2145-7-23**] Date of Birth: [**2069-4-8**] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base Attending:[**First Name3 (LF) 2485**] Chief Complaint: Hemolytic Anemia Major Surgical or Invasive Procedure: CVL - right IJ Endotracheal intubation History of Present Illness: Per admit note: 76 year old Female with chronic hemolytic anemia and pancytopenia, intermittant fevers transferred from [**Hospital **] center on [**2145-6-23**] with shortness of breath, weakness, and arthralgias as well as chest tightness. Subsequently developed fevers to 102 intermittantly. Her workup included bone marrow biopsies, echo, CT, hematology consultation. Per her transfer paperwork she was transfused blood and platelet products, but has remained pancytopenic. She has developed multiple antibodies, making transfusions more complicated. As per resident note: Per OSH records, patient's issues began in [**2145-3-6**] at which time she presented to Catholic MC with SOB. She was found to have pulmonary infiltrates and nodules on CT chest, negative for PE. She was also found to be anemic and thrombocytopenic with HCT in the high 20s and platelets in the low 100s, new since [**3-12**]. She was treated with IV Avelox and discharged on PO Avelox. When antibiotics were stopped, she had recurrence of symptoms and was admitted to [**Hospital1 **] MC and transfered to Catholic MC. Blood cultures were postive for pseudomonas and ECHO negative for endocarditis. CT continued to show lung nodules and LUL infiltrated. Recieved zosyn, gentamycin, vancomycin, amikacin and linezolid and had persistent thrombocytopenia and anemia in spite of multiple blood transfusions. Coombs test was initially negative but became positive. She developed additional antibodies and evidence of hemolysis with increased LDH and retic count. Evidence of hepatosplenomegaly. She was discharged from that admission with hematocrit of 24-31. Platelets in the 70s-100s. She was then readmitted showtly after with flank pain and discharged. Then in [**Month (only) **] was still thrombocytopenic with plt 90s, and anemic with Hct of 24-27. She had C. diff colitis in [**Month (only) **]. She then presented to her PCPs office on [**6-23**] at which time she was sent to the ED at Catholic MC as above. Past Medical History: Pancytopenia Hemolytic anemia Hyponatremia MRSA nares screen positive at OSH CAD s/p MI/CABG in [**2131**] Chest pain, work up negative for ACS at OSH HTN Hyperlipidemia COPD Hypothyroidism Depression B12 deficiency Pseudomonas bactermia s/p mulitple antibiotic treatments including Zosyn, gentamicin, vancomycin, amikacin, and linezolid Social History: The patient endorses a remote smoking history. She denies ETOH or drugs. She lives at [**Location (un) **] nursing home with her daughter in [**Name (NI) **], but has been in and out of the hospital and rehab since [**Month (only) 958**] Family History: Non-Contributory Physical Exam: Per Dr. [**First Name (STitle) **] ROS: GEN: + fevers, - Chills, - Weight Loss, - Night Sweats, - Pruritis EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, + Edema GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia, + rectal pain on BM PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: VSS: 95.7, 90/48, 85, 18, 93% GEN: NAD, anisarca, Pale Pain: 0/0 HEENT: PERRLA, EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CC, 2+ pitting edema NEURO: CAOx3, strength 5/5 UE/LE, CN II-XII wnl Pertinent Results: [**2145-7-16**] 05:40AM BLOOD WBC-3.4* RBC-2.85* Hgb-8.2* Hct-25.2* MCV-88 MCH-28.8 MCHC-32.6 RDW-17.9* Plt Ct-66* [**2145-7-23**] 12:03AM BLOOD WBC-16.2* RBC-1.87*# Hgb-5.9*# Hct-18.1*# MCV-97 MCH-31.5 MCHC-32.6 RDW-17.4* Plt Ct-58* [**2145-7-16**] 05:40AM BLOOD Glucose-82 UreaN-20 Creat-1.0 Na-130* K-3.8 Cl-95* HCO3-26 AnGap-13 [**2145-7-23**] 12:03AM BLOOD Glucose-409* UreaN-32* Creat-1.4* Na-128* K-6.1* Cl-100 HCO3-13* AnGap-21* . CE trends: [**2145-7-21**] 11:55PM BLOOD CK-MB-NotDone cTropnT-0.61* [**2145-7-22**] 06:10AM BLOOD CK-MB-NotDone cTropnT-0.48* [**2145-7-22**] 12:52PM BLOOD CK-MB-4 cTropnT-0.23* . Lactate trends: [**2145-7-22**] 02:50PM BLOOD Lactate-2.8* K-4.5 [**2145-7-22**] 06:15PM BLOOD Lactate-5.0* [**2145-7-22**] 06:37PM BLOOD Lactate-4.8* [**2145-7-22**] 09:13PM BLOOD Lactate-6.0* [**2145-7-23**] 12:17AM BLOOD Lactate-9.1* . [**7-22**] Echo: Left ventricular wall thicknesses and cavity size are normal. There is severe regional left ventricular systolic dysfunction with akinesis of the entire distal two-thirds of the left ventricle, and relative preservation of the basal one-third (LVEF <20%). This is consistent with either an extensive infarction or transient apical ballooning syndrome ("Takosubo cardiomyopathy"). No left ventricular thrombus is seen. Right ventricular chamber size is normal with mild global free wall hypokinesis. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Extensive regional left ventricular systolic dysfunction as described above. Moderate mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2145-7-20**], left ventricular systolic function has significantly deteriorated, and severity of mitral and tricuspid regurgitation is greater. Findings discussed with Dr. [**Last Name (STitle) **] at 1700 hours on the day of the study. Brief Hospital Course: 76F with compliacted PMH, with new dx large Bcell lymphoma c/b hemolytic anemia and thrombocytopenia, who was transfered to ICU for hypotension on [**7-22**] and died on [**7-23**]. . Brief hospital course: Course c/b hyponatremia and oliguria. She was hypotensive on floor with SBPs in the 80s. She was third-spacing NS so was given albumin for fluid resuscitation. This seemed to maintain her SBPs and renal perfusion. W/u during hosp included skin bx which proved malignant as well as news that onc w/u revealed lymphoma. She also was noted to have profound pancytopenia w hemolytic anemia. . On evening of [**7-21**], she began complaining of chest pain around 11 pm. On EKG, there were no ST changes or TWI, but there was loss of R wave progression. HR was in the HR 120's and she was given lopressor. She has had three sets of cardiac enzymes (trop 0.01 --> 0.61 --> 0.48; CK 36 --> 50 --> 50), and she was seen by cardiology. Given concers for ACS, she was started on heparin gtt. She also received albumin and NS overnight for hypotension. . On morning of [**7-22**], she was hypotensive to SBP low 70s. Started on neo and transferred to the ICU. En route, she also received a blood transfusion for HCT 24. On arrival to ICU, there was initial concern for a distributive shock, possibly infectious. She had fever the night prior, appeared dry, and was vasodilated. She finished unit of blood and received IVF and broad abx. Shortly thereafter, she experienced CP and acute SOB. CXR and exam c/w pulm edema. Placed on NRB and started on nitro gtt. Pain was controlled. Cards evaluated and recommened stat echo. It showed new anterior wall hypo/akinesis of LV. Cardiogenic shock was considered strongly as etiology of hypotension. At same time, pt was complaining of lower bilat abd pain. Exam fairly benign but we were concerned about mesenteric ischemia, RP bleed, or other acute process. . Given worsening status, family mtng occurred. Family requested invasive measures if meaningful recovery possible. We thus intubated patient, placed R IJ and L art line. She required neo briefly peri-procedure. CVP was [**2-7**] and SvO2 was 67 which suggested primary cardiogenic shock less likely. We resuscitated with approx 2L IVF and were able to wean neo almost completely off with improvement in BP and CVP. We planned for CT abd soon. However, rather unexpectedly, pt went into pulseless VT arrest. See metavision records for details. After 3 shocks, epi, amio, HCO3 -> BP and HR returned after approx 25m. Family was contact[**Name (NI) **] and requested no further CPR, cardioversion if indicated. Pt's BP deteriorated, she was placed on triple pressors and maintained on vent until family arrived. She was extubated and declared dead at 1:36am on [**7-23**]. Causes of death: VT arrest - immed NSTEMI - days Lymphoma - weeks also, consider infectious etiology or unrecognized bleed. Family refused post-mortem. Medications on Admission: MEDICATIONS PRIOR TO ADMISSION PER OSH RECORDS: Omeprazole 20mg daily Duoneb 4 times daily Colace 100mg daily Mucinex 600mg [**Hospital1 **] Prednisone 5mg daily Acidophilus 2 tabs TID Lasix 40mg daily Synthroid 125mcg daily ASA 81 mg daily Zyrtec 10mg daily Folic acid 1mg daily Zocor 10mg daily Zoloft 200mg daily . MEDICATIONS ON TRANSFER: Colace 100mg [**Hospital1 **] Albuterol and atrovent nebs Q6H Mucinex LA 600mg [**Hospital1 **] Synthroid 125mcg daily Zyrtec 10mg daily Folate 1mg daily Zocor 10mg daily ASA 81mg daily Zoloft 100mg daily Carafate 1g prior to meals and qhs Protonix 40mg [**Hospital1 **] Prednisone 2mg daily Reglan 10mg q6H Lasix 20mg daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary: VT arrest Secondary: NSTEMI Tertiary: Lymphoma Discharge Condition: expired Discharge Instructions: Patient expired Followup Instructions: none

[ "403.90", "410.71", "272.4", "261", "202.80", "276.6", "496", "276.52", "276.1", "458.9", "283.9", "788.5", "518.82", "284.1", "244.9", "427.5", "412", "287.5", "414.00", "585.3", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "99.60", "99.04", "86.11", "96.71" ]

icd9pcs

[ [ [] ] ]

9919, 9928

6420, 9172

308, 348

10028, 10038

3896, 6190

10102, 10110

3004, 3022

9890, 9896

9949, 10007

9198, 9516

10062, 10079

3636, 3877

252, 270

376, 2372

9541, 9867

2394, 2733

2749, 2988

75,782

150,777

37252

Discharge summary

report

Admission Date: [**2128-1-9**] Discharge Date: [**2128-1-23**] Date of Birth: [**2065-5-17**] Sex: M Service: NEUROSURGERY Allergies: Iodine / Penicillins Attending:[**First Name3 (LF) 1271**] Chief Complaint: SDH s/p fall Bilateral Wrist Fractures Major Surgical or Invasive Procedure: Trach PEG History of Present Illness: 62 year old male from [**Country 11150**] h/o pineal schwannoma, s/p VP shunt placement, on plavix, fell down 8 stairs today and was found unconscious at the bottom of the stairs. He was brought to an OSH where he was moving his extremities but not following commands. He was intubated for airway protection and received dilantin prior to transfer to [**Hospital1 18**]. Past Medical History: pineal schwannoma, s/p radiation - [**2104**] s/p VP shunt placement - [**2104**] angioplasty [**2111**] TIA [**2125**], [**2126**] seizure disorder Social History: From [**Country 11150**], staying with family here. Family History: N/C Physical Exam: ADMISSION EXAM: T:97.2 BP:127/77 HR:78 RR:18 O2Sats:100% vented Gen: Intubated, off sedation for exam. HEENT: Pupils: Equal, minimally reactive EOMs-unable to test Left conjunctival hematoma/periorbital hematoma. + Right corneal, absent left corneal Right shunt easily depressible and refills well. Neck: In cervical collar. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: unresponsive, no eye opening, GCS 6T Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 mm bilaterally, minimally reactive. III-XII: unable to test Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Right side moving to noxious. Left side withdraws to deep noxious. Discharge Exam eyes open to voice. RUE/RLE spontaneous, LUE plegic, LLE withdraws to noxious, right gaze deviation, Pupils 3/2.5 Pertinent Results: Admission CT Head: There is a VP shunt present on the right side. Right sided SDH that extends along the tentorium. It measure about 1 cm at the greatest thickness. There is slight mass effect on the right lateral ventricle. CT Head [**1-12**]: No interval change since prior examination. Stable right subdural hematoma with sulcal effacement and 4mm leftward midline shift. Stable pineal mass. Stable right VP shunt. No new hemorrhage MR [**Name13 (STitle) 430**] [**1-12**]: 1. Two foci of diffusion restriction in left parietal lobe, suspicious for acute infarcts. 2. Stable right subdural hemorrhage with stable mild mass effect and reactive hyperemia. CT Head [**2128-1-17**] 1. No significant change when compared to prior exam. Right subdural hematoma layering along the right convexity and right tentorium is similar in appearance. Stable midline shift towards the left by approximately 2 mm. 2. No significant change in ventricular configuration. 3. Stable calcified mass lesion in the pineal region. 4. Sinus opacification, similar in appearance. Labs: WBC 13.0 Hgb 13.6 Hct 38.9 Plts 239 PT: 11.5 PTT: 24.2 INR: 1.0 Fibrinogen: 263 Na:140 Cl:102 BUN:14 Glu:146 K:4.2 TCO2:24 Cr:0.7 Lactate:2.1 1 Source: Line-cntrl [**1-14**] Troponin 0.41*1 [**1-13**] Troponin 0.55*1 [**1-12**] Troponin 0.46 [**1-10**] Troponin 0.21 [**1-9**] Troponin <0.014 Brief Hospital Course: The patient was admitted to the Neurosurgery Service in the ICU for close observation. Because he takes plavix, he was given platelets to help control the extension of bleeding; however, the patient developed hives at the cessation of the infusion, and no further platelets were administered. He was given benadryl for the reaction, and the hives subsequently subsided. His neuro exam improved, as he moved all extremities spontaneously off sedation. His CK/Troponins were closely watched, as his Troponin started to elevate to as high as .46 on [**1-13**]. Ortho waited to take the patient to the OR for fixation of his L FA until his troponin decreased. on [**1-11**] he had an EEG, which was negative for seizure activity. A repeat Head CT on [**1-12**] demonstrated a stable SDH; however, given the stability and relatively small size of the SDH and the fact that the patient had a non-improving neuro exam, an MRI was obtained. Several focal areas of acute L parietal infarcts were discovered. Stroke Neurology was consulted for further management recommendations; however, they did not feel that these hyperdensities were strokes, but was likely evident of [**Doctor First Name **]. Regardless, they, too, felt that his CT/MRI findings could not fully account for his poor mental status exam, and felt confident that his exam would improve. Indeed, on HD #7, the patient's exam began to improve, as he moved his RUE/RLE spontaneously, followed simple commands, and opend his eyes to voice. A meeting was held with NSurg, Cardiology, and Ortho, and the plan was for Ortho to wait for his fractures to be repaired in the OR until his troponin was lower and stable. The patient underwent a Trach/Peg. The patient was considered to be stable enough to transfer out of the ICU to the stepdown unit. His Troponin level had decreased to 0.14. Ortho decided not to take the patient to the operating room, and casted his BUE fractures at the bedside. He was seen by PT on [**1-19**] and screened by Rehab,and a speech and swallow consultation was also obtained. While in the stepdown unit his exam remained stable on [**2128-1-21**] as he prepared to go to rehab. His troponin level decreased to 0.04 as well. An appointment was made for outpatient followup with Dr. [**Last Name (STitle) 38593**] in orthopedics for [**2128-1-27**]. His tube feeds were also restarted via his PEG. Speech adn swallow evaluated him and cleared him to take PO's with pureed solids, nectar thick liquids, and PMV at all times when taking PO's with small volumes. He was also screened for rehab. On [**2128-1-22**] he was accepted by [**Hospital **] Hospital for rehab and was prepared for discharge. Also on this day it was noted that he had thick secretions coming from his trach and as such a sputum culture and CXR were obtained. On [**2128-1-23**] he was discharged to [**Hospital **] hospital for rehabilitation. Medications on Admission: Plavix 75 mg Q noon Lovastatin 20 mg Qpm Phenobarbital 60 mg Qpm Dilantin 100 mg Qam, 200 mg Qpm Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: [**12-13**] PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-13**] Drops Ophthalmic QID (4 times a day). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Phenytoin 125 mg/5 mL Suspension Sig: One (1) PO QAM (once a day (in the morning)). 11. Phenytoin 125 mg/5 mL Suspension Sig: Two (2) PO QPM (once a day (in the evening)). 12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Heparin SQ Heparin 5000U TID Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: R SDH SAH Pineal gland mass (poss. meningioma) Bilateral radial fractures Bilateral hand fractures Discharge Condition: Mental Status:Confused - always Level of Consciousness:Lethargic but arousable Activity Status:Bedbound Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, you may safely resume taking this now, on [**2128-1-22**] ?????? Continue to take your Dilantin, as it was prescribed to you before you came to the hospital CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Please follow up with the orthopedic clinic on [**2128-1-27**] at 1000am Also, please follow up with Dr. [**Last Name (STitle) **] in the Brain [**Hospital 341**] Clinic to follow up on your pineal gland mass. Please call ([**Telephone/Fax (1) 27543**] to make an appointment to be seen within 1-2 weeks of your discharge. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2128-1-23**]

[ "V45.2", "263.9", "817.0", "E880.9", "518.81", "425.4", "331.4", "348.5", "813.42", "410.71", "215.0", "348.30", "414.01", "800.22", "426.3", "345.90", "997.31" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.6", "31.1", "96.72" ]

icd9pcs

[ [ [] ] ]

7476, 7549

3376, 6286

323, 335

7692, 7692

1967, 1977

9070, 9854

994, 999

6433, 7453

7570, 7671

6312, 6410

7822, 9047

1014, 1482

245, 285

363, 735

1551, 1948

1986, 3353

7706, 7798

757, 908

924, 978

58,141

124,181

51491

Discharge summary

report

Admission Date: [**2153-10-30**] Discharge Date: [**2153-11-7**] Date of Birth: [**2076-5-19**] Sex: F Service: UROLOGY Allergies: Ditropan / Norvasc / Codeine Attending:[**First Name3 (LF) 6736**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: [**10-31**]: Cystoscopy with left retrograde ureteral pyelogram and placement of left double-J stent. History of Present Illness: 77F with a history of Afib on coumadin, COPD, dementia and recurrent UTIs who developed a fever of 102 and WBC of 25 at nursing home yesterday, transferred to ICU for monitoring in the setting of concern for development for sepsis. She received Ceftriaxone x2 days and presented today to the ED for further management after continuing to spike fevers. Per report from husband/nursing home, patient has not had abdominal or flank pain, dysuria, hematuria, frequency or urgency. In the ED inital vitals were 98.2 92 124/60 24 98%. WBC 23 with left shift (no bands), creatinine 2.1 (from 1.1 in [**2151**]), INR 2.1 (on coumadin). She received 2L NS, vancomycin, zosyn. CT a/p showed 2 cm obstructive stone at the left UPJ; stone was in the renal pelvis on prior; has moved in the interval. Moderate stranding about the left kidney and left hydronephrosis. Multiple non-obstructive left renal calculi. Foci of air in the left renal pelvis; concerning for infection. Urology was consulted, recommended ICU admission for monitoring, and if decompensation should get percutaneous drainage with IR after INR correction (INR 2.1). The patient presented with findings consistent with urosepsis, has an obstructing left-sided stone and also has a prolonged INR, thus cannot have a nephrostomy tube placed. She was thus set up for placement of stent. The patient's family understands the procedure, alternate therapies, benefits, and risks including bleeding, infection, damage to kidney, ureter, adjacent organs, inability to stent, requiring emergent nephrostomy tube placement. Past Medical History: # Hypertension # Hypercholesterolemia # Gout # Atrial fibrillation # COPD # Dementia # Glucose intolerance # Chronic kidney disease (baseline cr 1.2-1.4) # Chronic leukocytosis # Osteoarthritis # Osteopenia # Obesity # Nephrolithiasis Social History: She is a resident at [**First Name4 (NamePattern1) 730**] [**Last Name (NamePattern1) 731**] and is a retired secretary. Distant smoking history, patient quit 23 years ago. Smoke for approximately 30 years prior less than 1 pack per day. No ETOH. No illicit drug use. Family History: Sister died of a cortical basal ganglion degeneration. Brother died at 61 of CAD versus a CVA. Father with CAD at 65. Brother with [**Name (NI) 2481**] his 70s. Mother with [**Name (NI) 2481**] in her 80s. Sister 70's with dementia. Physical Exam: Discharge EXAM AVSS General: Oriented x 0. Calm, no acute distress HEENT: Sclera anicteric Neck: supple, body habitus makes it difficult to appreciate JVD, no LAD Lungs: occasional wheeze b/l CV: Irreg irreg Abdomen: soft, non-tender, non-distended, bowel sounds present, RLQ with 1cm diameter well circumscribed defect, dressing in place --has appearance of SPT wound but she does not have any history of such Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2153-11-7**] 06:30AM BLOOD WBC-12.7* RBC-4.02* Hgb-13.0 Hct-36.7 MCV-91 MCH-32.3* MCHC-35.3* RDW-13.9 Plt Ct-327 [**2153-11-6**] 12:04PM BLOOD WBC-13.4* RBC-3.90* Hgb-12.6 Hct-35.8* MCV-92 MCH-32.4* MCHC-35.3* RDW-14.0 Plt Ct-311 [**2153-11-5**] 05:45AM BLOOD WBC-15.8* RBC-3.81* Hgb-12.0 Hct-34.8* MCV-91 MCH-31.4 MCHC-34.4 RDW-13.8 Plt Ct-246 [**2153-11-7**] 06:30AM BLOOD PT-66.8* INR(PT)-7.5* [**2153-11-6**] 04:08PM BLOOD PT-69.8* PTT-47.7* INR(PT)-7.9* [**2153-11-3**] 07:08AM BLOOD PT-25.0* PTT-31.0 INR(PT)-2.4* [**2153-11-5**] 05:45AM BLOOD Glucose-81 UreaN-18 Creat-1.1 Na-141 K-3.7 Cl-104 HCO3-27 AnGap-14 [**2153-11-4**] 10:50AM BLOOD Glucose-163* UreaN-22* Creat-1.2* Na-139 K-3.6 Cl-102 HCO3-26 AnGap-15 [**2153-11-5**] 05:45AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9 [**2153-11-4**] 10:50AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.9 = = = = = = = = ================================================================ Time Taken Not Noted Log-In Date/Time: [**2153-10-31**] 3:13 pm URINE Site: CYSTOSCOPY LEFT RENAL PELVIS. **FINAL REPORT [**2153-11-4**]** URINE CULTURE (Final [**2153-11-4**]): Piperacillin/Tazobactam Sensitivity testing per DR [**Last Name (STitle) **] ([**Numeric Identifier 42293**]). ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. 2ND TYPE. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- =>32 R 16 I CEFAZOLIN------------- =>64 R =>64 R CEFEPIME-------------- 16 I 8 S CEFTAZIDIME----------- 16 R 16 R CEFTRIAXONE----------- =>64 R =>64 R CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 32 S <=16 S PIPERACILLIN/TAZO----- S S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R <=1 S = = = = = = = = = = = = = = = = = = = = = ========================================================[**2153-10-31**] 4:21 am MRSA SCREEN **FINAL REPORT [**2153-11-4**]** MRSA SCREEN (Final [**2153-11-4**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. Sensitivity testing per DR [**Last Name (STitle) **] ([**Numeric Identifier 26537**]). 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. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S = = = = = = = = = = = = = = = = = ============================================================Time Taken Not Noted Log-In Date/Time: [**2153-10-30**] 5:46 pm BLOOD CULTURE **FINAL REPORT [**2153-11-5**]** Blood Culture, Routine (Final [**2153-11-5**]): NO GROWTH. = = = = = = = = = = = = = = = = = = = = = ========================================================[**2153-10-30**] 4:20 pm URINE Site: CATHETER **FINAL REPORT [**2153-10-31**]** URINE CULTURE (Final [**2153-10-31**]): <10,000 organisms/ml. = = = = = = = = = = = = ================================================================ Brief Hospital Course: Ms. [**Known lastname **] is a 77 y/o female with a history of Afib on coumadin, COPD, dementia and recurrent UTIs who presnted from her nursing facility after developing a fever to 102 and a WBC of 25. CT showed obstructing left renal stone. #. Sepsis/Nephrolithiasis: The patient received 2 doses of ceftriaxone prior to arrival at the ED. In the ED, the patient was initially stable. Labs revealed WBC 23 with left shift (no bands), creatinine 2.1 (from 1.1 in [**2151**]), INR 2.1 (on coumadin). She received 2L NS, vancomycin, zosyn. CT a/p showed 2 cm obstructive stone at the left UPJ. Admitted to the MICU for sepsis. In the MICU the patient was afebrile and stable. Oriented x0 which is her baseline. Received vitamin k to normalize her INR and coumadin was held. Went for stent in OR by GU after which she drained a large amount of pus. Returned to MICU afterwards where she was continued on antibiotics. On [**2153-11-1**] the patient was doing well and was without pressor requirements. Restarted on coumadin. She was admitted to Dr. [**Name (NI) 44614**] Urology service where she remained until discharge on [**11-7**]. Foley was removed and she remains incontinent at baseline. She did not mount any further fevers and she was kept on intravenous antibiotics. Her coumadin was continued but on date of discharge an INR was checked and revealed a supratherapeutic level of 10.4 off the midline with peripheral recheck revealing 7.9. A consult was placed with Hematology/Oncology and it was ascertained that multiple factors contributed to this. Given her perioperative status, her coumadin was therefore suspended and there were no further interventions (no vitamin K or frozen plasma administration). During her admission she was also followed by infectious disease team who will see her in follow up as well. At discharge Ms. [**Known lastname **] pain was well controlled with oral pain medications, she was tolerating a regular diet and at baseline with her pivoting with assistance to commode. Within the discharge instructions she was given explicit instructions for continued IV antibiotics and follow-up with the outpatient [**Hospital **] clinic, information to follow-up for definitive stone management and ureteral stent removal/exchange. Explicit instructions were given to [**First Name4 (NamePattern1) 730**] [**Last Name (NamePattern1) 731**], her rehab facility, to suspend coumadin dosing and monitoring during this perioperative period. Medications on Admission: AMOXICILLIN - 250 mg Capsule daily CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day HYDROCHLOROTHIAZIDE - 25 mg daily MOEXIPRIL - 30 mg Tablet [**Hospital1 **] NYSTATIN - 100,000 unit/gram Cream - apply to groin and between toes twice each day OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - [**1-7**] Tablet(s) QHS SIMVASTATIN - 40 mg Tablet daily SOLIFENACIN [VESICARE] - 5 mg Tablet - one Tablet(s) by mouth twice each night WARFARIN - 3 mg Tablet - 1 Tablet(s) by mouth every day MVI Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 2. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 3. simvastatin 40 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) Inhalation Q6H (every 6 hours) as needed for Wheezing. 5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for Wheezing. 6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. moexipril 15 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Vesicare 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to inguinal folds . 10. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: SUSPENDED: DO NOT RESUME UNTIL FURTHER ADVISED. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day): Hold for diarrhea. 13. Zosyn 2.25 gram Recon Soln Sig: One (1) Intravenous every six (6) hours for 2 weeks. 14. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 16. Outpatient Lab Work Your discharge antibiotic plan: Zosyn 2.25gm IV q6h (adjusted per renal function) x 2 weeks or until stents are out 17. Outpatient Lab Work -Your coumadin/warfarin dosing/titration and INR monitoring has been suspended. Dosing & monitoring will be restarted after definitive management of your kidney stones. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] - [**Location 8391**] Discharge Diagnosis: PREOPERATIVE DIAGNOSIS: Left ureteral stone with obstruction and sepsis. POSTOPERATIVE DIAGNOSIS: Left ureteral stone with obstruction and sepsis. Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Dimentia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Interactive. Not oriented. Activity Status: Out of Bed with assistance to chair or wheelchair (Pivots with assistance to commode/chair) Discharge Instructions: You will be discharged to the Extended Care Facility: [**First Name4 (NamePattern1) 730**] [**Last Name (NamePattern1) 731**] Discharge instructions after URETERAL STENT PLACEMENT: You have an indwelling ureteral stent that MUST be removed and/or exchanged in the next few weeks time. Please follow-up as advised. You may experience some pain/discomfort associated with spasm of your ureter especially while there is an INDWELLING URETERAL STENT. This is to be expected. Please take tylenol to help with this pain/discomfort. Discharge Instructions: -Resume all of your pre-admission/ home medications, unless otherwise noted. DO NOT RESUME COUMADIN/WARFARIN DOSING and do NOT take Aspirin. -Your coumadin/warfarin dosing/titration and INR monitoring has been suspended. You were taking 1mg coumadin daily for Atrial Fibrillation. Your coumadin has been suspended during the peri-operative period and will be restarted after definitive management of your kidney stones. -No vigorous physical activity for 4weeks. -Expect to see occasional blood in your urine and to experience urgency and frequency over the next month. -You may have already passed your kidney stones OR they may still be in the process of passing. -You may experience some pain associated with spasm of your ureter. This is normal. Take TYLENOL as directed AND/OR take the narcotic pain medication as prescribed if additional pain relief is needed. -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4. Replace Tylenol with narcotic pain medication. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -Make sure you drink plenty of fluids to help keep yourself hydrated and facilitate passage of stone fragments. -You may shower and bathe normally AND per the instructions from nursing regarding your MIDLINE/PICC intravenous access. -Do not drive or drink alcohol while taking narcotics or operate dangerous machinery -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Call your urologist??????s office for follow-up AND if you have any questions. Followup Instructions: -Call Dr.[**Name (NI) 10529**] office ([**Telephone/Fax (1) 921**]) for follow-up AND if you have any questions. --Your coumadin/warfarin dosing/titration and INR monitoring has been suspended. You were taking 1mg coumadin daily for Atrial Fibrillation. Your coumadin has been suspended during the peri-operative period and will be restarted after definitive management of your kidney stones. -You have an indwelling ureteral stent that MUST be removed and/or exchanged in the next few weeks time. -Please follow-up as advised and call Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] arrange follow-up, stent plan and definitive stone management plan. -Nursing will continue MIDLINE management w/ heparin flush as directed and/or per facility protocol. -Please make arrangements to follow up with the infectious disease OUTPATIENT clinic in two weeks time after completion of the two week course of Zosyn antibiotics. [**Hospital **] clinic follow up afterwards to address issues of suppressive therapy -Your discharge antibiotic plan: Zosyn 2.25gm IV q6h (adjusted per renal function) x 2 weeks or until stents are out Completed by:[**2153-11-7**]

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Discharge summary

report

Admission Date: [**2110-2-22**] Discharge Date: [**2110-3-9**] Date of Birth: [**2049-1-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2751**] Chief Complaint: Abdominal pain, Hip pain, Transfer from OSH Major Surgical or Invasive Procedure: Total hip arthroplasty, left Blood transfusion History of Present Illness: History of present illness: 61 yo M with a past medical history of fatty liver, COPD, gastritis, and OA of the left hip presents with acute onset of abdominal pain and diarrhea. Patient was in his USOH when he developed mild "heartburn" 3 days ago. Yesterday he developed multiple episodes of diarrhea without abdominal pain. He had stools roughly every 30 minutes that were beige, about 250 cc in volume and without frank melena or hematochezia. His last stool was yesterday morning, and he has reported decreased flatus since that time. No sick contacts and no out of the ordinary food products. At 4 am the morning of admission, patient developed acute onset 10 epigastric pain that woke him from sleep. Pain is burning in sensation, [**10-12**], nonradiating, nonpositional, unchanged with po intake and unlike any pain he has had in the past. Patient also noted acute on chronic left hip pain. Patient uses a walker at baseline [**2-4**] left hip OA (although patient is unclear on exact etiology of his hip pain), and does not recall any trauma or accidents. When patient awoke with abdominal pain he also noted [**10-12**] left hip pain localized to the greater trochater and radiating to his buttock. Pain is like his usual baseline pain, but more severe, and is exacerbated by weight bearing. Patient takes ibuprofen and excedrin for his OA, and usually takes 6-8 tabs daily for pain, but did not take any over the last 24 hours. Patient does report some dyspnea, but he says this is at baseline for him. He denies fevers, chills, cough, chest pain, nausea and vomitting. . At the [**Hospital 4199**] hospital ER LFTs and lipase were unremarkable. CT abdomen was remarkable for a small area in the proximal aorta consistent with small dissection, as well as a question of avascular necrosis of the hip. He was seen by vascular surgery who felt that he should be transferred to [**Hospital1 18**] for possible MRI. He received toradol 30 mg IV, Morphine 4mg IV, dilaudid 1 mg IV x2 prior to transfer. . At the [**Hospital1 18**] ER, Vascular surgery evaluated the patient. After reviewing the CT scan they surgery team felt there was no clear evidence of vascular injury and advised keeping the patient's SBP around 120 mmHg and HR less than 60 bpm. However, patient refused blood pressure medication because he reports having low blood pressure at baseline. On exam, patient was guaiac positive with brown stool. He received protonix 40 mg IV x1 and a gram of tylenol. Orthopedics was consulted for his hip pain, but they have not yet seen the patient. VS on transfer 90, 162/95, 15, 100 RA. . On the floor, patient reports abdominal pain [**10-12**] and hip pain [**10-12**]. . ROS was otherwise essentially negative. The pt denied recent unintended weight loss, fevers, night sweats, chills, headaches, dizziness or vertigo, changes in hearing or vision, including amaurosis fugax, neck stiffness, lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia, odynophagia, nausea, vomiting, constipation, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, chest pain, palpitations, increasing lower extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. Past Medical History: Per patient, his only medical problem is arthritis. Per OSH documentation he has: # COPD (unknown PFTs) # Fatty liver (presumed [**2-4**] alcohol) # Gastritis (never had upper EGD, never had colonoscopy) # H/o NSVT (3-4 beat run while admitted in [**3-11**]) # H/o tonsillectomy Social History: Quit smoking and etoh in [**3-11**]. Frankly denies current ethanol use, but very heavy use in past per records from OSH. History of 160 pack years tobacco ([**2-6**] ppd over 40-45 years). No IVDU. Currently unemployed, but formerly works as jeweler. Family History: NC Physical Exam: Vitals: T: 97.5 BP: 150/80 P: 76 R: 20 SaO2: 100 RA General: Awake, alert, NAD, pleasant, appropriate, cooperative. HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in OP Neck: supple, no significant JVD or carotid bruits appreciated Pulmonary: Decrease breath sounds bilaterally, no wheezes, ronchi or rales Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, TTP in epigastrum, no rebound/guarding, ND, normoactive bowel sounds, no masses or organomegaly noted Extremities: No edema, 2+ radial, DP pulses b/l Skin: Reduced LE hair. no rashes or lesions noted. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. No abnormal movements noted. No deficits to light touch throughout. Pertinent Results: On admission: OSH labs: Ua negative INR 1 PTT 29.9 lactate 0.8 WBC 7.8 Hct 36.7 Plt 280 Total bili 0.4 AP 85 AST 24 ALT 19 Amylase 63 Lipase 41 Na 141 K 4.3 Cl 110 CO2 23 Ca 9.4 Glu 89 BUN 13 Cr 0.8 TP 6.4 Alb 3.6 . [**Hospital1 **] admission labs: [**2110-2-22**] 06:20PM WBC-8.0 RBC-4.01* HGB-12.3* HCT-37.0* MCV-92 MCH-30.7 MCHC-33.3 RDW-14.8 [**2110-2-22**] 06:20PM NEUTS-61.5 LYMPHS-25.5 MONOS-6.2 EOS-5.7* BASOS-1.1 [**2110-2-22**] 06:20PM PLT COUNT-304 [**2110-2-22**] 06:30PM PT-12.7 PTT-31.3 INR(PT)-1.1 [**2110-2-22**] 06:30PM GLUCOSE-81 UREA N-11 CREAT-0.8 SODIUM-138 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-11 [**2110-2-22**] 06:30PM ALT(SGPT)-18 AST(SGOT)-23 LD(LDH)-138 ALK PHOS-96 AMYLASE-113* TOT BILI-0.2 [**2110-2-22**] 06:30PM CALCIUM-9.4 PHOSPHATE-2.9 MAGNESIUM-1.7 CHOLEST-202* [**2110-2-22**] 06:30PM LIPASE-181* [**2110-2-22**] 08:25PM LACTATE-0.7 [**2110-2-22**] 06:30PM TRIGLYCER-85 HDL CHOL-46 CHOL/HDL-4.4 LDL(CALC)-139* [**2110-2-22**] 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2110-2-22**] 08:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.019 . OSH CT report: No SBO. Extensive calcification of abdominal aorta extending into iliac and femoral arteries bilaterally. ? small localized dissection of proximal abdominal aorta. Possible avascular necrosis of left femoral head. . EKG: NSR 65 bpm. nl axis, nl intervals, No st changes or twave abnormalities . Plain films L hip/knee [**2-22**]: IMPRESSION: Deformity of the left femoral neck likely representing acute or subacute fracture superimposed on chronic post-traumatic deformity. This could be better evaluated by CT. Osteopenia. No evidence of acute fracture in L knee. . CT pelvis [**2-23**]: 1. Bilateral femoral head avascular necrosis, more significant on the left where there is flattening and remodeling of the left femoral head. 2. Subacute, nondisplaced bilateral femoral subcapital fractures. 3. Diffuse osteopenia. . EGD [**2-25**]: Normal stomach. Duodenitis with 1.5 cm duodenal ulcer. . Colonoscopy [**2-25**]: No polyps. Level 2 hemorrhoids. Scattered diverticulosis. . TSH-1.9 PTH-54 FreeTes-7.4 Testost-498 Echo [**2-28**]: 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. There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal study. Grossly preserved biventricular systolic function. Moderate pulmonary hypertension. . EKG [**2-28**]: Sinus tachycardia. Left axis deviation. Incomplete right bundle-branch block. Poor R wave progression which is non-diagnostic. Compared to the previous tracing of [**2110-2-22**] tachycardia is new. . CTA [**2-28**]: IMPRESSION: 1. Evaluation of LLL segmental and subsegmental pulmonary artery vasculature limited by motion artifacts. Otherwise, no evidence of pulmonary embolism. If clinical suspicion remains high, recommend repeating low-dose PE CT for that region. 2. Moderate-to-severe centrilobular emphysema with upper lobe predominance. 3. Several pulmonary nodules, measuring up to 6 mm. 13-mm subcarinal lymph node. Recommend followup CT in 6 months. 4. Focal opacity in left upper lobe which may be due to aspiration or early pneumonia. . KUB [**3-2**]:Overhead view of the supine abdomen and upright view of the diaphragmatic region show generalized distention of large and small bowel consistent with a paralytic ileus. There is no free subdiaphragmatic gas or dangerous intestinal dilatation. Atherosclerotic vascular calcification is heavy in the distal aorta and iliacs. . Gastric Mucosa [**2-25**] Path: Antral mucosa with chronic inactive inflammation. . KUB [**3-4**]: IMPRESSION: Prominent gaseous distention of both small and large bowel, most compatible with ileus. . CT A/P [**3-5**]: CT ABDOMEN: The lung bases demonstrate a small left pleural effusion and bibasilar dependent atelectasis. The moderate-to-severe emphysematous changes are stable. The heart and pericardium appear unremarkable. The liver enhances homogeneously, without focal lesion. There is no intra- or extra-hepatic biliary dilatation. The spleen, pancreas, adrenal glands, stomach appear unremarkable. The kidneys enhance and excrete contrast symmetrically without evidence of masses, stones, or hydronephrosis. There are diffusely dilated fluid-filled loops of small and large bowel, extending up to the sigmoid. The small bowel measures a maximum of 3.8 cm and the large bowel measuring up to 7.5 cm, these findings are consistent with ileus. The gallbladder is markedly dilated, fluid-filled without gallstones and no signs of cholecystitis. There is no free air or free fluid. No significant retroperitoneal or mesenteric lymphadenopathy is detected. CT PELVIS: The bladder, distal ureters, prostate and seminal vesicles are unremarkable. The rectum and sigmoid are fluid filled. There is no free fluid, free air or lymphadenopathy in the pelvis. BONY STRUCTURES: There are moderate degenerative changes in the thoracolumbar spine. A total left hip replacement prosthesis is seen with expected postoperative changes. There are no prosthetic complications. IMPRESSION: Diffuse dilated loops of small and large bowel, consistent with ileus. . CXR [**3-6**]: SINGLE FRONTAL CHEST RADIOGRAPH: The PICC terminates at the cavoatrial junction in appropriate position. Visualized lungs show minimal bibasilar scarring. The cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal. No pleural effusion or pneumothorax is present. There is a calcified left hilar lymph node. IMPRESSION: PICC terminating at the cavoatrial junction. . CXR [**3-8**]: Single frontal chest radiograph is compared to the prior study from [**2110-3-6**]. There is minimal atelectasis at the left lung base but this has decreased since prior study. The remainder of the lungs are clear. Cardiomediastinal silhouette is unremarkable. No focal pneumonia identified. . Discharge Labs: [**2110-3-8**] 04:35AM BLOOD WBC-19.8* RBC-3.87* Hgb-11.6* Hct-35.3* MCV-91 MCH-30.0 MCHC-32.9 RDW-15.5 Plt Ct-576* [**2110-3-9**] 03:57AM BLOOD WBC-16.9* RBC-3.54* Hgb-10.4* Hct-31.0* MCV-88 MCH-29.5 MCHC-33.7 RDW-15.5 Plt Ct-457* [**2110-3-8**] 04:35AM BLOOD Plt Ct-576* [**2110-3-9**] 03:57AM BLOOD Plt Ct-457* [**2110-3-8**] 04:35AM BLOOD PT-13.9* PTT-33.2 INR(PT)-1.2* [**2110-3-9**] 03:57AM BLOOD PT-13.3 PTT-33.2 INR(PT)-1.1 [**2110-3-8**] 04:35AM BLOOD Glucose-126* UreaN-9 Creat-0.8 Na-144 K-4.1 Cl-112* HCO3-22 AnGap-14 [**2110-3-9**] 03:57AM BLOOD Glucose-101* UreaN-4* Creat-0.5 Na-141 K-3.3 Cl-108 HCO3-25 AnGap-11 [**2110-3-4**] 10:18AM BLOOD ALT-11 AST-20 LD(LDH)-212 AlkPhos-73 Amylase-14 TotBili-1.4 [**2110-3-4**] 10:18AM BLOOD Lipase-16 [**2110-3-8**] 04:35AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.3 [**2110-3-9**] 03:57AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.7 Brief Hospital Course: 61 yo M with a past medical hitory fatty liver, COPD, gastritis, and OA of the left hip presents with abdominal pain, diarrhea and acute on chronic left hip pain. Problems during this hospitalization as listed below. . # R/O Aortic dissection: Per OSH radiology read, there was concern for a small type B proximal abdominal aortic dissection. Vascular surgery felt this was more likely consistent with "aberrant" calcification rather than an intimal tear. Although they advised blood pressure control to around 120 mmHg and HR control to around 60 bpm, the patient initially refused antihypertensive medications. He was monitored without any events. Pain control was addressed. Extensive vascular calcification was noted throughout on imaging performed during this hospitalization. A fasting lipid panel was checked on admission and this was found to be elevated so he was started on a statin. Given persistently elevated BPs to the 160s in the initial period of this hospitalization, a trial of low-dose beta blocker was started, however this was stopped on POD#1 given notable tachycardia and relative hypotension, as discussed below. He had no complaints of chest pain during this hospitalization. Rechallenge with beta blocker in outpatient setting may be considered by PCP. . # Abdominal Pain/diarrhea/guiac positive stool: He had epigastric abdominal pain and diarrhea. The patient had guaiac positive brown stool on initial exam. Although he had been having diarrhea, he denied melena or hematochezia. An upper GI source was suspected given his documented history of gastritis and heavy NSAID use. He was not hypotensive or tachycardic. Although he had history of fatty liver, his normal LFTs implied that he likely has compensated disease. He has never had an EGD, but the presence of varices was doubted. Ishemic colitis and mesenteric ischemia were considere, but given normal lactate, visualized arteries on OSH CT, and lack of abdominal angina, this seemed less likely. A viral cause of his diarrhea was considered most likely. He was started on [**Hospital1 **] protonix, given IVF, Maalox, and his LFTs were repeated and were normal. A GI consult was requested and they thought PUD was also most likely. He underwent an EGD/[**Last Name (un) **] on [**2-25**] after an inadequate prep on the evening of [**2-23**], which was ultimately successful by the morning of [**2-25**]. EGD demonstrated duodenitis and a non-bleeding duodenal ulcer. The PPI was changed to PO following his hip replacement, as below. GI determined that he would not need a follow-up EGD. . # Left hip pain: Patient reported a history of OA, but there was some concern for AVN on the hip on OSH imaging. He denied recent steroid use, but has been on steroids in the past (notably on discharge from OSH last [**Month (only) 958**] for a COPD exacerbation). Denies trauma and falls. He was started on morphine and lidocaine patch for pain. Ortho was consulted. CT of the pelvis at [**Hospital1 **] demonstrated bilateral AVN with bilateral femoral neck fractures. These were felt to be chronic with the left worse than the right. Ortho recommended hemi- or total arthroplasty and he was consented for the OR. See below for further discussion. The right hip fracture will need to be addressed at a later date as an outpatient. . # Left Total Hip Arthroplasty: Given the finding of avascular necrosis of both femoral heads, with worse disease on the left compared to the right, he underwent Left THA on [**2-27**] with Dr. [**Last Name (STitle) 1005**]. This operation was uncomplicated, however in the PACU the patient was noted to by hypotensive to the high-70s/50s. He was intensively fluid resuscitated, and serial hematocrits were drawn. Given a drop from a Hct of 39 pre-op to 30.5 in the PACU, the orthopedic service decided to transfuse two units PRBCs. His post-transfusion Hct was 32.8. He was transferred to the floor, but was noted to be persistently tachycardic to 110s as well as relatively hypotensive (had been around 150-160 SBP pre-op, then to 100s-120s post-op). He was noted to have a new oxygen requirement. Given the recent orthopedic procedure, concern for PE was high, and CTA was performed. A heparin drip was started before the read was in. This was negative for PE in the main branches and main segments, and although the RLL could not be completely evaluated, it was felt that he most likely did not have a PE, and the drip was stopped. Cardiac enzymes were drawn and were negative x __. An echocardiogram was done and was essentially normal. An EKG was sinus tachycardia with no other new features. His Hct was stable. The tachycardia continued, and he spiked a fever overnight on [**2-28**], and was started on vanc/levo. The final read came back as questionable developing pneumonia, levaquin was continued and vancomycin was stopped. He was changed from Lovenox prophylaxis to fondaparinux. He developed an ileus on POD # 3 and was kept NPO. The ileus continued, an NGT was placed on [**3-4**], and on [**3-5**] (POD#6), he developed a fever to 103. He also developed a concerning abdominal exam with rebound tenderness and decreased bowel sounds. A CT abdomen/pelvis was done, which showed only dilated bowel loops consistent with the known ileus. Surgery was consulted and recommended continuation of the NGT, but no acute intervention. However, his fevers persisted, and given the continued tachycardia (since [**2-27**]), there was concern for developing sepsis. He was transferred to the MICU on [**3-5**]. Patient's NG tube was kept. He was given PO naloxone 3 mg x 1 and subsequently had loose stools. A flexiseal rectal tube was placed. His abdomen became much less tense and less tender. Surgery recommended removing the NG tube on the second MICU day. Given the absence of any clear source of infection, all antibiotics were discontinued. Patient never spiked during his MICU stay. His tachycardia was much improved after 1 L of NS and pain control but he remained above 100 bpm. Patient had a hematocrit drop to 26 on the second MICU day; repeat Hct was 27. He was called out of the MICU, and transfused two units on the floor with an appropriate Hct bump to 33. On the floor, his tachycardia continued but was generally improved, with resting HR in the high 90s. Narcotics had been stopped, and he was taking around-the-clock tylenol. He did not have any further fevers, but his WBCs climbed to 19.3 on [**3-8**]. He had been felt to be ready for discharge, but this was postponed to monitor him for signs/sx of infection. A CXR was done which was negative for PNA. C. diff was collected and was negative. Blood and urine cultures were done and were pending at the time of discharge. His WBC trended downward, but with mild erythema around surgical site, kelex was initiated to surgical wound cellulities. Please monitor for evidence of extenstion. He will follow up with ortho on [**3-11**] to assess wound. He was ultimately felt ready for discharge on [**3-9**], and was sent to rehab with the rectal tube. Notably, throughout this, he was followed by PT and his weight-bearing status on the L hip was gradually increased to partial weight bearing. He will need continued rehabilitation for this hip and in general given his extended hospital stay. . # Osteopenia: Diffuse bone thinning was noted on imaging. The patient was started on Vitamin D and Ca. PTH was normal. TSH was normal. Total and free testosterone were normal, making hypogonadism a less likely cause of osteopenia. He will need bisphosphonates as an outpatient if approved by ortho. He will need to be started on [**Numeric Identifier 1871**] units of vitamin D for two months with continued calcium supplementation. Outpatient bone mineral density testing should be done. . # COPD: Unknown severity. He reported that he was not taking medications for this, but had been discharged in [**2109-3-3**] with medications for COPD. The Spiriva was re-started. He was given albuterol prn. He did not have active wheezing on admission. CTA of the chest was notable for several small pulmonary nodules that will need CT follow-up in 6 months. . # Fatty liver disease: Prior heavy ethanol use, but no use in nearly 1 year. LFTs normal and INR normal implying good synthetic function. EGD did not demonstrate varicosities. LFTs remained normal. He did have an increase in his INR during this hospitalization and was given subcutaneous vitamin K with return of INR to normal. . # Peripheral vascular disease: Lower extremity exam consistent with PVD, and extensive atherosclerosis on imaging. Lipids were checked and found to be elevated. He was started on simvastatin. . # Access: a heparin-dependent PICC was placed on [**3-6**] given difficult access in this patient. Medications on Admission: Per discharge summary [**3-11**], although patient reports that he only took multivitamins and folate: - Symbicort 2 puff daily - Folate - Mucinex 600 mg po BID - Lopressor 12.5 mg po BID - Nicotine patch - Prednisone taper (30mg -> 10 mg over 16 days) - Carafate - Thiamine 100 mg daily - Spiriva 1 inh daily - Xopenex prn Discharge Medications: 1. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for wheezing. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (). 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for reflux,indigestion. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fevers,pain. 11. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital **] - [**Location (un) **] Discharge Diagnosis: Avascular necrosis of the bilateral femoral heads Duodenal ulcer Duodenitis Illeus Secondary: Hypertension Hyperlipidemia Osteopenia 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 transferred to [**Hospital3 **] for inital concern that you may have had a life-threatening condition in your aorta. Repeat imaging demonstrated that you did not have this condition. However, we did find that you had a condition called avascular necrosis of a part of both of your femurs. You also had blood in your stool, and we were concerned that you could have an area of bleeding in your GI tract somewhere. . We did an EGD (esophagogastroduodenoscopy) and colonoscopy and found a small ulcer in your duodenum (small bowel) that was not actively bleeding. It is important that you continue to take your omeprazole, which is an acid-lowering medication. Other things to avoid include smoking, non-steroidal anti-inflammatory medications, and spicy meals. You will need to follow-up with your primary care doctor regarding future care. . The orthopedic surgeons saw you and determined that you needed surgery on your hip. They decided to do a total hip replacement on the left. Your rehab and physical therapy care is going to be very important to get you moving around again. You have a follow-up appointment with the orthopedic department in two weeks. They will discuss plans for the right hip with you. We recommend that you take vitamin D and calcium supplements as well as bisphosphonate medications. . Your post-operative course was complicated by a high heart rte (tachycardia) and concern for pneumonia. We started you on antibiotics, but you developed a high fever. You also developed a slowing of your bowels, called an ileus. You were sent to the intensive care unit briefly, and the cause of your fever was determined to be medication reactions. Your ileus began to resolve. Your antibiotics and narcotics were stopped and your fever went away. You were then transferred back to the inpatient medical floor. You needed a tube to help drain stool and you were discharged with this tube. . You came in with a long list of medications but were only taking a few of these when you were admitted. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2110-3-11**] 9:40 You have an appointment with Dr. [**Last Name (STitle) 7053**] in [**Month (only) 116**]. She will help you arrange a repeat CT scan of your lungs in 6 months. Completed by:[**2110-3-9**]

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icd9cm

[ [ [] ] ]

[ "00.74", "81.51", "45.23", "38.93", "45.16" ]

icd9pcs

[ [ [] ] ]

22609, 22674

12234, 20995

358, 407

22852, 22852

5110, 5110

25073, 25435

4245, 4249

21369, 22586

22695, 22831

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463, 3657

5359, 11323

5124, 5343

22867, 23008

3679, 3960

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14,253

159,179

53090+59497

Discharge summary

report+addendum

Admission Date: [**2153-1-23**] Discharge Date: [**2153-1-25**] Service: [**Hospital1 **] HISTORY OF PRESENT ILLNESS: The patient is an 80 year-old lady with a past medical history significant for diabetes, hypertension, hypothyroidism, coronary artery disease, who presents with pain and induration at Baclofen pump site. She was admitted status post pump removal. The patient's pump was placed [**2152-12-9**] and shortly after placement the patient developed fever and erythema. The patient was on broad spectrum coverage with Ceftazidime and Vancomycin until several days before admission. The patient called her physician on the day of admission to report on going erythema and fluctuance. The patient went to the Emergency Room. A decision was made to remove the pump and the patient was continued on broad spectrum antibiotics as stated above. The patient was followed closely by the pain service upon admission. An infectious disease consult was also obtained from the Emergency Room. She was admitted to the [**Hospital6 **] in stable condition. PAST MEDICAL HISTORY: 1. Multiple sclerosis with stagnant disease for ten years. 2. Diabetes mellitus noninsulin dependent. 3. Hypertension. 4. Hypothyroidism. 5. Coronary artery disease status post inferior myocardial infarction and percutaneous transluminal coronary angioplasty in [**2152-3-11**]. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Glucophage 500 b.i.d. 2. Aspirin 81 mg q day. 3. Toprol XL 125 mg q day. 4. Lipitor 10 mg q.d. 5. Levoxyl 88 micrograms q day. 6. Folate 1 mg q day. 7. Multivitamin q day. 8. Colace 100 mg b.i.d. SOCIAL HISTORY: The patient lives in [**Location 47**] at the [**Hospital6 80938**] Center. She has been a resident there for many years. She has close family and many grandchildren. She denies tobacco use and reports rare alcohol. No illicit drug use. The patient is wheel chair bound, but has good use of her upper extremities. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.9. Blood pressure 111/30. Pulse 53. Respirations 12. 99% oxygenation on room air. General, alert and oriented times three. Lungs were bilaterally clear to auscultation. Cardiovascular regular rate and rhythm. No murmurs, rubs or gallops. Abdomen is packed and bandaged, soft, appropriately tender. Normoactive bowel sounds. Lower extremities no edema or tenderness. The patient has no motor abilities in her lower extremities. She has clonus bilaterally with decreased reflexes throughout all extremities. The patient has normal speech. LABORATORIES UPON ADMISSION: White blood cell count 11.8, hematocrit 41.9, platelets 282. Chemistries were normal. TSH was 2.8, which is in the normal range. Differential of white blood cell count neutrophils 77 no bands. Kidney and liver function tests were normal. The patient had wound gram stain as well as swab during pump removal, which showed 3+ polys and no organisms. The swab grew staph aures with sensitivities pending at the time of this dictation. Wound culture from [**1-23**] also grew staph aureus. Blood cultures from [**1-23**] are no growth to date at the time of this dictation. HOSPITAL COURSE: 1. Pump site infection: Wound cultures grew rare staph aureus as well as coagulase negative staph. The patient was continued on Vancomycin as well as Ceftazidine for broad coverage. This regimen will likely be tailored to simply Vancomycin upon discharge since no gram negative organisms were grown on culture. The patient was afebrile with vital signs stable during admission. Infectious disease team followed the patient. A left PICC line was placed on the day of discharge for antibiotic infusion at the [**Hospital 228**] nursing home. The patient's white blood cell count normalized and she was stable from this perspective. 2. Coronary artery disease: The patient is status post inferior myocardial infarction with percutaneous transluminal coronary angioplasty [**2152-3-11**]. She was continued on her aspirin, Metoprolol and Atorvastatin. There were no acute issues during admission. 3. Hypertension: The patient continued on Metoprolol with good blood pressures. 4. Hypothyroidism: The patient was continued on her current dose of Levothyroxine. A TSH was checked and was normal. 5. Incisional pain: The patient was given Ketoralac as well as Tylenol for pain control. This was sufficient. These were recommended by the pain service. 6. Baclofen withdraw: The patient was started on a po regimen of Baclofen to prevent withdraw after discontinuation of the patient's pump. The patient had intermittent rigidity and flushing as well as slowed speech, likely due to the removal of Baclofen pump. The patient was given prn Ativan 1 mg q 4 hours with good effect as well as a titration upward of her po Baclofen to 20 mg t.i.d. The patient will continue to be followed by the pain service upon discharge. DISCHARGE DIAGNOSES: 1. Baclofen pump infection with staph aureus as well as coagulase negative staph. 2. Multiple sclerosis. 3. Diabetes mellitus. 4. Hypertension. 5. Hypothyroidism. 6. Coronary artery disease status post percutaneous transluminal coronary angioplasty and inferior myocardial infarction. 7. Incisional pain. 8. Baclofen withdraw. DISCHARGE STATUS: Stable. DISCHARGE CONDITION: Back to [**Hospital6 80938**] Nursing Home in [**Location (un) 47**]. MEDICATIONS ON DISCHARGE: Same as upon admission with continuation of Vancomycin 1 gram b.i.d. and Ativan 1 mg IV/PO prn with draw symptoms of rigidity, flushing, discomfort. FOLLOW UP: The patient is to follow up with the Pain Service as on her discharge paperwork. She will also follow up with her primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 10755**] within one week of discharge. A new Baclofen pump is planned for eight weeks from now pending clearing of infection. The patient will need dressing changes t.i.d. with wound packing and wet to dry with saline. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**] Dictated By:[**Last Name (NamePattern1) 9244**] MEDQUIST36 D: [**2153-1-25**] 12:37 T: [**2153-1-25**] 12:41 JOB#: [**Job Number 109373**] Name: [**Known lastname 13795**], [**Known firstname **] Unit No: [**Numeric Identifier 17931**] Admission Date: [**2153-1-23**] Discharge Date: [**2153-1-30**] Date of Birth: [**2072-4-11**] Sex: F Service: ADDENDUM: The patient was discharged to nursing home on [**2153-1-30**], instead of [**2153-1-25**], as previously reported. Please see previous discharge summary for complete details. The changes to this discharge summary are simply medication changes: 1. The patient will not be discharged on Vancomycin. 2. The patient will have two more weeks of Oxacillin two grams intravenous q6hours, and will be assessed by her primary care physician and [**Name9 (PRE) 2790**] service for need of continual antibiotics. 3. The patient's Baclofen dosing upon discharge is Baclofen 10 mg tablet four times a day p.o. The patient will have dressing changes three times a day and will follow-up as indicated in the previous discharge summary. [**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D. [**MD Number(1) 522**] Dictated By:[**Last Name (NamePattern1) 1791**] MEDQUIST36 D: [**2153-1-30**] 11:31 T: [**2153-1-30**] 19:50 JOB#: [**Job Number 17932**]

[ "996.63", "041.11", "V45.82", "414.01", "682.2", "E878.1", "E849.7", "412", "340" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.05", "86.22" ]

icd9pcs

[ [ [] ] ]

5356, 5427

4970, 5334

5454, 5604

3208, 4949

5616, 6826

6847, 7608

131, 1078

2612, 3190

1100, 1644

1661, 2001

31,551

193,495

46981

Discharge summary

report

Admission Date: [**2112-4-15**] Discharge Date: [**2112-4-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2234**] Chief Complaint: S/p unwitnessed fall/syncope Major Surgical or Invasive Procedure: Blood transfusions, four units Speech and swallow evaluation Video barium swallow evaluation [**4-20**] History of Present Illness: CC:[**CC Contact Info 99633**] HPI: 88 y.o. male with h/o parkinson's, dementia, chf, multiple myeloma and hypothyroidism sustained unwitnessed fall while on toilet. Wife found him. He does not recall circumstances initially but later reports his bottom "slipped off toilet." Does feel he actually moved his bowels. Unclear if LOC. Denies and assoc CP/SOB. No dizziness/lightheadedness. Per EMS sbp was in 80s. EKG unchanged in ED. Head/neck CT negative. SBP in ED 100. Family reports he has c/o increased urinary frequency over past few days. ROS: Denies pain. Denies weight loss. Denies prior falls. Feels as though he needs to urinate even though catheter is in place. Reports that he is at times forgetful and that his memory is "fair." Reports good sleep. Nml bowel pattern is 2x/day. Sleeps with two pillows at baseline Denies moist cough but often dry cough. All other ROS negative. Past Medical History: PMH: 1. Hypothryroidism 2. Parkinson's Disease 3. Glaucoma 4. Dementia 5. Cataracts 6. BPH s/p TURP [**2092**] 7. Chronic diarrhea 8. h/o adenomatous polyp [**2104**] 9. CHF 10. ? h/o multiple myeloma s/p tx with thalidomide 11. h/o squamous cell ca s/p deep resection with graft Home Medications: 1. Levothyroxine 75mcg daily 2. Aricept 10mg daily 3. Furosemide 20mg alt with 40mg daily 4. Namenda 10mg [**Hospital1 **] 5. levocarnitine 2 caps twice daily 6. Aspirin 81mg daily 7. Lumigan both eyes at bedtime 8. Timoptic both eyes morning/bedtime 9. Azopt left eye tid 10. Vitamin E 200 units daily 11. Vitamin D 1000 units daily Social History: Social History: Lives with his wife (second x 14 yrs). Wife is HCP but she often defers to sons. [**Name (NI) **] two sons, [**Name (NI) **] who is local and [**Name (NI) **] in [**State 4565**] is a ENT surgeon. Daighter in law [**Doctor Last Name 2048**] is also very involved. Prior worked as CPA x 40 yrs. Reports smoked less than pack per day but quit >20 yrs ago. Reports occ etoh use. Wife manages medications. Does cooking/finances. Prior level of function is walker. Has chair lift in home. Lives in single family two story home. Bedroom on [**Location (un) 1773**]. Has home health aide 5x week to help him shower and dress, goes to adult day care at [**Hospital 100**] Rehab 3x week. Has bilateral hearing aides. Has glasses for [**Location (un) 1131**]. Family History: non-contributory Physical Exam: Physical Exam on Admission: VS: BP 123/84 HR 96 T 97 97% RA General: Skin warm and dry. NAD. Alert, engaging. Neuro: Oriented to person, hospital [**2112-3-24**]. HEENT: Neck supple, Resp: lungs with crackles at LLL, good insp effort and air movement. CV: heart rrr ap 90 + IV/VI holosystolic murmur best heard 3rd ICS LSB radiates to axilla GI: abd soft, non-tender, +bs, + ventral hernia, no guarding. EXT: +pp no edema bilat, no hair on lower extremeties Skin: Right shin with large scar (~4inx3in) Rectal exam: vault full of stool, guiaic neg. Physical exam on discharge: 109-128/70-80 98% ra afebrile Skin warm and dry, NAD. voice strong. Oriented to situation "I don't to stay in the hospital another day. I want to go to rehab." Lungs with trace bibasilar rales no wheezes/rhonchi heart rrr ap 72, + IV/VI holosystolic murmur radiating to axilla abd s, nt +bs +pp no edema Pertinent Results: Admission Labs: =============== [**2112-4-15**] 07:15AM WBC-11.6*# RBC-3.12*# HGB-9.5*# HCT-29.3*# MCV-94 MCH-30.5 MCHC-32.6 RDW-15.1 [**2112-4-15**] 07:15AM NEUTS-84* BANDS-4 LYMPHS-9* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2112-4-15**] 07:15AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [**2112-4-15**] 07:15AM PLT COUNT-178# [**2112-4-15**] 07:14AM GLUCOSE-163* UREA N-65* CREAT-1.6* SODIUM-142 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-21* ANION GAP-21* [**2112-4-15**] 07:14AM estGFR-Using this [**2112-4-15**] 07:14AM CK(CPK)-28* [**2112-4-15**] 07:14AM cTropnT-<0.01 [**2112-4-15**] 07:14AM CK-MB-NotDone proBNP-6187* [**2112-4-15**] 07:14AM PT-17.5* PTT-31.6 INR(PT)-1.6* Discharge Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2112-4-25**] 11:00AM 7.8 3.32* 10.5* 30.7* 92 31.5 34.1 15.2 119* RENAL & GLUCOSE Glu UreaN Creat Na K Cl HCO3 AnGap [**2112-4-25**] 11:00AM 104 24* 1.4* 137 3.7 105 23 13 Imaging: ======== CT C-SPINE WITHOUT IV CONTRAST: There is no acute malalignment, prevertebral soft tissue swelling, or acute fracture. There are severe degenerative changes throughout the cervical spine. The C4 vertebral body demonstrates a large (approximately 5 mm) round lucency, which likely represents a large subchondral cyst with cortical breakthrough at the superior surface, however less likely consideration is a lytic lesion. There is anterior and posterior osteophyte formation at all levels, with disc height loss throughout the cervical spine. At C6-C7, there is severe disc height loss, with near bone- on-bone appearance. There is no evidence of indentation of the thecal sac, although CT does not provide the intrathecal detail comparable to MRI. The lung apices demonstrate no nodule or other opacity. There is no submandibular or cervical lymphadenopathy. IMPRESSION: 1. No fracture or acute malalignment abnormality. 2. No prevertebral soft tissue swelling or other evidence of acute injury. 3. Round lucency in C4 vertebral body with cortical breakthrough at superior surface likely represents large subchondral cysts, but lytic lesion is a less likely possibility. 4. Severe degenerative changes throughout the cervical spine. CT HEAD WITHOUT IV CONTRAST: There is no hemorrhage, mass, mass effect, edema, or shift of normally midline structures. Prominence of the ventricles and sulci with increased bifrontal CSF space are suggestive of age-related parenchymal atrophy. No fracture or soft tissue injury is identified. IMPRESSION: No evidence of hemorrhage, edema, or fracture. Chest XRAY FINDINGS: Portable AP upright chest radiograph is reviewed without comparison. Cardiac silhouette is upper limits of normal, with left ventricular prominence, which could suggest underlying hypertension. Prominence of the pulmonary vascularity may suggest pulmonary hypertension, but there is no pulmonary vascular engorgement or other evidence of pulmonary edema. There is ill-defined 1-cm nodular opacity in the right perihilar region. There is no focal airspace opacity to suggest pneumonia. There is no pleural effusion or pneumothorax. IMPRESSION: 1. 1-cm ill-defined right mid lung nodular opacity, incompletely evaluated. CT is recommended for further evaluation to exclude underlying mass. 2. Prominent cardiac silhouette with left ventricular configuration could suggest underlying hypertension. Prominence of the pulmonary vasculature, but no evidence of pulmonary edema. Portable TTE (Complete) Done [**2112-4-19**] at 10:33:19 AM Conclusions: The left atrium is markedly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] There is no ventricular septal defect. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**11-25**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. There is probable (partial) mitral leaflet flail. An eccentric, anteriorly directed jet of severe (4+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. If clinically indicated, a transesophageal echocardiographic examination is recommended to evaluate mitral valve morphology. IMPRESSION: severe mitral regurgitation secondary to (probable) partial flail leaflet RENAL U.S. [**2112-4-20**] 1:29 PM FINDINGS: The left kidney measures 10.4 cm and the right kidney measures 11.5 cm. Cortical echogenicity is within normal limits. There is moderate dilatation of the collecting system on the right. The right extrarenal pelvis is again noted. There is a exophytic simple cyst arising from the upper pole of the left kidney, measuring 3.3 x 1.9 x 1.8 cm. This is slightly increased in size when compared to the prior study of [**2104**], when it measured 2.8 cm. There is no mass or calculus in either kidney. There is no left hydronephrosis. Urinary bladder is collapsed. IMPRESSION: Moderate right hydronephrosis. VIDEO OROPHARYNGEAL SWALLOW [**2112-4-20**] 11:04 AM FINDINGS: Oral and pharyngeal swallowing videofluoroscopy was performed today in collaboration with speech and language pathology. Various consistencies of barium were administered. ORAL PHASE: Moderate oral dysphagia is seen, with decreased bolus formation, control and AP tongue movement, as well as increased oral transit times. There is a premature spillover into the larynx. Moderate oral residue remains after the swallow. PHARYNGEAL PHASE: Severely delayed initiation of this swallow trigger is noted. There is mildly reduced anterior laryngeal excursion and laryngeal valve closure. There is complete epiglottic deflection. There is a posterior pooling of contrast just below the upper esophageal sphincter, consistent with known large Zenker's diverticulum, resulting in backflow of the contrast above the upper esophageal sphincter into the piriform sinuses and eventually aspiration. IMPRESSION: 1. Mild-to-moderate oropharyngeal dysphagia. 2. Findings most consistent with Zenker's diverticulum, with backflow of contrast into the pharynx and resulting in the aspiration. Brief Hospital Course: 88 y.o. male with CHF, BPH, dementia s/p unwitnessed fall. Presented with elevated BNP and BUN, also with hgb drop (12.5-9.5) over past 6 weeks and sx of UTI. . 1. S/p fall: most likely multifactorial. Vasovagal vs volume depletion from GI bleed. - Head and c-spine ct negative, urine culture negative for UTI. 2. Acute renal failure: in setting of diuresis after volume administration. Echo done which showed severe MR. Lasix currently on hold. He was gently hydrated daily and Cr decreased to baseline of 1.5. Creatinine on discharge 1.4. 3. Zenkers diverticulum: This is a long standing issue ([**2104**]) and the family has declined intervention in the past due to risks involved. He has no known prior aspiration pneumonia. Of note his son is an ENT surgeon in [**Name (NI) 4565**]. At baseline he eats generally soft foods and cuts up other food into small bites. He was felt to be aspirating and seen by speech and swallow therapist who noted coughing and phonation changes with foods at the bedside. Video barium swallow evaluation showed large Zenker's Diverticulum that collects and fills with po throughout po trials and eventually results in aspiration due to backflow of po into the pharynx. He had a new finding on cxr that was pna vs pneumonitis s/p barium swallow. He has slight leukocytosis (12.3) and therefore was treated with a course of levofloxacin. He was made NPO for a few days, maintained with intravenous fluids, and ENT was consulted for recommendations on less invasive repair options. After discussion with the family it was decided that invasive surgery would not be ideal, but a less invasive procedure would be appropriate given his good functional status at home. ENT saw the patient and at that point his lethargy and delirium had improved, and they recommended to trial oral feeds again. He was started on a honey thick puree diet and tolerated this well. He has an appointment with ENT [**5-4**]. . 4. Upper GI Bleed: Developed melena on [**4-15**]. Received 4 units PRBC in ICU. He was given IV PPI and ASA was held. Family and GI decided against EGD given he was hemodynamically stable and HCT stabilized after blood. Possible cause is aspirin retention in Zenkers. Will f/u with ENT as outpatient. Discharge HCT 30.1. He was taking Vitamin E over the counter at home. This was discontinued because of increased risk of bleeding. Family members aware. 5. ? h/o multiple myeloma: -History of monoclonal gammopathy. Last colonoscopy [**2104**] with adenoma polyp removed and repeat suggested in three years, family reports it was not done. Oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23509**] [**Telephone/Fax (1) 72711**]. Last seen 4/[**2111**]. He is currently stable, received Reclast therapy for bone health over the winter, and will follow up in [**2-28**] months. 5. Systolic and diastolic congestive heart failure - Echo shows severe 4+ mitral regurgitation with prolapsed leaflet. Followed by Dr. [**Last Name (STitle) **] of the Lown group last seen 4/[**2111**]. He had acute congestive heart failure this admission in the setting of fluid volume overload from blood products and intravenous fluid in the ICU during GI bleed. He was given diuretics and diuresed to baseline. - Goal weight is 163 lbs per cardiology records. - Lasix restarted at 20 mg daily. Home dose is 40mg alternating with 20 mg. - Keep K >4.0 and Mg >2.0. - Had short runs of NSVT upon admission but improved, monitor K and Mg on lasix. . 6. Urinary retention - Foley catheter was inserted during ICU stay. It was discontinued on the general care unit and after 12 hours he failed to void. Bladder scan showed 700mL and foley was placed for 800mL urine. Urology was called and they recommended keeping the foley in place and following up as an outpatient. He has a history of BPH and had a TURP in [**2094**]. He has f/u [**4-28**]. Consider voiding trial in the am of [**4-26**] and if he fails starting tamsulosin. Does have h/o BPH s/o TURP. . 7. Dementia - Followed by geriatric psychiatrist at [**Hospital 1191**] Hospital. Assumed to be vascular dementia. Maintained on aricept and namenda. He was also taking vitamin e at home but it was advised that this be discontinued because of risk of bleeding. He has short term memory deficits and has declined in function over the last 6 months, now with incontinence and needing assistance with ADLs/IADLs. He has a home health aide 5x per week for bathing and goes to adult day care 3 days per week. His wife is increasingly more burdened by his needs and is considering increasing day care to 5 days per week. Family is supportive as well. Discussion with family about code status and overall goals of care. At this time they feel strongly that he remain Full code and would prefer to discuss resuscitation at the time of crisis. They do however prefer less invasive treatment options given his overall age and dementia. Further discussion about code status is ongoing given his poor survival potential. - He showed delirium during this hospitalization that slowly resolved, improving to his baseline cognitive level. He was given low dose x1 IV haldol in the ICU. He slowly improved and has been without sitter for several days with no attempts to get out of bed/chair. FAMILY DOES NOT WANT FEEDING TUBE. Medications on Admission: Home Medications: 1. Levothyroxine 75mcg daily 2. Aricept 10mg daily 3. Furosemide 20mg alt with 40mg daily 4. Namenda 10mg [**Hospital1 **] 5. levocarnitine 2 caps twice daily 6. Aspirin 81mg daily 7. Lumigan both eyes at bedtime 8. Timoptic both eyes morning/bedtime 9. Azopt left eye tid 10. Vitamin E 200 units daily 11. Vitamin D 1000 units daily Discharge Medications: 1. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic qhs (): Both eyes. 2. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic TID (3 times a day): left eye. 3. Donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): Both eyes. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal once a day as needed for constipation for 1 doses. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Upper gastroesophageal bleed Urinary retention Severe Mitral regurgitation Glaucoma benign prostatic hypertrophy s/p transurethral resection hypothroidism Parkinsonism dementia chronic diarrhea congestive heart failure colonic polyp Discharge Condition: Stable. Alert to person, hospital, [**2111**]. Cooperative. Uses rolling walker for ambulation. Discharge Instructions: You were admitted after falling at home. While you were in the hospital you had bleeding from your upper gastroesophageal system and were treated with blood transfusions and intravenous fluids. You will have follow up with an ENT doctor to help determine if you need a procedure to fix your Zenkers Diverticulum, hopefully it will improve without intervention. Please do not take Vitamin E any longer, it may contribute to gastrointestinal bleeding. Please also do not take aspirin until instructed by your doctor. Your lasix was held for several days but has been restarted at discharge. Followup Instructions: Appointment scheduled with Dr. [**Last Name (STitle) 1837**] [**2112-5-4**] at 4:15pm for evaluation of the zenker's divertivulum. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2112-4-28**] 11:15 Urologist, please follow up for outpatient voiding trial, Dr. [**Last Name (STitle) 33427**] was unable to see you in the near future. Please follow up with your cardiologist Dr. [**Last Name (STitle) **] at [**Hospital1 **] 1-2 weeks after discharge from rehab. ([**Telephone/Fax (1) 41173**]. Please follow up with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13183**] [**11-25**] weeks after discharge from rehab ([**Telephone/Fax (1) 99634**]. Completed by:[**2112-4-25**]

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Discharge summary

report

Admission Date: [**2156-1-1**] Discharge Date: [**2156-1-11**] Date of Birth: [**2075-5-3**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 5188**] Chief Complaint: ABD pain Major Surgical or Invasive Procedure: - ERCP History of Present Illness: HD 11 Unasyn [**1-1**] (11) 80M acute cholecystitis/cholangitis PMH: CRI (2.5), FEV1 70% ([**8-9**]), NIDDM, MI [**2138**], s/p LAD and LCx. [**Last Name (LF) **] , [**First Name3 (LF) **] 30-35%, Hx a-flutter, syncope, CVA x9 w/ cortical blindness PSH: Partial L. nephrectomy, b/l LE bypass([**Doctor Last Name 1476**]) [**Last Name (un) 1724**]: Lopressor 25", amiodarone 200", asa 81', lipitor 80', isosorbide mn 30', flogard 2.2", plavix 75", Coumadin 4 t/th/sat/saun, 3 m/w/f, hydralazine 25"', plavix 75' Plan: - ERCP chemical pancreatitis improving, clinically stable ->no plan to re-ERCP at this point - Cardiology informed of demand ischemia v NSTEMI, tele, BB, nitro - NPO for now - GI rec. f/u in [**2-7**] weeks when [**Date Range 100581**] is performed - f/u w/[**Date Range **] re: Carot. endart needs to be done Past Medical History: CRI S/P CVA x 9 w/ prior left PCA infarct with cortical blindness and [**10-7**] right parietal occipital cerebrovascular accident. MI x 2 Peripheral bypass bilaterally Diabetes Hypertension Hyperlipidemia Cyst removed from kidney Aflutter, s/p ablation [**11-5**] on amio/warfarin syncope renal arteries no stenosis by cath [**2154-5-17**] s/p EPS [**5-8**] [**5-8**] s/p TTE w/ EF to be newly depressed at 30-35% with left ventricular hypertrophy and [**12-8**]+MR. [**Name14 (STitle) **] w/ reversible defect -> cath w/ 60-70% LAD stenosis and an 80% LCX stenosis. The RCA was occluded with left to right collaterals. s/p [**Name14 (STitle) **] to LAD and LCx. Social History: Patient is married and lives at home with his wife; retired metal worker. He has had a prior tobacco history, but no alcohol use. Family History: non-contrib Physical Exam: vitals: wd, wn, nad supple, no lad ctab, no w/c/r rrr, no m/r/g soft, non-distended, non-ttp, nabs no c/c/e Pertinent Results: [**2156-1-6**] 06:35AM BLOOD WBC-9.2 RBC-3.94* Hgb-12.8* Hct-36.1* MCV-92 MCH-32.6* MCHC-35.5* RDW-14.8 Plt Ct-285 [**2156-1-4**] 07:40AM BLOOD WBC-10.4 RBC-3.91* Hgb-12.6* Hct-35.6* MCV-91 MCH-32.3* MCHC-35.5* RDW-14.7 Plt Ct-309 [**2156-1-3**] 03:36AM BLOOD WBC-10.8 RBC-3.74* Hgb-12.0* Hct-33.7* MCV-90 MCH-32.0 MCHC-35.5* RDW-14.7 Plt Ct-258 [**2156-1-2**] 09:56AM BLOOD WBC-14.7* RBC-3.96* Hgb-12.8* Hct-35.8* MCV-90 MCH-32.4* MCHC-35.8* RDW-14.7 Plt Ct-290 [**2156-1-2**] 06:25AM BLOOD WBC-14.0* RBC-4.26* Hgb-13.4* Hct-38.5* MCV-91 MCH-31.5 MCHC-34.8 RDW-14.8 Plt Ct-319 [**2156-1-1**] 06:50AM BLOOD WBC-12.6* RBC-4.12* Hgb-12.7* Hct-35.9* MCV-87 MCH-30.9 MCHC-35.5* RDW-14.6 Plt Ct-268 [**2155-12-31**] 10:30PM BLOOD WBC-14.8* RBC-4.36* Hgb-13.4* Hct-37.9* MCV-87 MCH-30.7 MCHC-35.3* RDW-14.7 Plt Ct-306 [**2156-1-3**] 03:36AM BLOOD Neuts-80.3* Lymphs-11.3* Monos-3.5 Eos-4.2* Baso-0.6 [**2156-1-2**] 09:56AM BLOOD Neuts-90* Bands-3 Lymphs-2* Monos-3 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2155-12-31**] 10:30PM BLOOD Neuts-62 Bands-5 Lymphs-16* Monos-6 Eos-11* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2156-1-2**] 09:56AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL [**2156-1-6**] 06:35AM BLOOD Plt Ct-285 [**2156-1-6**] 06:35AM BLOOD PT-12.7 INR(PT)-1.1 [**2156-1-4**] 07:40AM BLOOD Plt Ct-309 [**2156-1-4**] 07:40AM BLOOD PT-12.7 PTT-22.5 INR(PT)-1.1 [**2156-1-3**] 03:36AM BLOOD Plt Ct-258 [**2156-1-3**] 03:36AM BLOOD PT-15.4* PTT-24.5 INR(PT)-1.4* [**2156-1-2**] 09:56AM BLOOD Plt Smr-NORMAL Plt Ct-290 [**2156-1-2**] 09:56AM BLOOD PT-17.9* PTT-25.2 INR(PT)-1.7* [**2156-1-2**] 06:25AM BLOOD Plt Ct-319 [**2156-1-2**] 06:25AM BLOOD PT-19.1* INR(PT)-1.8* [**2156-1-1**] 03:48PM BLOOD PT-21.3* INR(PT)-2.1* [**2156-1-1**] 06:50AM BLOOD Plt Ct-268 [**2156-1-1**] 06:50AM BLOOD PT-30.9* PTT-29.2 INR(PT)-3.3* [**2155-12-31**] 10:30PM BLOOD Plt Ct-306 [**2155-12-31**] 10:30PM BLOOD PT-28.3* PTT-28.0 INR(PT)-2.9* [**2156-1-6**] 06:35AM BLOOD Glucose-124* UreaN-36* Creat-1.9* Na-146* K-3.8 Cl-110* HCO3-24 AnGap-16 [**2156-1-4**] 07:40AM BLOOD Glucose-80 UreaN-48* Creat-2.3* Na-147* K-3.6 Cl-107 HCO3-26 AnGap-18 [**2156-1-3**] 03:36AM BLOOD Glucose-99 UreaN-42* Creat-2.6* Na-142 K-3.3 Cl-104 HCO3-30 AnGap-11 [**2156-1-2**] 09:56AM BLOOD Glucose-136* UreaN-35* Creat-2.3* Na-141 K-5.1 Cl-103 HCO3-27 AnGap-16 [**2156-1-2**] 06:25AM BLOOD Glucose-133* UreaN-34* Creat-2.1* Na-142 K-4.2 Cl-103 HCO3-24 AnGap-19 [**2156-1-1**] 06:50AM BLOOD Glucose-151* UreaN-43* Creat-2.2* Na-139 K-4.5 Cl-106 HCO3-22 AnGap-16 [**2155-12-31**] 10:30PM BLOOD Glucose-192* UreaN-48* Creat-2.4* Na-137 K-4.4 Cl-101 HCO3-22 AnGap-18 [**2156-1-6**] 09:45AM BLOOD CK(CPK)-86 [**2156-1-6**] 06:35AM BLOOD ALT-91* AST-113* LD(LDH)-217 AlkPhos-535* Amylase-267* TotBili-1.4 [**2156-1-6**] 02:21AM BLOOD CK(CPK)-90 [**2156-1-5**] 06:30PM BLOOD CK(CPK)-83 [**2156-1-5**] 06:25AM BLOOD CK(CPK)-84 Amylase-263* [**2156-1-4**] 07:40AM BLOOD ALT-95* AST-103* AlkPhos-408* Amylase-721* TotBili-2.0* [**2156-1-3**] 08:10PM BLOOD Amylase-1388* [**2156-1-3**] 11:39AM BLOOD CK(CPK)-96 [**2156-1-3**] 03:36AM BLOOD ALT-110* AST-116* LD(LDH)-177 CK(CPK)-120 AlkPhos-398* Amylase-1643* TotBili-3.3* [**2156-1-2**] 10:14PM BLOOD CK(CPK)-175* [**2156-1-2**] 09:56AM BLOOD CK(CPK)-214* [**2156-1-2**] 06:25AM BLOOD ALT-125* AST-150* LD(LDH)-223 AlkPhos-501* Amylase-91 TotBili-3.7* [**2156-1-1**] 06:50AM BLOOD ALT-110* AST-180* AlkPhos-402* Amylase-104* TotBili-2.4* [**2155-12-31**] 10:30PM BLOOD ALT-70* AST-122* AlkPhos-328* Amylase-141* TotBili-1.4 [**2156-1-6**] 06:35AM BLOOD Lipase-684* [**2156-1-5**] 06:25AM BLOOD Lipase-477* [**2156-1-4**] 07:40AM BLOOD Lipase-741* [**2156-1-3**] 08:10PM BLOOD Lipase-1797* [**2156-1-3**] 03:36AM BLOOD Lipase-3806* [**2156-1-2**] 06:25AM BLOOD Lipase-43 [**2156-1-1**] 06:50AM BLOOD Lipase-54 [**2155-12-31**] 10:30PM BLOOD Lipase-108* [**2156-1-6**] 09:45AM BLOOD CK-MB-NotDone cTropnT-0.25* [**2156-1-6**] 02:21AM BLOOD CK-MB-NotDone cTropnT-0.27* [**2156-1-5**] 06:30PM BLOOD CK-MB-NotDone cTropnT-0.24* [**2156-1-5**] 06:25AM BLOOD CK-MB-NotDone cTropnT-0.23* [**2156-1-4**] 07:40AM BLOOD CK-MB-3 cTropnT-0.18* [**2156-1-3**] 08:10PM BLOOD CK-MB-3 cTropnT-0.17* [**2156-1-3**] 11:39AM BLOOD CK-MB-NotDone cTropnT-0.19* [**2156-1-3**] 03:36AM BLOOD CK-MB-5 cTropnT-0.24* [**2156-1-2**] 10:14PM BLOOD CK-MB-7 cTropnT-0.25* [**2156-1-2**] 09:56AM BLOOD CK-MB-6 cTropnT-0.08* [**2156-1-6**] 06:35AM BLOOD Albumin-3.2* Calcium-8.8 Phos-2.4* Mg-2.0 [**2156-1-4**] 07:40AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1 [**2156-1-3**] 03:36AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.2 [**2156-1-2**] 09:56AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0 [**2156-1-2**] 06:25AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.9 [**2156-1-1**] 06:50AM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.1 Mg-2.1 [**2156-1-2**] 08:53AM BLOOD Type-ART Rates-/24 pO2-58* pCO2-41 pH-7.43 calHCO3-28 Base XS-2 Intubat-NOT INTUBA Comment-NON-REBREA RADIOLOGY Final Report CT ABDOMEN W/O CONTRAST [**2155-12-31**] 10:42 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: eval for leaking AAA [**Hospital 93**] MEDICAL CONDITION: 80 year old man with ab pain, known AAA REASON FOR THIS EXAMINATION: eval for leaking AAA CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 80-year-old man with abdominal pain and known abdominal aortic aneurysm. COMPARISONS: Prior abdominal ultrasound from [**2154-5-9**]. At that time, the abdominal aortic aneurysm measured 43 x 35 cm (transverse x AP). TECHNIQUE: Axial non-contrast CT images of the abdomen and pelvis were obtained without intravenous contrast, and sagittal and coronal reconstructions were also performed. No oral contrast was administered. Intravenous contrast was not administered because of renal insufficiency. CT OF THE ABDOMEN WITH IV CONTRAST: There is subsegmental atelectasis in the right lower lobe, but no effusions. There are coronary artery calcifications. The hepatic density is rather elevated, consistent with amiodarone therapy for example. The gallbladder is somewhat distended with dependent gallstones. There is no surrounding stranding. There is no intra- or extrahepatic biliary ductal dilatation. The distal common duct measures approximately 8 mm in diameter without evidence of stones. There are some scattered pancreatic calcifications. [**Year (4 digits) **] calcifications in the aorta and splenic artery. The spleen appears normal and is not enlarged. The adrenal glands are unremarkable. Of note, there are enlarged periportal lymph nodes. The largest measures 19 x 14 mm. There is a 25 mm hypoattenuating focus in the right kidney, which has previously been ascertained as a simple cyst by ultrasound. There is also a tiny 5 mm hyperdense cyst in the upper pole. There is a calcification, probably [**Year (4 digits) 1106**] in the left kidney. Both kidneys are atrophic. The maximum dimensions of the abdominal aortic aneurysm are 45 x 41 mm in axial dimensions (AP x transverse), and the maximum diameter is 40 cm. The appearance is likely unchanged allowing for differences in technique, and there is no evidence of a surrounding hematoma. There is also a common iliac artery aneurysm on the right measuring 27 mm in diameter. The stomach, small and large bowel are within normal limits. There is no retroperitoneal or mesenteric lymphadenopathy, or free air or fluid. CT OF THE PELVIS WITH IV CONTRAST: There are prostate calcifications. The sigmoid, rectum, seminal vesicles are unremarkable, and the bladder appears normal. There is a normal appearance appendix, with its tip herniating into the right inguinal ring. BONE WINDOWS: There are marked degenerative changes of thoracolumbar spine, but no suspicious lytic or blastic lesions. IMPRESSION: 1. Likely similar appearance of abdominal aortic aneurysm, allowing for differences in technique, with maximum diameter of 40 mm. 2. Moderately distended gallbladder, with stones. 3. No intra- or extrahepatic biliary ductal dilatation. 4. Prominent periportal lymph nodes. 5. Elevated density of the hepatic parenchyma, which could be seen in amiodarone therapy for example. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**] DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**] Approved: [**First Name8 (NamePattern2) **] [**2156-1-1**] 2:51 PM RADIOLOGY Final Report LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2156-1-1**] 12:47 AM LIVER OR GALLBLADDER US (SINGL Reason: eval for cholecystis, stones [**Hospital 93**] MEDICAL CONDITION: 80 year old man with diffuse ab pain, R>L; elevated LFTs REASON FOR THIS EXAMINATION: eval for cholecystis, stones INDICATIONS: 80-year-old man with diffuse abdominal pain. COMPARISONS: CT of the same day. TECHNIQUE: Right upper quadrant ultrasound. FINDINGS: The echotexture of the liver appears normal, and no focal lesions are identified. There is no intra- or extra-hepatic biliary ductal dilatation. The visualized proximal portion of the pancreas appears normal. The main portal vein demonstrates appropriate hepatopetal flow. The gallbladder is moderately distended. Some tenderness is present about the gallbladder, more so than in adjacent areas. There is layering sludge within the gallbladder and multiple shadowing stones. Although much of the wall is normal in thickness, there are areas of focal wall thickening, with intramural edema in some areas, particularly along the mid and fundal portions up to a maximum thickness of 6 mm. There is no ascites. IMPRESSION: High suspicion for cholecystitis. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**] DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**] Approved: [**First Name8 (NamePattern2) **] [**2156-1-1**] 2:51 PM PATIENT/TEST INFORMATION: Indication: Coronary artery disease. Height: (in) 70 Weight (lb): 193 BSA (m2): 2.06 m2 BP (mm Hg): 154/89 HR (bpm): 58 Status: Inpatient Date/Time: [**2156-1-6**] at 12:11 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W011-0:00 Test Location: West Echo Lab Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.8 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.6 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.2 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%) Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm) Aorta - Ascending: 3.3 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: *2.3 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 21 mm Hg Aortic Valve - Mean Gradient: 10 mm Hg Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A Ratio: 1.00 Mitral Valve - E Wave Deceleration Time: 139 msec INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV cavity size. Moderately depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of mitral valve chordae. Mild (1+) MR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Compared with the findings of the prior study, there has been no significant change. Conclusions: 1. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. Posterior akinesis and lateral and distal septal hypokinesis are present. 2. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 3. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 4. Compared with the findings of the prior study of [**2153-4-23**], there has been probably no significant change. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1445**], MD on [**2156-1-6**] 12:44. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Brief Hospital Course: Pt was monitored post ERCP and treated with ABX ERCP Report [**Hospital1 **] [**Hospital Ward Name 517**] Date: [**Last Name (LF) 2974**], [**2156-1-2**] Endoscopist(s): [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 28439**], MD (fellow) Patient: [**Known firstname 122**] [**Known lastname 100582**] Ref.Phys.: [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2472**], M.D.; Per-[**Name6 (MD) **] [**Name8 (MD) 5182**], MD PhD Birth Date: [**2075-5-3**] (80 years) Instrument: TJF 160 048 40 25 Indications: Cholecystitis and concern for cholangitis. ERCP to evaluate further. Medications: general anesthesia ASA Class: P2 Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. The patient was placed in the prone position and an endoscope was introduced through the mouth and advanced under direct visualization until the second part of the duodenum was reached. Careful visualization was performed. The procedure was not difficult. The quality of the preparation was good. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: A single non-bleeding diverticulum with small opening was found on the rim of the major papilla. Cannulation: Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. The procedure was not difficult. Cannulation of the pancreatic duct was not attempted. Biliary Tree: A moderate diffuse dilation was seen at the common bile duct. These findings are compatible with biliary obstruction. Procedures: A 9cm by 10 f Cotton [**Doctor Last Name **] biliary [**Doctor Last Name **] was placed successfully in the common bile duct. Impression: Papilla major diverticulum Biliary dilation compatible with biliary obstruction CBD [**Doctor Last Name **] placement Recommendations: Continue ICU management Consider cholecystectomy Repeat ERCP in 1 month to remove [**Doctor Last Name **] and clear CBD - will need [**Doctor Last Name 100581**]. Additional notes: Images sub-optimal in the ICU with a C arm. CBD dilatation probable CBD stone. Given coagulopathy [**Doctor Last Name 100581**] not possible. Stnet placed. Will require definitive ERCP in [**3-11**] weeks. _________________________________ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD _________________________________ [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 28439**], MD (fellow) Pt is to F/U with Dr. [**Last Name (STitle) **] for [**Last Name (STitle) **] removal and Spincterotomy Medications on Admission: lopressor 25" amiodarone 200" asa 81' lipitor 80' isosorbide mn 30' flogard 2.2" plavix 75' coumadin 4 t/tr/sa/sn coumadin 3 m/w/f hydralazine 25'" Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QAM (once a day (in the morning)). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QAM (once a day (in the morning)). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. Warfarin 3 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-[**Last Name (STitle) 2974**]). Disp:*30 Tablet(s)* Refills:*0* 10. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QTUTHSASU (). Disp:*30 Tablet(s)* Refills:*0* 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: - acute cholecystitis - ERCP pancreatitis Discharge Condition: - good Discharge Instructions: - Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. - Adhere to 2 gm sodium diet - Fluid Restriction: - You may resume all home medications with the changes that have been made during your hospitalization - You may resume your regular, salt restricted diet - You may shower - [**Name8 (MD) **] MD or return to ER if T>101.5, chills, nausea, vomiting, chest pain, shortness of breath, severe abdominal pain, or any other concern. Pt had ABD pain and a chemical pancreatitis, it is very important for the patient to return if he complains of any ABD. pain at all or if there are any signs of complications related to his Gallbladder Followup Instructions: - You need to follow up with the Gastro-Intestinal doctors [**First Name (Titles) **] [**Name5 (PTitle) 100583**] and [**Name5 (PTitle) 100581**]. You had a plastic [**Last Name (un) 2435**] placed and will need to have that removed in 3 weeks time you will likely need to stop your coumadin prior to spincterotomy at time of ERCP - You should follow-up with Dr. [**Last Name (STitle) 5182**] in 3 weeks. Please call his office at ([**Telephone/Fax (1) 15350**] to schedule an appointment. - Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1694**] Date/Time:[**2156-1-29**] 8:30 - Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2156-6-29**] 11:00. Please call to confirm this/or an earlier appointment. - You should also follow-up with your primary doctor for a blood pressure check and further monitoring of your blood pressure. [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**] Completed by:[**2156-1-11**]

[ "401.9", "250.00", "V45.82", "574.61", "576.1", "428.0", "433.10", "997.4", "427.32", "272.4", "412", "441.4", "593.9", "790.92", "576.8", "577.0" ]

icd9cm

[ [ [] ] ]

[ "51.87", "99.07" ]

icd9pcs

[ [ [] ] ]

19743, 19813

14821, 17799

322, 332

19899, 19908

2197, 7320

20611, 21788

2040, 2054

17997, 19720

10855, 10912

19834, 19878

17825, 17974

19932, 20588

12199, 14686

2069, 2178

274, 284

10941, 12173

360, 1188

14718, 14798

1210, 1876

1892, 2024

22,474

120,894

28192

Discharge summary

report

Admission Date: [**2192-10-12**] Discharge Date: [**2192-10-22**] Date of Birth: [**2122-10-14**] Sex: M Service: CARDIOTHORACIC Allergies: Fulvicin U/F Attending:[**First Name3 (LF) 922**] Chief Complaint: Exertional angina Major Surgical or Invasive Procedure: [**2192-10-12**] - Cardiac Catheterization [**2192-10-15**] - CABGx2 (LIMA->LAD, Vein graft->Obtuse marginal artery) History of Present Illness: 69-yo-man w/ HTN, hyperlipidemia presented today for elective cardiac cath to evaluate exertional chest pain. Was feeling well until 7-10 days ago, when he developed a pattern of substernal chest pain with exertion, which he first noticed while doing yardwork. The pain began just above his navel and continued up to his sternal notch. The pain occured only during activity, resolved within 5-10 minutes of rest. The pain has been increasing in severity until now. With this pain, he did not have dyspnea, palpitations, or dizziness. Denies any recent fever, rigors, or cough. He does have positional left shoulder joint pain triggered with specific positioning and which began following an injury to that joint. ROS reveals no weight loss, abd pain, dysuria, diarrhea, melena, or hematochezia. . He initially presented for admission to the CMI service for cardiac catheterization today. However, his cath revealed significant left main CAD requiring bypass surgery. He is now admitted to the [**Hospital1 1516**] service for workup in preparation for surgery. At this time, he is feeling restless because he is lying flat. He is without chest pain. He is being evaluated by CT surgery. . He does describe extreme fatigue which occurred in 3 episodes earlier this summer. He did have night sweats and fever up to 102 at that time. He thinks that this was secondary to a tick bite, and he was worked up by his PCP who treated him with 3 weeks of doxycycline (finished in mid-[**Month (only) 205**]). He has not had recent fevers or night sweats. . Past Medical History: - Hypertension - Hyperlipidemia - Diverticulosis: c/b GI bleed in [**1-7**] (had colonoscopy at that time) - Elbow surgery [**2189**]: for treatment of infected cryotherapy site - Nephrolithiasis - ? lyme disease this past summer Social History: He is married. He denies tobacco use. He does drink several beers or glasses of wine each day. He denies cocaine and IVDU. Family History: - stroke: mother died in early 60's. Physical Exam: 60 135/74 72" 180 lbs GEN: WDWN in NAD HEENT: Unremarkable HEART: RRR, Nl S1-S2 LUNGS: Clear ABD: Benign EXT: warm, 2+ pulses, no varicosties. Limited ROM in left shoulder Pertinent Results: [**2192-8-1**] Echo: LVEF 65%, mild to moderate MR, mild TR, left atrial enlargement, evidence of diastolic dysfunction. . [**2192-10-11**] ETT: The patient exercised for 3'[**27**]" [**First Name8 (NamePattern2) **] [**Doctor First Name **] protocol to 80% of APHR and complained of dyspnea and [**4-8**] chest pressure at peak exercise. EKG significant for 1mm ST segment depressions in V4-V6. Patient noted to have PVC's/junctional rhythm in recovery. . Cardiac cath ([**2192-10-12**]): 90% stenosis of distal left main coronary artery. Non-obstructive otherwise. [**2192-10-12**] 02:00PM WBC-3.3* RBC-4.08* HGB-12.7* HCT-35.1* MCV-86 MCH-31.1 MCHC-36.1* RDW-15.5 [**2192-10-12**] 02:00PM PLT COUNT-136* [**2192-10-12**] 02:00PM PT-12.0 PTT-24.9 INR(PT)-1.0 [**2192-10-12**] 02:00PM GLUCOSE-119* UREA N-17 CREAT-0.9 SODIUM-138 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12 [**2192-10-12**] 02:00PM ALT(SGPT)-19 AST(SGOT)-24 ALK PHOS-66 AMYLASE-31 TOT BILI-0.6 [**2192-10-12**] 05:12PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2192-10-18**] 06:10AM BLOOD WBC-11.6* RBC-3.47* Hgb-10.7* Hct-30.5* MCV-88 MCH-30.9 MCHC-35.1* RDW-15.5 Plt Ct-231 [**2192-10-18**] 06:10AM BLOOD Plt Ct-231 [**2192-10-18**] 06:10AM BLOOD Glucose-159* UreaN-25* Creat-1.2 Na-140 K-4.8 Cl-100 HCO3-32 AnGap-13 [**2192-10-15**] - ECHO PRE-BYPASS: 1. The left atrium is normal in size. The left atrial appendage emptying velocity is depressed (<0.2m/s). The right atrial appendage ejection velocity is depressed (<0.2m/s). The interatrial septum is aneurysmal. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. Trivial mitral regurgitation is seen. POST-BYPASS: 1. [**Hospital1 **]-ventricular function is unchanged from pre-bypass 2. Aorta is intact post decannulation 3. Other findings are unchanged [**2192-10-17**] CXR Small right hydropneumothorax Brief Hospital Course: Mr. [**Known firstname 487**] was admitte dto the [**Hospital1 18**] on [**2192-10-12**] for a cardiac catheterization. This was significant for severe left main coronary artery disease. Heparin was started for anticoagulation. Given the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. Mr. [**Known firstname 487**] was worked up in the usual preoperative manner and deemed suitable for surgery. On [**2192-10-15**], Mr. [**Known firstname 487**] was taken to the operating room where he underwent coronary artery bypass grafting to two vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. By postoperative day one, Mr. [**Known lastname 15499**] was awake, extubated and neurologically intact. Aspirin, beta blockade and a statin were resumed. He was then transferred to the step down unit for further recovery. The physical therapy service was consulted for strength and mobility. He was gently diuresed towards his preoperative weight. On [**10-19**], there was some erythema noted at distal aspect of sternal wound. This was sharply debrided at the bedside, and packed with wet to dry normal saline dressings. Cultures were sent, which were negative. He was placed on IV Vancomycin & PO levofloxacin prophylactically while awaiting final culture results. His Vanco was d/c'd, and will be discharged on oral Levofloxacin for 1 week. Mr. [**Known lastname 15499**] continued to make steady progress and was discharged home on [**2192-10-22**]. He will follow-up with Dr. [**Last Name (STitle) 914**], his cardiologist and his primary care physician as an outpatient. Medications on Admission: - Aspirin 81mg daily - Plavix 75mg daily, started 9/7/6 without loading dose - Toprol XL 25mg daily - ferrous sulfate 325mg daily - MVI - folic acid 1 mg [**Hospital1 **] 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD s/p CABGx2 Hypercholesterolemia HTN Lymes disease Diverticulosis Nephrolithiasis Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5 3) Report any weight gain of greater then 2 pounds in 24 hours or 5 pounds in 1 week. 4) No driving for 1 month or whenever taking narcotics. 5) No lifting greater then 10 pounds for 10 weeks. Followup Instructions: Follow-up with surgeon Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with cardiologist Dr. [**Last Name (STitle) 11493**] in [**2-6**] weeks. [**Telephone/Fax (1) 11650**] Follow-up with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 22763**] Wound check on Monday, [**10-29**], on [**Hospital Ward Name 7717**] as discussed Completed by:[**2192-10-22**]

[ "414.01", "272.4", "998.59", "424.0", "427.31", "E878.2", "401.9", "284.8" ]

icd9cm

[ [ [] ] ]

[ "36.11", "39.61", "36.15", "88.55", "88.52", "37.22" ]

icd9pcs

[ [ [] ] ]

8230, 8279

5168, 6839

299, 418

8408, 8417

2656, 5145

8791, 9255

2406, 2445

7061, 8207

8300, 8387

6865, 7038

8441, 8768

2460, 2637

242, 261

446, 1995

2017, 2250

2266, 2390

16,678

145,659

14164

Discharge summary

report

Admission Date: [**2102-6-28**] Discharge Date: [**2102-7-1**] Date of Birth: [**2075-12-17**] Sex: F HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old Asian-American female with no past medical history who was down in her hallway of her apartment. Center and found to be in diabetic ketoacidosis with blood sugars of 809, a bicarbonate of 9, and a pH of 7.02. The patient was also found to have a rhabdomyolysis with a creatine kinase of 46,000. The patient was admitted to the Medical Intensive Care Unit on [**6-28**] and was given aggressive fluid resuscitation, and gap and acidosis. Her rhabdomyolysis was attributed to her falling and being down for an unknown amount of time. The precipitating factor for her diabetic ketoacidosis was worked up, but no specific factor was determined. Once called out from the Medical Intensive Care Unit, the patient did not have any pain or discomfort and denied any nausea, vomiting, fevers, chills, chest pain, abdominal pain, diarrhea, or dysuria. PAST MEDICAL HISTORY: The patient had no past medical history prior to admission. ALLERGIES: SULFA (the patient gets a rash). MEDICATIONS ON ADMISSION: Oral contraceptive pills. MEDICATIONS ON TRANSFER: Medications on transfer from the Medical Intensive Care Unit to the floor revealed the patient was taking Glargine, Humalog sliding-scale, and had droperidol 0.625 mg intravenously q.4-6h. as needed. SOCIAL HISTORY: The patient is an intern at the [**Hospital6 8866**]. She is married, and her husband is also a resident at [**Hospital6 1708**]. The patient denies any tobacco or alcohol history and denies drug use. FAMILY HISTORY: The patient's father has a history of type 2 diabetes. The patient has no known thyroid disease. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed vital signs were stable. The patient was pleasant and cooperative. Heart was regular. The lungs were clear. The abdomen was unremarkable, and extremities had no edema. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories were notable only for a hematocrit of 31.2, potassium of 3, bicarbonate of 31, calcium of 7, phosphate of 2, albumin of 2.7, and a creatine kinase of 29,190. HOSPITAL COURSE: 1. ENDOCRINE: The patient with new onset diabetic ketoacidosis and was admitted to the Medical Intensive Care Unit and had aggressive fluid resuscitation as well as an insulin drip which was eventually changed to subcutaneous insulin. The patient responded well to this therapy with resolution of her anion gap and her acidosis and was nicely transitioned to a Humalog sliding-scale with q.i.d. fingersticks. The patient also tolerated the Glargine very well. At the time of discharge, her anti-insulin antibody, GAD antibody, and islet cell antibody, as well as her hemoglobin A1c were all pending. 2. RHABDOMYOLYSIS: Her creatine kinase was decreasing each day of her hospitalization. Because the patient had normal renal function, no further workup was considered. She tolerated this well. 3. FLUIDS/ELECTROLYTES/NUTRITION: The patient had some electrolyte deficiencies including potassium, phosphate, and calcium which were all expected secondary to her massive diuresis from her diabetic ketoacidosis. The patient was supplemented with potassium; and although not within the normal range, all her electrolytes were expected to improve as she started taking an oral diet, and no further supplements were given. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. DISCHARGE STATUS: Her discharge status was to home. DISCHARGE DIAGNOSES: 1. Diabetic ketoacidosis. 2. New onset diabetes mellitus type 1. MEDICATIONS ON DISCHARGE: (The patient's discharge medications included) 1. Glargine 20 units q.h.s. 2. Humalog sliding-scale. 3. Lancets and syringes and test strips for her diabetic management. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [**Last Name (STitle) 9671**] on Monday, [**7-3**]. At that time, they will discuss her sliding-scale. The patient also received diabetic teaching and nutrition counseling while she was in house. She was to receive further nutrition and diabetic teaching at the [**Last Name (un) **] Center when she follows up at that time. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 27068**] Dictated By:[**Name8 (MD) 42155**] MEDQUIST36 D: [**2102-7-1**] 12:04 T: [**2102-7-6**] 10:50 JOB#: [**Job Number 42156**]

[ "728.89", "079.99", "250.11" ]

icd9cm

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icd9pcs

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22154

Discharge summary

report

Admission Date: [**2115-9-11**] Discharge Date: [**2115-9-18**] Date of Birth: [**2062-9-7**] Sex: F Service: MEDICINE Allergies: Codeine / Demerol Attending:[**First Name3 (LF) 3266**] Chief Complaint: CC - fever, n/v, headache Major Surgical or Invasive Procedure: IJ line placement [**2115-9-12**] History of Present Illness: HPI - This is a 53 y/o female with alcoholic cirrhosis s/p OLT [**1-12**] clb acute rejection [**7-14**], had biliary stent placements on [**2115-6-21**] and [**2115-9-10**] for strictures, who p/w with high fevers, headache, n/v since 4 am this morning. Headache is frontal in nature, sharp and stabbing, no vision changes, no dizziness, no syncope. No neck stiffness. Fever up to 104.7 today at home, which prompted pt to come to ED. Also having nausea and vomiting x 10, with yellowish-green emesis, no blood. She denies any abdominal pain or diarrhea. Having chills as well. Pt also reports left arm/leg numbness and tingling. ROS - Pt denies any vision changes, neck stiffness, SOB, chest pain, cough, abd pain, LE swelling. 53 yo f w/ h/o systolic hf (LVEF 10-20%), s/p AICD placement [**3-16**], alcoholic cirrhosis s/p OLT chronically immunosuppressed, who underwent ERCP w/ stent placement 1d PTA, who was transferred from the floor [**3-13**] intermittent hypotension. Patient originally presented to the ED [**9-11**] w/ fever, vomiting, and HA over the prior 24 hours. Rec'd levo/vanc/flagyl in ED, admitted to floor, where she was initially stable, but febrile to 101 and tachycardic. SBP dropped to 60s, bxcx's returned at 4/4 bottles +for GNRs. Transferred to ICU for further management. . Reports that she now generally feels weak, c/o shoulder,neck pain. Denies any abd pain. States that vomiting at home was not associated w/ meals, ?bilous. Denies diarrhea, change in skin color, [**Male First Name (un) 1658**] colored stools, dk urine. Denies changes in urinary or bowel habits. No prior fevers. Past Medical History: Past Medical History: - Alcoholic cirrhosis with portal HTN, thrombocytopenia, coagulopathy s/p orthotopic liver transplantation on [**2115-1-27**]. Increased alk phos has been increasing since end of [**Month (only) 958**] and beg of [**2115-5-10**]. - s/p ERCP and new biliary stent placement [**2115-6-21**]: showed anastomotic stricture 3 mm compatible with post-op stricture, which was dilated; also 6 mm stone in lower [**2-11**] of CBD which was extracted, placed 9 cm and 7 cm stent in common hepatic duct - CHF, EF 10-20% on echo [**2115-4-28**], dry weight around 57 kg [**5-14**], possibly from secondary iron overload disorder - s/p AICD /VVI ppm - RV perforation after R heart biopsy, s/p drain - A fib with RVR - hyperkalemia s/p aldactone - pulmonary nodule on chest CT, not amenable to VATS - pulmonary infiltrate on chest CT - hypertension - hypothyroidism - diabetes mellitus - H/o upper and lower GI bleeding in [**2111**] with EGD positive for varices which were maybe banded - no records here - Heavy ETOH abuse since age 20 for about 30 years. Used to drink pint a day, now does not drink - h/o HTN - h/o low back pain - s/p tubal ligation [**2093**] - Ectopic pregnancy [**2099**] Last colonoscopy per pt last year was nl (no records available here) Last mammogram per pt last year nl Last PAP smear was abnormal last year s/p colposcopy Social History: Social History: Lives with husband at home. Tobacco ?????? [**3-15**] cigarettes/day. EtOH ?????? Stopped drinking on [**3-15**], previously [**4-12**] vodka drinks per day for 30 years. No IVDA Family History: Strong hx of alcohol abuse and cirrhosis. Father died from MI at 53. Mother died at 57 from alcohol abuse, brother died in the last two years from alcohol abuse Physical Exam: t 97.5, bp 105/61, p 82, r 20 100% on 2L NC, cvp 3-5, mvo2 77% Ill appearing female, conversant. VS - T 104, BP 113/60, HR 128, RR 18, sats 99%/2LNC General - Ill-appearing, flushed woman in some distress. Pt AO x 3 HEENT - NC/AT, PERRL, EOMI. OP wnl, MMM dry. Neck - supple, no stiffness/meningismus. Kernig's/Brudzenski's negative. No LAD, TMG appreciated Chest - CTA-B, no w/r/r CV - RR, tachy s1 s2 normal. no m/g/r Abd - soft, slight tenderness to in RUQ to palpation, negative Murhpy's signs, ND, pos BS Ext - no c/c/e, pulses 2+ b/l Skin - flushed, warm, dry, no skin rashes or petechiae Neuro - Pt AO x 3, CN II-XII grossly intact, sensation and motor exams WNL grossly, no focal neurological deficits Pertinent Results: 132 99 19 /324 AGap=18 3.5 19 1.1 \ . Ca: 8.6 Mg: 1.1 P: 3.6 . 10.7 \ 16.2 / 85 / 48.2 \ . 7.35/31/127 . ALT: 91 AP: 214 Tbili: 0.7 Alb: 4.4 AST: 118 LDH: Dbili: TProt: [**Doctor First Name **]: 23 . bxcx: GNRs 4/4 bottles . CT abd: 1. New bowel wall thickening consistent with colitis involving the ascending and transverse colon. Probable patchy areas of thickening within the sigmoid and descending colon also. This may be secondary to a low flow ischemia. If the sigmoid and descending colon are also affected, this may be secondary to infection. No obstruction, pneumatosis or abscess is identified. 2. New cavitary lesion in the right lower lobe with surrounding patchy opacities. This is in the location of a previously seen consolidation which has mostly resolved. 3. Liver transplant and common bile duct stents are unremarkable. No free air or intrahepatic biliary dilatation identified. 4. Diffuse soft tissue stranding within the mesentery and subcutaneous soft tissues consistent with anasarca. Small pericardial effusion. . RUQ u/s: Unremarkable right upper quadrant ultrasound. . CT head: No evidence of intracranial hemorrhage, edema or abnormal areas of post- contrast enhancement. Brief Hospital Course: Ms. [**Known lastname 57853**] was admitted on [**2115-9-11**] for fever, headache, n/v, and subjective left UE/LE numbness and weakness for one day. Given her recent biliary stent placement the day before, elevated WBC with 85% N and 7 bands, and her high-grade fever of 104, she was started on empiric Ceftriaxone, Flagyl, and Vancomycin, while her studies were pending. CT of the head was negative for increased ICP, and diagnostic LP performed was negative for any meningitis. U/S of the abdomen was negative for any biliary perforation. Her abdominal CT showed new bowel wall thickening consistent with colitis involving the ascending and transverse colon, with probable patchy areas of thickening within the sigmoid and descending colon also. She was initially stable when transferred to the floor, but was febrile to 101 and tachycardic. The next morning, [**2115-9-12**], her SBO dropped to the 60's and her blood cultures returned at 4/4 bottles + for GNRs. She was transferred to the ICU for further management for E.coli sepsis/bacteremia and pressures. While in the MICU - 1) Sepsis - Her initial blood cultures were 4/4 bottles positive for gram negative rods. Given her history of ESBL in the past, she was covered with Imipenim and gentamicin. On hospital day 2, the bacteria was identified as ESBL e.coli that was sensitive to meropenem. She was started on a 14 day course of meropenem. Surveillance cultures have been negative. She became hypotensive requiring fluid boluses and pressors. By hospital day 3, the pressors were weaned and she no longer required fluid boluses. Since she has been on chronic prednisone, she was treated with stress dose steroids fludrocortisone and hydrocortisone. Once her pressure was stable on hospital day 3, she was transitioned from hydrocortisone to a prednisone taper. The fludrocortisone was stopped on hospital day 4. 2) CHF - Initally she required fluid boluses to maintain her pressure. She was gently hydrated and monitored closely to prevent pulmonary edema. An ECHO on hospital day 3 showed an EF of 50-55%, which was increased from 10-20% a few months prior. The etiology of the increase in EF is unclear. Once her pressure was stable, she was restarted on a low dose carvedilol. 3) S/P OLT - She was maintained on her immunosuppression regimen througout the admission. 4) Thrombocytopenia- This was likely secondary to the acute infection. There was no evidence of TTP. 5) Swelling at IJ site - She had some swelling and discomfort at the site of her IJ catheter. There was no erythema or evidence of infection. An ultrasound was negative for a fluid collection or hematoma. The swelling and discomfort decreased once the line was removed. 6) Hypothyroidism - Her synthroid was continued throughout the admission. 7) History of atrial fibrillation - Her coumadin was held given her low hematocrit. She was maintained on digoxin. 8) DM - Shw was initially on an insulin drip given poor glycemic control most likely [**3-13**] increased steroids. She was transitioned to an insulin sliding scale prior to being called out from the ICU. 9) FEN - She was initially on clears and was advanced to a full diabetic diet prior to leaving the ICU. Her electrolytes were repleted. 10) Prophylaxis - She was maintained on subcutaneous heparin and a PPI. 11) Pain control - She was maintained on Morphine for pain control. Her requirement morphine decreased thoughout her ICU stay. After she was stabilized, she was transferred back to the floor for further management of her bacteremia on [**2115-9-15**]. 1) Sepsis - she was continued on Meropenem, to finish a 14-day course. She had a PICC placed to go home with to finish her regimen on [**2115-9-25**]. She was weaned off the stress-dose steroids back to her maintainence dose of 10 mg Prednisone daily. 2) CHF - Recent echo showed EF 50%, increased from 10-20% on prior echo. After discussion with Dr. [**Last Name (STitle) **], the patient's cardiologist, she was continued on all her prior cardiac meds and will have outpatient follow-up to reassess her CHF status in lieu of the recent echo with EF 50%. 3)h/o Asymptomatic bradycardia while in house - overnight, down to 38-40 with pacer kicking in for a few beats, patient asymptomatic. Discussed with EP attending, Dr. [**Last Name (STitle) 284**], who put the pacer in, and decided that as patient was stable, she should have outpatient follow-up to have device tested. She is to see Dr. [**Last Name (STitle) **] (referral from Dr. [**Last Name (STitle) **] re: pacer check this month. 4) S/P OLT - On Sirolimus, Cellcept, and Prednisone -sirolimus level pending upon discharge -to follow with Dr. [**Last Name (STitle) 497**] this month 5) Hypothyroidism - On synthroid. 6) History of atrial fibrillation - on coumadin 2 mg, INR subtherapeutic currently at 0.9 as coumadin was held for several days. Pt was in sinus rhythym while in the hospital. 7) L arm/leg tingling and pain - neuro followed, concern for thalamic stroke given symptoms in left arm and leg vs. cervical disk disease; their recs were to continue pt on coumadin with follow-up in stroke clinic 8) DM - Her blood sugars were normalized after tapering the steroids and were managed well on Lantus 14 U at bedtime and coverage with Humalog SS, with which she was discharged with. 9) Dispo - she was stable after receiving her PICC on [**2115-9-17**] to be discharged on [**2115-9-18**] with follow-up with Dr. [**Last Name (STitle) 497**], Dr. [**Name8 (MD) 57854**] NP, [**Name8 (MD) **]. [**Name5 (PTitle) 1693**]/[**Doctor Last Name **], and Dr. [**Last Name (STitle) 57855**]. Medications on Admission: MEDS ON ADMISSION: 1. CALCIUM CARBONATE 500 MG [**Hospital1 **] 2. PROTONIX 40 MG QD 3. LEVOTHYROXINE 125 MCG QD 4. COUMADIN 2 MG DAILY 5. DIGOXIN 0.125 MG QD 6. ISOSORBIDE MONONITRATE 60 MG DAILY 7. LASIX 40 MG DAILY 8. HYDRALAZINE 30 MG DAILY 9. BACTRIM DS 1 TAB DAILY 10. SIROLIMUS 4 MG DAILY 11. PREDNISONE 10 MG DAILY 12. CARVEDILOL 12.5 MG [**Hospital1 **] 13. CELLCEPT [**Pager number **] MG [**Hospital1 **] 14. CELEXA 10 MG QHS 15. LANTUS 14 U QHS 16. HUMALOG SS 17. TRAZADONE 100 MG QHS PRN 18. XANAX 0.5 MG [**Hospital1 **] PRN 19. VICODIN 5/500 2 TABS Q4-6 HOURS PRN Discharge Medications: 1. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 9 days: Last dose of this antibiotic on [**2115-9-25**]. Disp:*27 Recon Soln(s)* Refills:*0* 2. PICC line Please maintain PICC line per protocol 3. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Celexa 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Lantus 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime. 11. humalog sliding scale Sig: resume as you were taking at home per fingersticks: Resume as you were taking at home. 12. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 13. Trazadone Sig: One Hundred (100) mg at bedtime as needed for insomnia. 14. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 15. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a day: Hold for SBP < 100. 16. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day: Hold for SBP < 100. 17. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 18. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for HR < 60. 19. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)): Hold for HR < 60. Disp:*30 Tablet(s)* Refills:*2* 20. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 21. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain: DO NOT EXCEED MORE THAN 2 TABLETS A DAY. Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Therapies Discharge Diagnosis: Primary - E.coli sepsis/bacteremia Secondary - CHF (EF 50% by TTE [**2115-9-13**]), s/p OLT, s/p ERCP and biliary stent placement [**2115-9-10**], s/p AICD/VVI ppm, hypothyroidism, DM, HTN, h/o a fib Discharge Condition: Good Discharge Instructions: -continue taking all medications as prescribed upon discharge -please follow-up with liver and cardiology appointments as scheduled -weigh yourself daily -if any symptoms of fever, chest pain, shortness of breath, abdominal pain, profuse diarrhea, or any other concerning symptoms arise, please seek medical attention -please have blood checked for [**Month/Day/Year **] work on friday as already scheduled -call Dr.[**Name (NI) 948**] office on Friday to check Sirolimus level Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-10-2**] 10:40 Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2207**] Date/Time:[**2115-10-7**] 2:45 Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name 2781**] Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2115-10-29**] 3:00 Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 3670**]: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2115-10-8**] 3:30 Completed by:[**2115-9-24**]

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Discharge summary

report

Admission Date: [**2192-4-12**] Discharge Date: [**2192-4-25**] Date of Birth: [**2155-12-25**] Sex: M Service: MEDICINE Allergies: Compazine Attending:[**First Name3 (LF) 1257**] Chief Complaint: hypotension and hypoxia after missing dialysis Major Surgical or Invasive Procedure: Intubation, Bronch and BAL History of Present Illness: 36-year-old male with ESRD on HD (T/Th/Sat), hypertension, and chronic abdominal pain who presents with cough and dyspnea. He reports that he was in his USOH until Sat AM. He reports that his niece and other family members are [**Name2 (NI) **] at home. He reports that he had chills, but was afebrile with a temperature of 98.8. He developed a non-productive cough. He went to dialysis per usual routine. On Sunday, he reports that he developed runny eyes and felt "mucus in [his] throat." He developed SOB as well. He denies fevers, diarrhea, abdominal pain. He missed his HD session on Tuesday as he was feeling [**Name2 (NI) **], with nausea. He reports one episode of post-tussive emesis. Today, he went in for his dialysis session and was noted to have HR 140. He was referred to the ED for concern of volume overload. . In the ED, initial VS - 5 98.6 140 143/105 16 97% RA. Patient reported cough and abdominal pain, last BM yesterday. Denied CP. Labs notable for K 5.5, lactate 2.5, troponin 0.71, CK 543, MB 12, phos 9.8, wbc 13, hct 38, plt 170, INR 1.3. CT abdomen and pelvis performed, showing "RLL centrilobular opacities, likely aspiration. Moderate cardiomegly and atherosclerosis. Renal atrophy and cysts. Trace ascites, unchanged. No acute bowel pathology. SB-ctg R inguinal hernia w/o obstruction. Renal osteodystrophy." CXR showed cardiomegaly, mild fluid overload. EKG showed ? sinus tachycardia, with new TWI inferiorly, without CP. Shock US showed extra fluid (large IVC), no ascites. . Patient was given vancomycin, zosyn, aspirin, and zofran. He was given 1L IVF. Renal team was consulted for possible UF. Past Medical History: 1. ESRD on HD for at least ten years, felt to be due to longstanding hypertension vs glomerulonephritis - HD at [**Location (un) **] [**Location (un) **], T/Th/Sat, followed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] - s/p two failed kidney transplants, most recently in [**4-/2188**] 2. HTN, longstanding, poorly controlled 3. Chronic abdominal pain, s/p workup in [**3-/2190**] including normal US, EGD with esophagitis and several large duodenal ulcers. 4. Hypercholesterolemia 5. Anemia 6. GIB, likely hemorrhoidal Social History: Lives with brother, denies smoking, ETOH. Some marijuana use. Family History: Grandmother and mother with possible history of diabetes. Sister with ESRD, possibly due to HTN. Physical Exam: On admission: VS: 98.0, HR 134, BP 147/111, 25, 97% 2L NC GEN: AA male, mild distress HEENT: PERRL, EOMI, anicteric, MMM, OP without lesions, no supraclavicular or cervical lymphadenopathy, JVD 8 cm, no carotid bruits, no thyromegaly or thyroid nodules RESP: crackles at L base, but rhonchi and rales bilaterally with good air movement throughout CV: tachycardic, nl S1 and S2, 2-3/6 systolic murmur heard at lower sternal border ABD: minimally tender diffusely, +b/s, soft, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps Pertinent Results: Labs upon admission: . [**2192-4-12**] 02:20PM BLOOD WBC-13.0* RBC-4.82 Hgb-12.1* Hct-38.0* MCV-79* MCH-25.2* MCHC-31.9 RDW-17.3* Plt Ct-170 [**2192-4-12**] 02:20PM BLOOD Neuts-80* Bands-0 Lymphs-12* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2192-4-12**] 02:20PM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-3+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Burr-2+ Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 24904**] Ellipto-1+ [**2192-4-13**] 05:27AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-2+ Schisto-1+ Burr-2+ [**2192-4-12**] 02:20PM BLOOD PT-15.4* PTT-29.4 INR(PT)-1.3* [**2192-4-13**] 04:49PM BLOOD Fibrino-536* [**2192-4-12**] 02:20PM BLOOD Glucose-113* UreaN-86* Creat-15.1*# Na-135 K-8.4* Cl-92* HCO3-21* AnGap-30* [**2192-4-12**] 02:20PM BLOOD ALT-19 AST-31 CK(CPK)-543* TotBili-1.0 [**2192-4-12**] 02:20PM BLOOD Lipase-29 [**2192-4-12**] 02:20PM BLOOD CK-MB-12* MB Indx-2.2 [**2192-4-12**] 02:20PM BLOOD cTropnT-0.71* [**2192-4-12**] 10:12PM BLOOD CK-MB-13* MB Indx-3.1 cTropnT-0.66* [**2192-4-13**] 06:44AM BLOOD CK-MB-9 cTropnT-0.63* [**2192-4-12**] 02:20PM BLOOD Calcium-9.5 Phos-9.8* Mg-2.6 [**2192-4-12**] 05:50PM BLOOD Iron-37* [**2192-4-12**] 05:50PM BLOOD calTIBC-155* Ferritn-1837* TRF-119* [**2192-4-13**] 12:05PM BLOOD D-Dimer-782* [**2192-4-14**] 08:54PM BLOOD Hapto-149 [**2192-4-12**] 05:50PM BLOOD TSH-1.5 [**2192-4-13**] 05:27AM BLOOD PTH-2681* [**2192-4-14**] 03:22AM BLOOD Cortsol-38.8* [**2192-4-15**] 01:36PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2192-4-15**] 01:36PM BLOOD HCV Ab-NEGATIVE [**2192-4-12**] 02:26PM BLOOD Lactate-3.2* K-6.1* [**2192-4-13**] 01:30PM BLOOD freeCa-1.10* [**2192-4-18**] 11:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- [**2192-4-15**] 01:36PM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test (Negative titer) [**2192-4-15**] 01:36PM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test {Positive titer) . Labs upon discharge: . [**2192-4-25**] 07:20AM BLOOD WBC-4.1 RBC-3.63* Hgb-9.0* Hct-29.5* MCV-81* MCH-24.9* MCHC-30.7* RDW-19.4* Plt Ct-97* [**2192-4-19**] 05:05AM BLOOD Neuts-87.7* Lymphs-7.8* Monos-2.2 Eos-2.0 Baso-0.3 [**2192-4-24**] 08:40AM BLOOD PT-14.9* PTT-29.7 INR(PT)-1.3* [**2192-4-25**] 07:20AM BLOOD Glucose-70 UreaN-19 Creat-4.9*# Na-139 K-4.3 Cl-95* HCO3-34* AnGap-14 [**2192-4-25**] 07:20AM BLOOD ALT-77* AST-45* LD(LDH)-455* AlkPhos-259* TotBili-0.9 [**2192-4-15**] 03:14AM BLOOD CK-MB-18* MB Indx-2.8 cTropnT-0.66* [**2192-4-25**] 07:20AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.2 . ECHO [**2192-4-16**]: Compared with the prior study (images reviewed) of [**2192-4-13**], the effusion is similar. The severity of mitral and tricuspid regurgitation may be slightly increased on the current study and the measured pulmonary aterty systoilc pressure is much higher. . CXR [**2192-4-20**]: BEDSIDE AP UPRIGHT RADIOGRAPH OF THE CHEST: An endotracheal tube has been removed as has a nasogastric tube. Cardiomegaly is unchanged as are mediastinal and hilar contours. Left basal atelectasis persists, though is improved. Pulmonary edema is however unchanged. There is no pleural effusion, pneumothorax, or focal consolidation. . CT abd/pelvis [**2192-4-15**]: 1. Bibasilar atelectasis, with more dense consolidation in the left base, where infection cannot be excluded. Right lung tree-in-[**Male First Name (un) 239**] opacities also remain concerning for an infectious process. 2. Apparent wall thickening involving the sigmoid colon, but without adjacent inflammatory change. This may represent collapse and third spacing. 3. Diffuse anasarca. 4. Atrophic kidneys with multiple cysts. 5. Bony changes consistent with renal osteodystrophy . RUQ US [**2192-4-13**]: IMPRESSION: Markedly edematous gallbladder wall is unlikely to be related to cholecystitis. This is considered to be more likely related to the patient's low albumin state or other causes of third spacing, including right heart failure. Brief Hospital Course: 36 y/o w/ ESRD on HD, presented on [**2192-4-12**] for cough, dyspnea and was admitted to the MICU for tachycardia (HR 130s) and hypervolemia. He was started on UF, but later developed hypotension and hypoxia, requring intubation and bronchoscopy. All cultures including BAL were negative. Lactate was elevated and peaked at 12. He was evaluated by surgery but CT scan torso x2, RUQ US, and bronchoscopy was unrevealing for a septic source. Infectious disease evaluated him and recommended 8 day treatment with Vanco/Cefepime/Cipro for possible PNA (although CXR not convincing of consolidation). He developed transaminitis secondary to shock liver with resultant hypoglycemia (necessitating temporary D50 drip). He was extubated on [**2192-4-18**] without complication. Upon transfer to the medical floor, he was treated with both ultrafiltration and hemodialysis for fluid removal; he reached his dry weight and was weaned off of oxygen supplementation. Repeat echocardiogram was completed which suggested severe pulmonary hypertension. This prompted a right heart catheterization which showed pulmonary hypertension and elevated wedge pressure. The pulmonary hypertension is more than expected secondary to his left sided heart function, therefore primary pulmonary source may be possible. . Of note, he initially presented with supraventricular tachycardia consistent with either atrial tachycardia vs. atrial flutter, he was given a bolus of amiodarone but this was discontinued secondary to liver dysfunction and his SVT did not recur. . Overall, the etiology of his hypotension and hypoxia was unknown. He may have suffered septic shock, however an identifiable infectious source could not be determined. He has known ESRD secondary to collapsing FSGS. He may have a new pulmonary source of pulmonary hypertension versus long standing poorly controlled HTN and hypervolemia resulting in elevated left sided and therefore pulmonary pressures. We feel once he recovers and inflammation of acute illness decreases, he should undergo a autoimmune/lupus/vasculitis workup which may help connect both kidney, heart and lung disease. . Upon discharge, he will be seen in consultation by pulmonology. He will also f/u with cardiology, nephrology and we have established him with a primary care doctor at [**Hospital **]. He stated he was not seeing a primary care doctor prior to admission. . The patient was FULL CODE for this admission. Medications on Admission: 1. cinacalcet 90 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). Disp:*120 Tablet, Chewable(s)* Refills:*2* 3. nifedipine 60 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 4. labetalol 200 mg Tablet Sig: Two (2) Tablet PO twice a day: do not take if systolic blood pressure is less than 120mm Hg. 5. Minoxidil 5 mg daily Discharge Medications: 1. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). Disp:*30 Tablet Extended Release(s)* Refills:*2* 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 * Refills:*2* 4. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Septic shock - likely pneumonia as the source, no positive cultures Acute Respiratory Failure Supraventricular tachycardia - likely atrial fibrillation, resolved Severe pulmonary hypertension Transaminitis - thought to be due to hypotension End stage renal disease Pulmonary edema Thrombocytopenia Anemia Diarrhea Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital because of shortness of breath. You were admitted to the intensive care unit for a fast heart beat. You later developed low blood pressure and were unable to breath. You were temporarily intubated and given intravenous fluids and antibiotics. You received multiple imaging studies without finding a cause for your low blood pressure and breathing difficulty. You received dialysis and your breathing improved. You also received a right heart catheterization that showed that you have pulmonary hypertension (elevated pressures in the arteries of your lungs). You have an appointment to see cardiology to help determine if you would benefit from treatment and monitoring of your pulmonary hypertension. . We made the following changes to your medications: - DECREASE labetolol to 200mg twice daily - STOP minoxidil - STOP cinacalcet - STOP calcium carbonate - START sevelamer 800mg three times daily with meals - START nephrocaps 1 tab daily . It was a pleasure caring for you. We wish you a speedy recovery. Followup Instructions: Department: [**Hospital3 249**] When: MONDAY [**2192-4-30**] at 3:50 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 24905**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ***Dr [**Last Name (STitle) **] is your new physician in [**Name9 (PRE) 191**] and Dr [**Last Name (STitle) **] works closely with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in your care. For insurance purposes please indicate Dr. [**Last Name (STitle) **] as your Primary Care Physician*** Department: CARDIAC SERVICES When: TUESDAY [**2192-5-29**] at 10:00 AM With: [**Name6 (MD) **] [**Name8 (MD) 10828**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 **] PULMONARY, CRITICAL CARE & SLEEP MEDICINE Address: [**Location (un) **], E/KS-B23, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 612**] We are working on a follow up appointment with Dr. [**Last Name (STitle) **] within 1-2 weeks. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above. Completed by:[**2192-4-27**]

[ "038.9", "507.0", "285.21", "403.91", "785.52", "585.6", "427.31", "518.81", "995.92", "996.73", "570", "276.2", "276.1", "416.8", "427.32", "287.5" ]

icd9cm

[ [ [] ] ]

[ "88.55", "96.6", "33.24", "96.04", "88.49", "39.50", "37.21", "96.72", "38.97", "39.95", "00.40" ]

icd9pcs

[ [ [] ] ]

10943, 10949

7468, 9922

318, 346

11320, 11320

3531, 3538

12535, 14118

2667, 2765

10467, 10920

10970, 11299

9948, 10444

11471, 12228

2780, 2780

12257, 12512

232, 280

5457, 7445

374, 2006

3552, 5441

11335, 11447

2028, 2571

2587, 2651

32,774

164,288

42956

Discharge summary

report

Admission Date: [**2127-11-4**] Discharge Date: [**2127-11-7**] Date of Birth: [**2074-10-3**] Sex: M Service: MEDICINE Allergies: Didanosine (Ddi) / Zidovudine / Ceftin / Lithium Attending:[**First Name3 (LF) 3556**] Chief Complaint: # Alcohol withdrawal # Atypical chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 53M h/o depression, anxiety, alcohol abuse, HIV, HCV, presented to the ED [**11-3**] with c/o sharp substernal chest pain radiating to jaw and R arm, rated [**2130-9-19**], constant, after drinking alcohol. On arrival pt expressed SI, later denied when sober. No ischemic ECG changes, cardiac enzymes negative x3 from 2138 hrs through 1016 hrs. Pt was to be discharged when became agitated; pt was therefore admitted for possible alcohol withdrawal. . ED course: # VS: T 96.8, HR 88, RR 16, BP 117/72. BP max at 183/106 with HR 130 at 1300 hrs, decreased to 124/78 with HR 88, then increased later to 166/101 with HR 107 at [**2150**] hrs prior to transfer to MICU. # Meds: Ativan 13mg IV, Valium 5mg PO, Valium 5mg IV x3, morphine 2mg IV. . ROS: On arrival to MICU, pt visibly tremulous, complaining of sweats and agitation. Noted recent mild HA x few days without neck stiffness; chronic, baseline photophobia "because I have blue eyes"; increased thirst and uriniation only since being in the ED; "tick bite" on R arm for "[**5-15**]" minutes that pt stated developed an erythematous rash, now resolved. Denied recent travel; currently homeless in [**Location (un) 86**]. PPD negative "a few months ago." Denied recent weight change, fevers, chills, cough, SOB, night sweats, pain on swallowing, oral sores, tooth pain, abdominal pain, nausea, vomitting, diarrhea, constipation, dysuria, melena, hematochezia, LE pain, tingling, numbness, and back pain. Past Medical History: Past psychiatric history: # MDD, anxiety d/o, panic d/o, benzodiazepines/ETOH dependence # Multiple hospitalizations: Most recent hospitalization on [**Hospital1 **] 4 ([**Date range (1) 92712**]) during which pt received 9 ECT treatments with some reported improvement in mood. # Mutiple SA: --Jumped onto T tracks, removed by fire department, hospitalized at [**Location (un) 745**]-[**Location (un) 3678**] ([**2125-7-11**]) --Jumped from train ([**2121-4-10**]) --Attempted hanging ([**2109**]) --TCA OD ([**2106**]) . Past medical history: # Hepatitis C ([**2109**]) # HIV ([**2110**]) # AIDS (latest CD4 156) c/o dementia # DM2 ([**2122**]): DKA # Barrett's esophagus # Gastroesophageal reflux disease # Cervical radiculopathy # L shoulder impingement # PCP pneumonia [**Name Initial (PRE) **]/p lung biopsy ([**2122**]) # Viral meningitis ([**2117**]) # Recurrent bacterial pneumonia # Rectal fissure s/p surgery ([**2120**]) # Head injury [**3-14**] MVA ([**2096**]) . Providers: # DMH case manager: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 92713**] [**Telephone/Fax (1) 92714**] # PCP/ID: Dr. [**Last Name (STitle) 92715**] (sp?), [**Hospital1 2177**] Social History: # Personal: Grew up in [**Location (un) 686**]. No social supports. Recently ejected from group home for disruptive behavior ([**Street Address(1) 92716**] Community Group Home: [**Telephone/Fax (1) 18408**]); homeless. Former bank teller and nursing assistant. Currently on SSDI. . # Substance use: EtOH dependence, h/o w/d sz's and possible DT. Longest period of sobriety [**8-17**] mos, multiple detoxes. Relapsed on EtOH within last week. IV heroin use ([**2100**]). Family History: # Father: CVA, HTN # Mother: Completed suicide # One sister: [**Name (NI) **] contact Physical Exam: VS: T 98.7, HR 101, BP 155/92, RR 18, O2Sat 98% on RA Gen: Disheveled, agitated man with tremor HEENT: NCAT, EOMI, R pupil ~9mm, L pupil ~8mm (states has been present since small stroke), sclera anicteric, no ulcers, oropharynx clear, very poor dentition, MM slightly dry, no photophobia Neck: Supple, no cervical lymphadenopathy, JVP = 6cm CV: Normal S1/S2, RRR, no m/r/g Resp: Clear to auscultation bilaterally, no w/r/rh Abdomen: Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly, no ascites Ext: No peripheral edema, no clubbing, no cyanosis, no calf pain, DP pulses are 2+ bilaterally Neuro: A + O x 3, CN II-XII grossly intact, motor [**6-14**] both upper and lower extremities, sensation grossly intact to light touch, DTR 2+ throughout, toes downgoing, no asterixis Skin: Diffuse, non-blanching, erythematous, fine, macular-papular rash accross upper torso, back; right arm in area of tick bite without rash Psych: Denies SI/HI currently Pertinent Results: Notable labs: . [**2127-11-3**] 09:38PM WBC-4.4 LYMPH-36 ABS LYMPH-1584 CD3-77 ABS CD3-1220 CD4-21 ABS CD4-338* CD8-54 ABS CD8-858* CD4/CD8-0.4* [**2127-11-3**] 09:38PM ASA-NEG ETHANOL-178* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2127-11-3**] 09:38PM cTropnT-<0.01 [**2127-11-4**] 04:10AM cTropnT-<0.01 [**2127-11-4**] 10:16AM cTropnT-<0.01 [**2127-11-4**] 11:40PM AMMONIA-57* . Notable imaging: . # CT HEAD W/ & W/O CONTRAST [**2127-11-5**] 11:19 AM IMPRESSION: No significant change since prior studies with no new intracranial masses or areas of abnormal enhancement. Brief Hospital Course: 53M h/o HIV, HCV, DM2, anxiety/depression, admitted to MICU from ED for alcohol withdrawal and chest pain. . # Alcohol withdrawal: Pt managed with diazepam on CIWA scale, later changed to lorazepam, frequent CIWA checks with holding parameters. MVI, thiamine, B12, folate supplementation received; social work consulted. Pt normotensive, not tachycardic, VSS x approx 48hrs by the time of discharge to [**Hospital1 **] 4. . # Chest pain: Multiple EKGs demonstrated no changes, negative CEs. GI cocktail administered. Aspirin administered for primary prevention, no beta blocker given withdrawal, statin held given transaminitis with HCV. . # Altered mental status: AMS noted by psychiatry during ED consult, concern given pt did not appear A&O; however, pt A&O x3 upon transfer to MICU. Question ICH given pt's reported h/o falls. CT head w/ and w/o negative for (1) bleed, (2) toxoplasmosis (HIV history). Osmolality normal, no toxic ingestion likely; HIV dementia appears stable as repeated MICU interviews demonstrated pt A&Ox3. Ammonia elevated, but no asterixis, and low likelihood of hepatic encephalopathy. Vitamin B12, folate, TSH normal. LFTs only mildly elevated. Negative Lyme. Pt has documented h/o Korsakoff's dementia but again no deterioration in mental status. Pt likely soporific with benzodiazepine administration per CIWA as well as standing doses. By the time of discharge to [**Hospital1 **] 4, pt A&O x3 throughout MICU stay. . # Depression/anxiety: Denied SI on MICU transfer but in ED was a major complaint. Later threatened to kill others. Continued Geodon 40mg QAM, 80mg HS, and Effexor XR 150mg QD per psych recs. Haldol 5mg PO/IV TID PRN extreme agitation and standing lorazepam 2mg Q4H (pt had repeatedly demanded lorazepam earlier, on Q3H schedule, although was not noted to be withdrawing and did not qualify under CIWA; however, pt continued to escalate when lorazepam q4h scheduling was attempted). Sitter present; pt later placed in seclusion. By the time of discharge to [**Hospital1 **] 4, pt continued to be disruptive but no SI/HI. . # HTN: Pt ranging normotensive, continued on CIWA for alcohol withdrawal; lisinopril for baseline hypertension. . # Anion gap: Resolved upon MICU presentation, originally possibly [**3-14**] starvation ketosis, DKA or alchoholic ketosis. . # DM2: Continued on insulin 70/30 30units QAM and 30units QHS, [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs. . # HIV: CD4 count pending by the time of discharge to [**Hospital1 **] 4, [**Hospital1 2177**] contact[**Name (NI) **] to determine regimen for appropriate meds. . # HCV: Not currently on treatment, mild transaminitis but at baseline, coags WNL, hepatotoxic medications held as able. . # Code: DNR/DNI per patient. Medications on Admission: Per D/C summary [**9-16**]: Docusate Sodium 100 mg PO DAILY Folic Acid 1 mg PO DAILY Thiamine HCl 100 mg PO DAILY Clonazepam 0.5 mg PO BID Ziprasidone HCl 60 mg PO BID Lamivudine 150 mg PO BID Trazodone 200 mg QHS Trimethoprim-Sulfamethoxazole 160-800 mg PO 3X/WEEK (MO,WE,FR) Pantoprazole 40 mg daily Venlafaxine 225 mg Sust. Release PO DAILY Hexavitamin PO DAILY Efavirenz 600 mg PO DAILY Stavudine 40 mg PO DAILY Stavudine 40 mg PO Q12H Quetiapine 25 mg PO TID Insulin 70/30, 100units SQ QAM, 75units SQ QHS . Per pt report: Lisinopril 10mg daily Geodon 40mg QAM, 80mg QPM Effexor 150mg daily Prilosec 20mg daily Bactrim DS M/W/F Trazodone 50mg daily Klonopin 1mg [**Hospital1 **] Sustiva 600mg QHS Zerit 40mg [**Hospital1 **] Epivir 150mg [**Hospital1 **] Insulin 70/30 40units [**Hospital1 **] Tums PRN . Allergies: # Didanosine-->Edema # Zidovudine-->BM suppression # Ceftin-->Rash # Lithium-->Renal failure Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. Ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:*60 Capsule, Sust. Release 24 hr(s)* Refills:*0* 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*15 Tablet(s)* Refills:*0* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 8. Stavudine 20 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*120 Capsule(s)* Refills:*0* 9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK(MO, WE, FR) (). Disp:*21 Tablet(s)* Refills:*0* 10. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*0* 11. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: One (1) as directed Subcutaneous twice a day. Disp:*10 as directed* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: # Substance-induced mood disorder, r/o MDD # Alcohol withdrawal # Alcohol abuse Discharge Condition: Stable, improved Discharge Instructions: You are being discharged from the hospital. Take all of your medications and keep all follow-up appointments. If you are feeling unsafe or suicidal, call 911 or go to the nearest emergency department. Do not drink alcohol or abuse drugs. Monitor your blood sugar levels carefully. Followup Instructions: 1) Primary Care Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - For an appt, you can go to the [**Hospital 11074**] clinic during daytime business hours Monday through Friday, ph [**Telephone/Fax (1) 92717**], fax [**Telephone/Fax (1) 92718**] . 2) Psychiatrist, Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 976**] - Your appt is scheduled for Wednesday, [**11-12**] at 12:00pm, [**Street Address(2) 92719**], [**Location 8391**] MA, ph [**Telephone/Fax (1) 27181**], fax [**0-0-**] . 3)DMH Case worker, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ph [**Telephone/Fax (1) 92720**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] Completed by:[**2127-12-26**]

[ "291.81", "V60.0", "401.9", "250.00", "303.91", "042", "786.59", "070.54" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

10550, 10556

5288, 5943

352, 358

10679, 10697

4661, 5265

11026, 11837

3564, 3651

9047, 10527

10577, 10658

8109, 9024

10721, 11003

3666, 4642

270, 314

386, 1850

5958, 8083

2417, 3055

3071, 3548

17,539

127,310

50447

Discharge summary

report

Admission Date: [**2203-1-4**] Discharge Date: [**2203-1-14**] Date of Birth: [**2159-5-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: fever, abdominal distention Major Surgical or Invasive Procedure: paracentesis x 2 History of Present Illness: Pt is a 43 y.o male with h.o anoxic brain injury (non-verbal) s/p cardiac arrest [**9-10**] (EF 20%), chronic trach (requires frequent suctioning), who was found to have abdominal distention, fluid retention and pitting edema in his upper and lower extremities, fever, ARF, abnormal LFTs at [**Hospital 671**] rehab. He is on Vanco ([**1-1**]), levaquin (+ucx [**1-1**]). He was noted to have a leukocytosis. [**12-6**] bcx bottles growing staph aureus. . Pt was recently admitted [**Date range (1) 96035**] with concerns of bleeding from a trach, formerly admitted for tongue laceration ([**Date range (1) 58377**]). During that course pt had all of his teeth removed and was clonazepam. He was noted to have a high grade MRSA bacteremia and started on 4 wk course of Vanco (last day [**12-19**]). Pt also has ground glass opacities on the CT scan that were thought to represent aspiration of blood, bronch negative for hemorrhage. TEE negative. He also completed a 7 day course of Cefepime and Cipro for VAP. LUE US showed developed thrombus and pt was discharged on lovenox [**Hospital1 **] (day 1 [**11-30**])-however given repeat u/s showing no clot-lovenox was dc'd. . In the ED, initial VS: 14:44 0 97 97 124/76 16 100 o2 100% on 6L, HR 99, BP 101/69, RR 18, no temp. Chest x-ray, CT performed (showing large amount of ascites), flagyl given. Para performed. Tube feeds found to have large residuals in the ED. . Unable to assess ROS. Past Medical History: Diabetes Dyslipidemia Hypertension Systolic CHF: EF 20% S/p STEMI [**6-/2193**], w/ large thrombus in the proximal LAD complicated by cardiogenic shock w/ DES to prox LAD [**11/2193**]: [**Month/Year (2) 3941**] placement for Low EF, runs of NSVT. H/o alcohol and substance abuse H/o deep vein thrombosis partially treated with Coumadin Positive hepatitis B serologies in the past S/p PEA arrest in [**9-/2202**] with resulting anoxic brain injury during VT ablation in EP lab. At baseline, the pt is responsive only to deep painful stim (such as deep suctioning), although he does appear alert and open his eyes (no tracking). He is completely dependent for all ADLs. Social History: He had been on disability for 10 years since his first heart attack. Prior to that he was a manager at [**Company **]'s. He reported smoking approximately one pack of cigarettes per week. He also reported history of ETOH but denied any IVDA. Now unresponsive to all but deep painful stim, and completely dependent for all ADLs. Baseline GCS of 9. Family History: Non-contributory Physical Exam: Vitals - T. 97.8, HR 104, BP 107/66, RR 20, sat 96% on 6L GENERAL: trached, lying in bed, tongue writing HEENT:nc/at, would not keep eyes open for exam, no icterus. CARDIAC: s1s2 RRR 3/6 LLSB systolic murmur, no r/g LUNG: b/l AE +transmitted upper airway noses, lower rhonchi. ABDOMEN: +bs, distended with ascites, NT (no grimace), no guarding. EXT: moves R.arm and legs slightly. no c/c/e 2+pulses NEURO:AAOx0, unable to assess cranial nerves. no tremor, does not follow any commands. Eyes occasionally open and look around. DERM: no apparent rashes Pertinent Results: CT: IMPRESSION: 1. Tense ascites significantly larger than the prior study. No other acute intra-abdominal processes identified. However the study is limited due to non-contrast setting and streak artifacts from folded arms. 2. A small pericardial effusion, larger than the prior study. 3. LLL opacity configuration favors atelectasis, can not exclude infection. US: 1. Normal flow and waveforms within the hepatic vasculature. 2. Gallbladder wall thickening and sludge within the gallbladder. Gallbladder wall thickening is likely due to third spacing in the setting of hepatitis. 3. No intrahepatic biliary ductal dilation. CBD measures 5 mm. 4. Abdominal ascites. ECHO: unchanged from prior EF 20%, TEE without vegetations or appararent infection of pacer/[**Company 3941**] wires US of [**Company 3941**] pocket negative for fluid collection ASCITES: cytology: NEGATIVE FOR MALIGNANT CELLS. MICRO: [**2203-1-4**] 3:12 pm BLOOD CULTURE #1. **FINAL REPORT [**2203-1-10**]** Blood Culture, Routine (Final [**2203-1-10**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S [**2203-1-4**] 3:20 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPH AUREUS COAG +. FINAL SENSITIVITIES. STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | STAPHYLOCOCCUS, COAGULASE N | | | CLINDAMYCIN----------- R =>8 R R ERYTHROMYCIN---------- =>8 R =>8 R =>8 R GENTAMICIN------------ <=0.5 S 1 S <=0.5 S LEVOFLOXACIN---------- =>8 R =>8 R =>8 R OXACILLIN------------- =>4 R =>4 R 1 R RIFAMPIN-------------- <=0.5 S <=0.5 S <=0.5 S TETRACYCLINE---------- <=1 S <=1 S =>16 R TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S 1 S 1 S [**2203-1-5**] 1:04 am SPUTUM Site: ENDOTRACHEAL **FINAL REPORT [**2203-1-10**]** GRAM STAIN (Final [**2203-1-5**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2203-1-9**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. 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. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | STAPH AUREUS COAG + | | CEFEPIME-------------- 16 I CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=1 S <=0.5 S LEVOFLOXACIN---------- =>8 R MEROPENEM------------- 4 S OXACILLIN------------- =>4 R PIPERACILLIN/TAZO----- =>128 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S No growth in ascites. Cdiff and other stool studies negative Sureveillance cultures from [**1-5**] all without growth PICC tip culture without growth ADMISSION: [**2203-1-4**] 03:12PM WBC-19.4*# RBC-3.22* HGB-8.6* HCT-27.6* MCV-86 MCH-26.7* MCHC-31.1 RDW-15.9* [**2203-1-4**] 03:12PM NEUTS-91.3* LYMPHS-4.7* MONOS-2.3 EOS-1.5 BASOS-0.2 [**2203-1-4**] 03:12PM PT-16.8* PTT-31.7 INR(PT)-1.5* [**2203-1-4**] 03:12PM GLUCOSE-111* UREA N-60* CREAT-2.0*# SODIUM-138 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15 [**2203-1-4**] 03:12PM ALT(SGPT)-168* AST(SGOT)-99* LD(LDH)-182 ALK PHOS-1018* TOT BILI-5.0* DIR BILI-4.3* INDIR BIL-0.7 [**2203-1-4**] 03:12PM LIPASE-82* GGT-578* [**2203-1-4**] 03:12PM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-4.5 MAGNESIUM-2.2 IRON-36* [**2203-1-4**] 03:12PM calTIBC-248* FERRITIN-312 TRF-191* [**2203-1-4**] 03:12PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-POSITIVE HAV Ab-NEGATIVE [**2203-1-4**] 03:12PM HCV Ab-NEGATIVE [**2203-1-4**] 04:10PM ASCITES TOT PROT-4.7 LD(LDH)-157 ALBUMIN-1.9 [**2203-1-4**] 04:10PM ASCITES WBC-510* RBC-295* POLYS-35* LYMPHS-0 MONOS-0 MACROPHAG-65* OTHER: Repeat para: ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Macroph [**2203-1-6**] 04:21PM 560* 220* 71* 1* 6* 22* ASCITES CHEMISTRY TotPro Glucose LD(LDH) Albumin [**2203-1-6**] 04:21PM 4.7 81 134 1.9 DISCHARGE: Hematology WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 13.4* 3.04* 8.5* 26.6* 88 28.2 32.1 16.8* 270 PT PTT INR(PT) 17.6* 33.4 1.6* Chemistry [**2203-1-11**] 03:12AM Glucose UreaN Creat Na K Cl HCO3 AnGap 94 42* 1.7* 145 3.9 111* 21* 17 ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili 34 27 535* 3.0* Lipase 45 Calcium Phos Mg 9.3 3.0 2.2 Brief Hospital Course: Pt is a 43 yo M with a PMHx significant for anoxic brain injury (non-verbal) s/p cardiac arrest [**9-10**], chronic trach (requiring frequent suctioning), and recent MRSA bacteremia on [**11-20**] s/p 4 weeks of IV vanco who presented to [**Hospital1 18**] after he was noted to have abdominal distention, fluid retention and pitting edema in his upper and lower extremities. He was also febrile at rehab. 1. MRSA and Coag negative staph bacteremia Likely related to PICC infection. PICC was replaced and he went several days without PICC. TEE negative, ultrasound of pocket around [**Hospital1 3941**] without fluid collection. On vancomycin for 14 day course. Pt transferred to floor, spiked T 100.2F, pan-cultured and transferred back to [**Hospital Unit Name 153**] [**2203-1-13**]. ***continue vancomycin until [**2203-1-20**] 2. SBP Para cell counts c/w SBP. Treated with meropenem x 7 days. Ascites fluid culture negative. ***continue cipro 250 daily for ppx 3. Ascites/transaminitis Thought to be secondary to CHF and congestive hepatopathy. Had diagnostic and therpeutic paracenteses. Received albumin per SBP protocol. Seen by liver team. Likely [**1-4**] CHF. Monitor Is and Os. On lasix and spironolactone. Held statin, restarted with resolving transaminitis. 4. CHF, acute on chronic, systolic, EF 20% Decompensation may have been related to increased sodium load from vancomycin if mixed in NS. ECHO unchanged. ***Daily weights, Is and Os, mix IV meds in D5 whenever possible ***Continue carvedilol, lasix and spironolactone ***Titrate lasix dose for weight gain or I/O imbalance ***Consider restarting ACE if creatinine stabilizes 5. Sputum with MRSA and pseudomonas Likely represents colonization rather than true infection. Nevertheless, completed full course of [**Last Name (un) 2830**] for HCAP. Pt had copious thick sputum on floor, required increased trach suctioning, CXR showed decreased pulm edema but no clear signs of infection, sputum re-cultured [**2203-1-13**]. 6. Hypernatremia Free water losses [**1-4**] trach. ***continue free water flushes via G tube ***monitor serum sodium and adjust free water 7. Acute renal failure Baseline around 1. Cr improved over course of stay. Likely related to poor forward flow from CHF. Held ACE. ***Avoid neprhotoxins ***consider restarting ACE 8. Anemia, chronic and stable [**Month (only) 116**] benefit from iron supplementation 9. Coronary artery disease Continued asa and carvedilol. Holding ACE and statin as above. 10. DM, type II Controlled with insulin sliding scale 11. Anoxic brain injury stable ***Monitor vitals and facial expression. Grimacing may represent pain. ***Tramadol or ativan for pain and agitation 12. Sacral ulcer Continue wound care Medications on Admission: Vancomycin 1,000 mg IV Solution Intravenous daily Zocor 20 mg Tab Oral qhs Genasyme 80 mg Chewable Tab Oral 2 tabs daily Senokot -- Unknown Strength [**Hospital1 **] Miralax 17 gram/dose Oral Powder Oral daily daily Prilosec 10 mg Oral Susp Oral-40mg daily Therapeutic Vitamin & Mineral -- Unknown Strength daily Ativan 2 mg/mL Injection Injection 1mg q8hrs Prinivil 5 mg Tab Oral daily Novolin R 100 unit/mL Injection Injection sliding scale Klonopin 0.5 mg Tab Oral TID Coreg 6.25 mg Tab Oral [**Hospital1 **] Calmoseptine 0.44 %-20.625 % Ointment Topical q8hrs Dulcolax 5 mg Tab Oral-2tabs daily Baby Aspirin 81 mg Chewable Tab Oral daily Combivent 18 mcg-103 mcg/Actuation Aerosol Inhaler Inhalation 2 QID Tylenol 325 mg Tab Oral-2 Tablet(s) Four times daily, as needed Levaquin in D5W 500 mg/100 mL IV Piggy Back Intravenous daily Lasix 40 mg Tab Oral-1 Tablet(s) Twice Daily [**Hospital1 **] Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 5. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 6. Ciprofloxacin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every 24 hours). 7. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) mL Injection TID (3 times a day). 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. Lorazepam in D5W 100 mg/100 mL (1 mg/mL) Solution [**Last Name (STitle) **]: 0.5-1 mg Intravenous Q6H (every 6 hours) as needed for agitation. 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 12. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Tramadol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 14. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 15. Spironolactone 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 16. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: per SS units Subcutaneous ASDIR (AS DIRECTED). 17. Carvedilol 12.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day. 18. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID (4 times a day) as needed for Thrush. 19. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1) Intravenous Q 24H (Every 24 Hours) for 4 days: To end [**1-17**]. 20. Tramadol 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Discharge Disposition: Extended Care Facility: Radius [**Hospital 7755**] Hospital Discharge Diagnosis: Primary: bacteremia ascites peritonitis Congestive heart failure, acute on chronic, systolic, EF 20% Secondary: anoxic brain injury coronary artery disease Diabetes Dyslipidemia Hypertension Discharge Condition: Mental Status: non-verbal Activity Status:Bedbound Discharge Instructions: Mr [**Known lastname **] was admitted for fevers and increasing size of his abdomen. He had a recurrence of his blood stream infection. The fluid in his abdomen is from problem with his liver that are related to his heart disease. He was also treated for a possible infection in this fluid and for an infection in his urine and his lungs. Followup Instructions: Your PCP will follow you at the Rehab center. Completed by:[**2203-1-14**]

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icd9cm

[ [ [] ] ]

[ "88.72", "38.93", "54.91", "96.6", "00.14" ]

icd9pcs

[ [ [] ] ]

16038, 16100

9848, 12665

341, 359

16337, 16337

3511, 5160

16778, 16855

2905, 2923

13615, 16015

16121, 16316

12691, 13592

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5204, 9825

274, 303

387, 1831

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1853, 2524

2540, 2889

18,191

166,119

24855

Discharge summary

report

Admission Date: [**2114-9-29**] Discharge Date: [**2114-9-29**] Service: SURGERY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 5880**] Chief Complaint: Patient fely from her own high came to ED for evaluation was seen in the trauma bay as a trauma basic admitted to the TICU for further management. Pt was diagnosed with bilateral fracture of the posterior arch of C1 with anteroposterior distraction of the fracture fragment on the left, and comminuted fracture of the dens with posterior displacement and angulation of the dens fracture fragment with respect to the body of C2, as well as possible ligamentus injury on the cervial spine. Major Surgical or Invasive Procedure: None History of Present Illness: Patient felt from her own high came to ED for evaluation was seen in the trauma bay as a trauma basic admitted to the TICU for further management. Pt was diagnosed with bilateral fracture of the posterior arch of C1 with anteroposterior distraction of the fracture fragment on the left, and comminuted fracture of the dens with posterior displacement and angulation of the dens fracture fragment with respect to the body of C2, as well as possible ligamentus injury on the cervial spine. Past Medical History: HTN Hypercholesterolemia Colon Cancer sp ressection (outside institution) Hx of hepatic hemangioma Diverticulitis Physical Exam: Lungs CTA Heart rrr Abd soft nt nd CNS A&Ox4, speech fluent, follows commands CN: I-II intact Strength: [**4-5**] all extremities Reflexes 2+ biceps b/l, brachioradialis b/l, patellar b/l. 1+ Achilles b/l. down-going toes Sensation: to crude touch and light touch intact Pertinent Results: Head CT: 1. Bilateral fracture of the posterior arch of C1 with anteroposterior distraction of the fracture fragment on the left. Question of mild subluxation of C1 with respect to the occipital condyles. 2. Comminuted fracture of the dens with posterior displacement and angulation of the dens fracture fragment with respect to the body of C2. This results in angulation and narrowing of the canal at this level. 3. Widening of the intervertebral disc spaces at C3-4 and C4-5, finding that could possibly indicate ligamentous injury. This is supported by widening of the facets at C4-5 particularly on the left. Negative for other injuries by physical exam and radiology results Brief Hospital Course: 88F s/p mechanical fall around 19:00 [**2114-9-28**]. No loss of consciousness. The patient remembered the event. However, she was not boarded or collard unit [**Unit Number **]:00 when C1-C2 fractures discovered. She complains of pain in the back of her neck. No other symptoms, including, weakness, numbness, tingling, The husband witnessed the fall and accounts that she fell forward. She was seen at an outside hospital where her head CT was negative. Transfer from OSH arrived at [**Hospital1 **] DMC at am [**2114-9-29**]. Was send to TI CU after cat scan results. In the afternoon of [**9-29**] pt was made DNR, DNI by her own wishes with the family present at the bed site. ( Daughter and his band). During the afternoon pt developed bradycardia down to 20's. Following pt wishes pt was not chemically or mechanically resuscitated and expired. Medications on Admission: Cozar, Lipitor, Metoprolol Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: bilateral fracture of the posterior arch of C-1 HTN, Hypercholesteremia, Colon cancer [**2109**], Dirveritculitis, CABG [**2105**], Arthritis, Osteoporosis, Hx of hepatic hemangioma Discharge Condition: Expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2114-11-6**]

[ "802.0", "V45.81", "401.9", "272.0", "873.42", "805.08", "V10.05", "E888.9", "414.00", "813.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3367, 3376

2406, 3260

732, 738

3602, 3611

1700, 1700

3667, 3705

3338, 3344

3397, 3581

3286, 3315

3635, 3644

1409, 1681

203, 694

766, 1257

1709, 2383

1279, 1394

11,236

176,081

52421

Discharge summary

report

Admission Date: [**2194-4-9**] Discharge Date: [**2194-4-19**] Date of Birth: [**2112-2-19**] Sex: F Service: MEDICINE Allergies: Belladonna Alkaloids Attending:[**First Name3 (LF) 800**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 108328**] is an 81 year old [**Known lastname 595**] speaking female with a history of anemia and thrombocytopenia, Crohn's disease on chronic steroids, PE, returned from rehabilitation for somnolence. Found to be hypoxic and somnolent in the emergency room (VS T 98, BP 132/53, HR 92, RR 24, 95% on NRB). New infiltrate on CXR in the left upper lobe, and ABG showed hypercarbia. She was admitted to the ICU and started on meropenem and vancomycin. She was given IV fluids for hypotension and responded appropriately. She was started on bipap in the ICU which improved her somnolence, and mental status returned to baseline. Past Medical History: PAST MEDICAL HISTORY: -Anemia [**3-3**] CRI, chronic disease -MDS dx 3 yrs ago -Crohn's disease -CAD s/p NSTEMI '[**89**] -CRI w baseline Cr 1.5-1.8 -BL DVTs and saddle embolus in [**2190**], previously on warfarin now on Lovenox -Chronic BL LE edema -Breast cancer s/p lumpectomy & XRT -GERD -Intracranial bleed and fx after pedestrian vs car 20 yrs ago -Cataracts -Venous stasis dermatitis -Tinea pedis -?Arrhythmia unspecified which daughter says is tx with metoprolol -dHF with EF 60-70% . PAST SURGICAL HISTORY: -CCY 10 yrs ago -Lumpectomy 13 yrs ago Social History: Married; lives with her husband who is demented, her daughter [**Name (NI) 108329**], [**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. Presently in temporary housing while awaiting renovations on their [**Last Name (un) **] which was damaged during a fire last winter. [**Last Name (un) 108329**] is the caretaker for both of her parents. [**Last Name (un) 108329**] very stressed and overwhelmed. Her mother-in-law in [**Name (NI) 4565**] died this past month which required her husband to leave for [**Name (NI) 4565**]. She is in the midst of trying to place her father in nursing care facility and is quite guilty about this decision. Ms. [**Known lastname 108328**] [**Last Name (Titles) 108331**]y recieves near daily RN visits from Suburban Home Care. [**Last Name (Titles) 108329**] is reliant on "sitters" to bring her mother to appointments. Family History: non-contributory Physical Exam: VS: T HR 84 BP 112/41 RR 15 O2 86% on 4L NC General: NAD, pleasant and interactive, NC in place [**Last Name (Titles) 4459**]: NCAT MMM anicteric pink conjunctiva Neck: no JVD appreciated, supple Lungs: crackles at LLL CV: RRR 2/6 SEM at LUSB, PMI nondisplaced Abd: soft, NT, ND, bowel sounds present, palpable non-moveable mass c/w ventral hernia Ext: + anasarca, LLE cellulitis - warm, erythematous, tender Skin: numerous ecchymoses and sites of skin breakdown over torso and extremities Pertinent Results: [**2194-4-8**] 05:56AM PT-13.2 PTT-25.0 INR(PT)-1.1 [**2194-4-8**] 05:56AM PLT SMR-LOW PLT COUNT-82* [**2194-4-8**] 05:56AM WBC-11.8* RBC-2.86* HGB-9.6* HCT-29.5* MCV-103* MCH-33.7* MCHC-32.6 RDW-18.8* [**2194-4-8**] 05:56AM CALCIUM-7.9* PHOSPHATE-3.9 MAGNESIUM-1.6 [**2194-4-8**] 05:56AM estGFR-Using this [**2194-4-8**] 05:56AM GLUCOSE-110* UREA N-67* CREAT-2.5* SODIUM-143 POTASSIUM-5.2* CHLORIDE-109* TOTAL CO2-27 ANION GAP-12 [**2194-4-8**] 10:11AM URINE MUCOUS-RARE [**2194-4-8**] 10:11AM URINE RBC-4* WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 [**2194-4-8**] 10:11AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2194-4-8**] 10:11AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2194-4-9**] 03:00PM URINE RBC-[**4-3**]* WBC-[**4-3**] BACTERIA-FEW YEAST-NONE EPI-0-2 [**2194-4-9**] 03:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2194-4-9**] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2194-4-9**] 03:00PM URINE GR HOLD-HOLD [**2194-4-9**] 03:00PM URINE UHOLD-HOLD [**2194-4-9**] 03:00PM URINE HOURS-RANDOM [**2194-4-9**] 03:00PM URINE HOURS-RANDOM [**2194-4-9**] 03:45PM PT-14.2* PTT-29.3 INR(PT)-1.2* [**2194-4-9**] 03:45PM PLT SMR-LOW PLT COUNT-104* [**2194-4-9**] 03:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL STIPPLED-1+ [**2194-4-9**] 03:45PM NEUTS-74* BANDS-12* LYMPHS-6* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* [**2194-4-9**] 03:45PM WBC-15.9* RBC-3.19* HGB-11.0* HCT-33.8* MCV-106* MCH-34.4* MCHC-32.5 RDW-19.2* [**2194-4-9**] 03:45PM CK-MB-NotDone cTropnT-0.07* [**2194-4-9**] 03:45PM CK(CPK)-18* [**2194-4-9**] 03:45PM GLUCOSE-107* UREA N-58* CREAT-2.3* SODIUM-144 POTASSIUM-5.3* CHLORIDE-110* TOTAL CO2-25 ANION GAP-14 [**2194-4-9**] 05:27PM freeCa-1.15 [**2194-4-9**] 05:27PM HGB-10.9* calcHCT-33 O2 SAT-92 CARBOXYHB-1 [**2194-4-9**] 05:27PM GLUCOSE-137* LACTATE-1.0 NA+-143 K+-5.4* CL--107 [**2194-4-9**] 05:27PM TYPE-ART PO2-69* PCO2-73* PH-7.18* TOTAL CO2-29 BASE XS--2 Brief Hospital Course: # Pneumonia: The patient was admitted to the medicine service for new left upper lobe pneumonia thought to be consistent with aspiration. She was started on vancomycin and meropenem. Given she was afebrile, no leukocytosis and was hemodynamically stable vancomycin was discontinued two days into admission meropenem was continued for a 10 day course. On day 10 of admission she was found to be somnolent in the morning. Per her daughter she received valerian root overnight for insomnia and anxiety. ABG indicated respiratory acidosis, with PCO2 at 81 (baseline high 50s to 60). She was transferred to the ICU for further management. She was started on BiPAP until her blood gas improved. She was able to come off to eat her dinner. She was put back on BiPAP overnight to get some rest. In the morning, she again came off and continued to do well. Patient did receive one 250cc bolus for hypotension and an appropriate increase in her blood pressure. She completed her 10 days of meropenem. Prior to discharge she was scheduled for a sleep study to further evaluate for home bipap. . # Diastolic Heart Failure: Echo done on previous discharge showed mild LVH, hyperdynamic systolic function (EF>75%), right ventricular pressure/volume overload, 2+TR, and moderate pulmonary artery hypertension. Her lasix was continued at 10mg daily and intake/output was monitored as well. She continued to do well without need for further intervention. Prior to discharge she was restarted on her home beta blocker (metoprolol succinate 12.5mg PO bid) with good BP control. . # CKD: Admitted with Cr of 2.3, which was near her baseline. With conservative treatment creatinine improved to 1.4. Nephrotoxins were avoided. . # Crohn's Disease: She did not experience frequent bouts of diarrhea on this admission. Prednisone [**Year/Month/Day 15123**] was initially continued, but changed to a slower [**Year/Month/Day 15123**] per daughters request. Ciprofloxacin and mesalamine was continued. . # MDS and Related Anemia: She was given 1U PRBC for hct 24, and weekly epogen was restarted on this admission. She will need further follow-up with hematology. . # DVT/PE: Patient had chronic DVT/PE in the past for which she was on lovenox. The patient's daughter refused heparin (previous history of worsening thrombocytopenia w/use although HIT Ab negative) and pneumoboot to arm given patients poor skin condition. Given her anemia and thrombocytopenia, her previous bloody stools, it was felt the risk of bleeding with anticoagulation was highter than her risk for worsening DVT or PE at this time. This should be re-evaluated by her PCP in the future. . # Wound care: the patients skin looked much improved since her last admission, with decreased extremity edema. Nursing wound care was continued per previous recommendations. . # GERD: omeprazole 20mg twice daily was continued . # Prophylaxis: Calcium and vitamin D were continued, bactrim was added for PCP [**Name Initial (PRE) 1102**] . # Social/psych: During this admission, social work and ethics were called to assist in determining what was the appropriate level of care for the patient (rehabilitation or home with services). A family meeting was held, and the medical team and family were in agreement that the patient can be cared for at home with 24h care to assist her daughter. She did not want to consider rehabilitation, although this would have been the ideal setting for the patient at this time. . # Code: DNR/DNI Medications on Admission: Acetaminophen prn pain Vitamin D 800 U q day Mesalamine 1200 [**Hospital1 **] Camphor-Menthol lotion prn Miconazole powder prn Atrovent q 6 hours Albuterol q2 prn Ciprofloxacin 250 mg [**Hospital1 **] Loperamide 2 mg PO QID Calcium Carbonate 1000 mg TID Timolol Maleate 0.5 drops daily Polyvinyl alochol-Povidone drops prn Predinosone 60 mg [**Hospital1 15123**] Lasix 10 mg daily Discharge Medications: 1. semi-electric bed [**Hospital 485**] hospital bed for diagnosis of respiratory failure and congestive heart failure 2. bipap bipap machine: ST pressures [**11-3**], with backup RR of 10 3. PICC flushes PICC heparin flushes: per NEHT protocol 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO BID (2 times a day). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed: apply up to 4 times daily to affected area. Disp:*qs 1* Refills:*2* 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 11. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Prednisone 10 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): 35mg daily until [**4-22**]; [**Date range (1) 85977**] take 30mg daily then follow your outpatient doctors orders for [**Name5 (PTitle) 15123**]. Disp:*10 Tablet(s)* Refills:*0* 14. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection once a week. 15. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection once a month. 16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 17. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Topical twice a day: for venous stasis. 18. Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection once a day: On going daily flush for PICC line and PRN. Disp:*30 syringes* Refills:*2* 19. Calcium 500 mg Tablet Sig: Two (2) Tablet PO three times a day. 20. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: hypercarbic respiratory failure diastolic heart failure Discharge Condition: hemodynamically stable and afebrile Discharge Instructions: You were admitted to the hospital for increasing shortness of breath and somnolence. You were treated for high bicarbonate levels with bipap and oxygen supplementation. You were also found to have a new pneumonia with was treated with meropenem for 10 days and vancomycin for 2 days. You will need to make an appointment with Dr.[**Last Name (STitle) 3357**] at your convenience to follow your anemia and other symptoms. Please make sure that you use your bipap machine at home and continue your medications as ordered. If you experience increasing shortness of breath, chest pains, fevers, chills or any other concerning symptoms please call your doctor or return to the emergency room. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:2L Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2194-4-24**] 10:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2194-4-29**] 3:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2194-4-29**] 3:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 4606**] Date/Time: [**2194-5-6**] 2:45 Please make sure to attend your sleep study on [**5-2**] at 12:45pm in the [**Hospital Ward Name 1950**] building. Please call [**Telephone/Fax (1) 6856**] for questions on directions or if you need to reschedule. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11455, 11530

5214, 7863

287, 294

11630, 11668

3002, 5191

12527, 13470

2457, 2476

9129, 11432

11551, 11609

8723, 9106

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1509, 1550

2491, 2983

240, 249

7875, 8697

322, 970

1014, 1486

1566, 2441

43,708

105,445

52659

Discharge summary

report

Admission Date: [**2105-9-3**] Discharge Date: [**2105-9-11**] Date of Birth: [**2026-6-15**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: fall from standing at home Major Surgical or Invasive Procedure: embolisation of L5 lumbar artery History of Present Illness: This is a 76 year old woman who trip and fell at home. She was initially brought to [**Hospital 1474**] hospital and subsequently transferred to the [**Hospital1 18**] for treatment of a retroperitoneal bleed and a pubic rami fracture. Past Medical History: A fib (on coumadin) Coronary Artery Disease Cerebrovascular accident Osteoporosis Social History: lives at home alone, has VNA to check on coumadin levels Family History: non-contributory Physical Exam: Physical Exam: Vitals - T: 98.5 BP:146/66 HR: 98.2 RR: 20 02-Sat: 99%/2L GENERAL: Pleasant woman in NAD, appears to be somewhat labored breathing. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: irregular rhythm, tachycardic. No murmurs, rubs or [**Last Name (un) 549**]. no JVP LUNGS: Crackles to basis bilaterally ABDOMEN: NABS. Soft, NT, ND. EXTREMITIES: Trace of edema SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. Pertinent Results: [**2105-9-3**] 09:07PM GLUCOSE-184* UREA N-35* CREAT-2.2* SODIUM-140 POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-21* ANION GAP-19 [**2105-9-3**] 09:07PM CK(CPK)-234* [**2105-9-3**] 09:07PM CK-MB-11* MB INDX-4.7 cTropnT-0.14* [**2105-9-3**] 09:07PM CALCIUM-8.1* PHOSPHATE-5.2* MAGNESIUM-2.7* [**2105-9-3**] 09:07PM WBC-13.2* RBC-3.06* HGB-9.3* HCT-29.3* MCV-96 MCH-30.4 MCHC-31.8 RDW-15.3 [**2105-9-3**] 09:07PM PLT COUNT-159 [**2105-9-3**] 09:07PM PT-21.3* PTT-31.8 INR(PT)-2.0* [**2105-9-3**] 09:07PM FIBRINOGE-286 [**2105-9-3**] 06:16PM GLUCOSE-173* LACTATE-3.2* NA+-138 K+-4.9 CL--104 TCO2-21 [**2105-9-3**] 05:50PM UREA N-33* CREAT-2.2* [**2105-9-7**] 05:45AM BLOOD Plt Ct-129* [**2105-9-5**] 06:00PM BLOOD PT-11.4 PTT-25.8 INR(PT)-0.9 [**2105-9-8**] 07:35PM BLOOD Glucose-131* UreaN-43* Creat-2.2* Na-134 K-4.3 Cl-96 HCO3-28 AnGap-14 CT ABDOMEN W/CONTRAST Study Date of [**2105-9-3**] 6:26 PM Findings 1. Left large retroperitoneal hematoma with active extravazation has only mildly increased in size since the prior exam from 3.5 hours prior making large arterial bleed an unlikely possibility. Source of active extravazation is likely venous or small arterial lumbar branch. Additionally, there is likely a tamponade efffect of the retroperitoneum. 2. Small right retroperitoneal hematoma. 3. right sup/inf pubic rami fx, right sacral fracture. Bilateral L5 and left L4 transverse process fractures. 4. Probable grade 1 laceration of the spleen. 5. Simple small pericardial and bilateral pleural effusions. Brief Hospital Course: The patient was admitted to trauma service on 09//[**4-9**] after a fall at home. She has a history of chronic atrial fibrillation treated with Coumadin. Upon admission her INR was 6.0. CT scans from [**Hospital 1474**] hospital as well as our institution showed a large left retroperitoneal hematoma and a contrast study showing acute extravasation. The patient had been generally hemodynamically stable but has required pressors and several units of packed red blood cells after admission. She underwent embolization on the [**2105-9-5**] after arteriography showed a acute contrast extravasation consistent with bleeding from the left L5 lumbar artery. This branch was successfully Gelfoam embolized. Her lateral compression pelvic fracture was complicated by bleeding but did not require surgical orthopedic management for stability. Mrs [**Known lastname 24397**] is encouraged to weight bearing as tolerated and when able with a walker. Orthopedics will follow her course and see her as an outpatient 4 weeks after discharge. We diuresed her with several doses of IV furosemide. Her breathing and clinical exam greatly improved. The patient was not able to ambulate in the hospital yet, but remained stable. During her hospital stay she was not anticoagulated with coumadin, given her recent episode of bleeding. She is receiving 5000 units sq heparin twice daily and is instructed to get in touch with her PCP as soon as possible to resume her coumadin therapy. We increased her beta-blocker dose to 50 mg QID. Her most current hematocrit is 27.9%. Medications on Admission: Acetaminophen, Insulin, Famotidine, Simvastatin, Dilaudid, Heparin, Hydralazine, Metoprolol, Nitro, Aspirin, Lisinopril Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 14. Oxycodone 5 mg/5 mL Solution Sig: One (1) ml PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:*400 ml* Refills:*0* 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks. Disp:*30 Capsule(s)* Refills:*0* 17. Insulin Regular Human 100 unit/mL Solution Sig: One (1) units per sliding scale Injection ASDIR (AS DIRECTED): Sliding scale: Glucose 0-60mg/dL 1/2ampD50 61-160mg/dL 0 Units 161-180mg/dL 2 Units 181-200mg/dL 3 Units 201-220mg/dL 4 Units 221-240mg/dL 5 Units 241-260mg/dL 6 Units 261-280mg/dL 7 Units > 280 notify MD. 18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 Injection [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital **] Rehab Discharge Diagnosis: -ight LC1 pelvic ring injury -right L5 TP fx -left L4/L5 TP fx -left retroperitoneal bleed Discharge Condition: good, hemodynamically stable Discharge Instructions: You have been admitted because because of pelvic fracture and an inner bleeding sustained after a fall. Please call your doctor or return to the ED if you experience any of the following any signs and symptoms of infection, including fevers, chills any chest pain or shortness of breath or any other symptoms that may be of concern. You are weight bearing as tollerated on your lower extremities. It is of importance that you follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17887**] as soon as possible for further guidance on your coumadin therapy. Please schedule this appointment as soon as possible (refer to follow up instructions) Followup Instructions: Please follow up with Orthopedics in 4 weeks. Call [**Telephone/Fax (1) 1228**] to make an appointment. Follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17887**] for resuming your coumadin therapy. Call [**Telephone/Fax (1) 45878**] to make an appointment. Follow up with Dr [**Last Name (STitle) 519**] (Trauma service) in 2 weeks. Call [**Telephone/Fax (1) 108664**] for an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2105-9-10**]

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icd9cm

[ [ [] ] ]

[ "39.79" ]

icd9pcs

[ [ [] ] ]

6620, 6668

2991, 4553

341, 376

6803, 6834

1434, 2968

7552, 8132

838, 856

4723, 6597

6689, 6782

4579, 4700

6858, 7529

886, 1415

274, 303

404, 642

664, 747

763, 822

2,652

178,686

13149

Discharge summary

report

Admission Date: [**2131-6-21**] Discharge Date: [**2131-6-27**] Date of Birth: [**2051-9-27**] Sex: M Service: SURGERY Allergies: Lipitor Attending:[**First Name3 (LF) 4111**] Chief Complaint: Right flank pain Major Surgical or Invasive Procedure: Abscess excision, right flank History of Present Illness: 79 year-old gentleman who presents with a 30-pound weight loss over 4 years duration and some feeling of fatigue and lack of function in addition to a mass, which has now become quite prominent. This first came to attention when he presented with an enlarging mass of the right flank approximately twelve months ago. He had a CT scan on [**2130-4-11**] which reported a subcutaneous mass and/or collection of 2.7 x 3.9 cm overlying the posterior lateral subcutaneous fat. He noted the mass enlarging in size for the past 6 months. He has slight discomfort when he sits. He denies fever, chills, and redness. Past Medical History: * CAD * CABG x 2 * anterior MI at age 37 * CHF, EF 25% s/p cardiac resynchronization and biv pacer placement * hypertension * dyslipidemia * ccy [**2127**] * remote motor vehicle accident Social History: retired sales officer, lives along in [**Location (un) 11790**], remote tobacco, occasional ETOH Family History: diabetes, hypertension on both sides of the family Physical Exam: Well appearing male in no acute distress Chest is clear Regular sinus rhythm, grade 3-4/6 mitral valve murmur Abdomen soft, non-tender, non-distended, well healed small laparoscopic scar at umbilicus. On the right flank, there is a 12 x 13 cm mass, which is bulging upward and feels somewhat cystic. No hernias Pertinent Results: Admission/Post-op Labs [**2131-6-21**] 02:10PM BLOOD WBC-12.1* RBC-3.87* Hgb-10.7* Hct-32.5* MCV-84 MCH-27.8 MCHC-33.1 RDW-15.7* Plt Ct-233 [**2131-6-21**] 02:10PM BLOOD Glucose-133* UreaN-24* Creat-1.1 Na-137 K-4.7 Cl-102 HCO3-28 AnGap-12 [**2131-6-21**] 02:10PM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0 MICROBIOLOGY~~~~~~~~~~~~~~~~~ #1 [**2131-6-21**] 12:40 pm TISSUE CONTENTS OF ABSCESS. GRAM STAIN (Final [**2131-6-21**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2131-6-24**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2131-6-27**]): NO GROWTH. #2 [**2131-6-21**] 11:50 am ABSCESS RT FLANK. GRAM STAIN (Final [**2131-6-21**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2131-6-23**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2131-6-27**]): NO GROWTH. PATHOLOGY~~~~~~~~~~~~~~~~~~~~~ SPECIMEN SUBMITTED: ABSCESS RIGHT FLANK, CAVITY STONES, AND GALLSTONES (1). DIAGNOSIS: I. Skin, right flank (A-C): Skin with subcutaneous abscess formation. II. Abscess cautery stones: Gross examination only. III. Gallstones: Gross examination only. RADIOLOGY~~~~~~~~~~~~~~~~~~~~ CAROTID SERIES COMPLETE [**2131-6-26**] 1:24 PM FINDINGS: Duplex evaluation was performed of both carotid arteries. Moderate plaque was identified on the right. On the right, peak systolic velocities are 136, 62, 75 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 2.1. This is consistent with a 40-59% stenosis. On the left, peak systolic velocities are 95, 57, 66 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.6. This is consistent with less than 40% stenosis. There is antegrade flow in both vertebral arteries. IMPRESSION: On the right, there is moderate plaque with a 40-59% carotid stenosis. On the left, there is a less than 40% stenosis. Brief Hospital Course: The patient was admitted on the day of surgery. Due to his significant cardiac history a pulmonary artery catheter was placed in the OR for hemodynamic monitoring post-operatively. He was extubated easily and transferred to the recovery room. He was monitored in the intensive care unit post-operatively for fluid management and cardiology was involved for recommendations. He was maintained on antibiotics throughout his hospital stay, however the culture from the operating room failed to reveal a pathogen. He tolerated a regular diet POD1. The PA catheter was removed on POD3. He was transferred to the floor on POD4. A carotid duplex ultrasound was obtained to evaluate a soft left carotid bruit heard during his hospital stay. (see results section). Dr. [**Last Name (STitle) **] of vascular surgery was consulted and will follow-up with the patient as an outpatient for further monitoring. The patient had [**Location (un) 1661**]-[**Location (un) 1662**] drains placed during the surgery and these remained in for his hospitalization. The output of each was less than 30cc of serosanguinous fluid at discharge. He was instructed as to care and emptying of the drains and will record outputs regularly. He will also have visiting nursing care to aid in his wound and drain care. He was discharged to home on Augmentin for another week and will follow-up with Dr. [**Last Name (STitle) 957**] in clinic. Medications on Admission: Lasix 10mg po bid Lopressor 50mg po bid Lanoxin 0.25mg po bid Fosinopril 10mg po qday Aspirin 325 po qday (held) Zetia 10mg po qday Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Fosinopril 20 mg Tablet Sig: One (1) Tablet PO daily (). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**First Name8 (NamePattern2) 40133**] [**Last Name (NamePattern1) 32495**] Discharge Diagnosis: Dropped gallstone abscess, right flank Discharge Condition: Good Discharge Instructions: Please call if you are experiencing fevers (>101.5), are having a significant increase in pain or discomfort, notice increasing redness, swelling, or drainage from your wound. Followup Instructions: please call Dr.[**Name (NI) 6275**] office for your follow-up appointment in 2 weeks. Follow-up with your outpatient cardiologist. You may make an appointment with Dr. [**Last Name (STitle) 11255**] at ([**Telephone/Fax (1) 7236**] if you wish to remain under his care for cardiology. Follow-up with Dr. [**Last Name (STitle) **] will be arranged through Dr. [**Last Name (STitle) 957**] after your follow-up visit.

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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284, 316

6193, 6200

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6424, 6846

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1362, 1675

228, 246

344, 954

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52,478

159,840

54944+59639

Discharge summary

report+addendum

Admission Date: [**2140-6-27**] Discharge Date: [**2140-7-1**] Date of Birth: [**2081-4-24**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2291**] Chief Complaint: Emphysematous pyelonephritis. Major Surgical or Invasive Procedure: Arterial blood gases. History of Present Illness: 59F w/ h/o DM type 2 and GERD who is transferred from [**Hospital1 **] for concern for emphysematous pyelonephritis and possible PE. Pt reports she developed left leg pain on [**6-16**]- aching in her thigh not associated w/ back pain, paresthesias or weakness. No injury or trauma. She medicated w/ ibuprofen and later her husband's oxycodone w/ minimal relief. On taking the oxycodone on [**6-22**], patient vomited. The next day she developed abdominal cramping, increased nausea, palpitations and a headache. Reports poor PO intake and metallic taste in mouth. No CP, fevers, or chills. Did have some increased "work of breathing and respiratory rate" which she now attributes to her diabetes. Denies exertional component, PND, hemopytsis or pleuritic symptoms. + dry cough. Patient presented [**Hospital1 **] primarily due to the leg pain, nausea, and headache. She feels the respiratory symptoms were a relatively minor issue. Denies h/o blood clots, recent surgery or immobilization. She denies any hematuria, dysuria, frequency, or increased urgency. Of note, patient reports a prior UTI diagnosed a month ago at NEBH and treated w/ 7 days of antibiotics, though she does not remember which one nor what organism she grew. At that time, had no urinary symptoms but presented w/ malaise and w/u revealed leukocytosis w/ positive UA, negative CXR. . At [**Hospital1 **], her blood sugar was found to be in the 300s with ketones in her urine. She had an elevated d-dimer so she underwent a CT chest which showed questionable small PEs. She also had a CT of her abdomen and pelvis which showed right hydronephrosis with gas. EKG sinus tachy at 105 w/o any concerning ST changes, q's or S waves. She was given Flagyl and Levaquin as well as 2 L NS, 1 tab vicodin, 2 mg morphine, and 10 units of insulin IV. She was transferred to [**Hospital1 18**] for further management. . In the ED, initial VS were: 97.8 95 111/59 18 95%. FSBS was noted to be 284 for which patient received 5 units of regular insulin SC. Labs here w/ Na 132, anion gap of 15, normal lactate. UA with >182 WBCs, few bac, Lg LE, neg Nit. A second read of the CT scans performed at [**Hospital1 **] was requested and was notable for a central filling defect in the posterior basal segment of the right lower lobe concerning for PE, though not fully characterized. Also, confirmed R emphysematous pyelonephritis/ureteritis, and probable early L pyelonephritis on wet re-read. Urology was made aware of the patient. The patient was started on heparin for likely PE after rectal exam was guaiac negative. She also received morphine 5 mg x1, dilaudid 0.5 mg x2, and zofran 4 mg x1. Vital signs on transfer were: 97.1 po, 101/42, 95, 16, 95% RA. . Currently, patient is comfortable and reports some mild nausea. Denies abdominal pain. Reports [**6-26**] pain in the left thigh that has not improved w/ any of the narcotics she has received. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, chest pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Insulin Dependent Diabetes Mellitus GERD Social History: Pt lives with her husband and works as a respiratory therapist. Tobacco: None. Alcohol: None. Recreational Drugs: None. Family History: Father died of AAA at age 73. Mother died of breast cancer at age 49. Physical Exam: ON ADMISSION: VS - Temp 98.6F, BP 115/53, HR 91, R 18, O2-sat 95% RA Wt 84.7kg GENERAL - well-appearing woman in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear NECK - supple, no thyromegaly, no JVD, no LAD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding BACK - no CVA tenderness EXTREMITIES - L thigh w/ tenders in IT band region, slightly worsened w/ palpation; negative straight leg raise; negative [**Last Name (un) 5813**]; no calf tenderness; WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-21**] throughout, sensation grossly intact throughout . ON DISCHARGE: Pertinent Results: OSH LABS PRIOR TO ADMISSION: WBC 27.3 hct 37.6 Plt 228; 85% polys, 8% bands D-dimer 4602; trop negative Na 129, K 3.4, glucose 381, creatinine 1.0, lactate 1.5; anion gap 16 UA: Neg nitrite, Larg LE, Beta hydroxybutyrate 3.78 . LABS ON [**Hospital1 18**] ADMISSION: [**2140-6-26**] 11:00PM BLOOD WBC-21.6* RBC-3.87* Hgb-11.2* Hct-36.1 MCV-93 MCH-29.0 MCHC-31.2 RDW-13.6 Plt Ct-246 [**2140-6-26**] 11:00PM BLOOD Neuts-90.1* Lymphs-6.4* Monos-3.1 Eos-0.1 Baso-0.3 [**2140-6-26**] 11:00PM BLOOD PT-12.1 PTT-23.8* INR(PT)-1.1 [**2140-6-26**] 11:00PM BLOOD Glucose-243* UreaN-26* Creat-0.8 Na-132* K-3.6 Cl-98 HCO3-19* AnGap-19 [**2140-6-28**] 07:05AM BLOOD CK(CPK)-24* [**2140-6-26**] 11:00PM BLOOD cTropnT-0.02* proBNP-1316* [**2140-6-27**] 06:20AM BLOOD Calcium-7.6* Phos-1.7* Mg-1.7 [**2140-6-28**] 07:05AM BLOOD Acetone-SMALL Osmolal-293 [**2140-6-28**] 10:41AM BLOOD Type-ART pO2-83* pCO2-29* pH-7.33* calTCO2-16* Base XS--9 [**2140-6-26**] 11:04PM BLOOD Lactate-1.7 [**2140-6-28**] 10:41AM BLOOD Lactate-0.9 [**2140-6-28**] 07:05AM BLOOD BETA-HYDROXYBUTYRATE-PND . LABS ON DISCHARGE: IMAGING & STUDIES: [**2140-6-26**] OSH CT CHEST: IMPRESSION PER [**Hospital1 18**] RADS: 1. Suboptimal examination, with no central pulmonary embolus. Questionable nonocclusive filling defect in the posterior basal segment of the right lower lobe. Recommend repeat chest CTA to reevaluate this finding. 2. Left lower lobe pulmonary nodules measuring up to 8 mm. Recommend three-month followup chest CT. . [**2140-6-26**] OSH CT ABD/PELV: IMPRESSION PER [**Hospital1 18**] RADS: Ascending urinary tract infection, with right emphysematous pyelonephritis/ureteritis and left pyelonephritis. . [**2140-6-27**] LENI (LEFT): IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity. . [**2140-6-28**] ECHOCARDIOGRAM (TTE): IMPRESSION: Normal global and regional biventricular systolic function. Mild pulmonary hypertension. . [**2140-6-28**] CTA CHEST/CT ABD/PELV: IMPRESSION: 1. No evidence of pulmonary embolus. 2. Unchanged right emphysematous pyelonephritis/ureteritis and left pyelonephritis. No abscess or fluid collection identified. 3. No retroperitoneal hematoma present. . [**2140-6-29**] RENAL U/S: IMPRESSION: No hydronephrosis and no fluid collection identified. Air within the right kidney, consistent with the known right emphysematous pyelonephritis. Diminished right cortical vascularity may also relate to underlying pyelonephritis. Brief Hospital Course: This is the brief hospital course for a 59 year-old female admitted to [**Hospital1 18**] from [**Hospital3 **] on [**2140-6-27**] for management of emphysematous pyelonephritis. . #. DM2: with DKA. Infection migh have caused this patient with DM2 to go into DKA. Has ketones in blood (and had ketonuria at OSH). No prior history to suggest ketosis-prone/Flatbush DM. Has gotten insulin SC and tonight got insulin 5units IV. Initial anion gap 23, and though decreased to 11 in the setting of receiving insulin/bicarb for pre-cath hydration/IV fluids, there is concern that the gap could open again. Her BG was monitored closely. She was given aggressive IV fluid hydration. She was initially maintained on insulin drip then transitioned to long acting and sliding scale short acting humalog with uptitration as necessary. Her Anion gap closed, patient remained stable and was transferred to the medicine floor. --She should follow up with the [**Last Name (un) **] DM center for further management. . #. Emphysematous pyelonephritis: with bacteremia. Patient presented form OSH with c/f emphysematous pyelo. OSH Blood cultres growing pan-S E. coli. WBC had been 26 at OSH but now ~21. Patient has been maintained on Cefepime (started Cefepime [**6-26**]) b/c of continued leukocytosis. Now quite stable, afebrile with no signs of sepsis; urinating well, lactate normal, mentating fine, BP stable. Urology was consulted and incomplete bladder emptying was ruled out. Antibiotics were narrowed to Ceftriaxone based on UCx sensitivities. A lag in resolution of leukocytosis was initally concerning, however, repeat imaging with ultrasound revealed no abscess or other complications. An infectious disease c/s was obtained, with recommendation to increase her dose of CTX. She continued to improve clincially on this regimen. - surveillance cultures needed - renal u/s in 3 weeks as an outpatient - needs long-term abx 3-4 weeks . #. LLE pain: unclear etiology. No DVT per LENI. CK normal. No Hct drop while on Heparin gtt to suggest r-p bleed. No suggestion of abscess, though team considering. Team had asked for Pt to have CT thigh/leg after CTA and Radiology suggested ordering it as a CT abd/pelvis with extension to mid-thigh but the thigh was not done. A CTA chest was negative for PE. -f/[**Location 112214**] read of imaging . #. Lung nodules: incidental. On CTA chest a LLL, ~8 mm in size w/ diffuse reactive LAD was noted. -outpatient f/u CT in 3 months . #. GERD: stable. -continue home omeprazole . Transitional issue: 1. Left lower lobe pulmonary nodules measuring up to 8 mm. Recommend three-month followup chest CT. 2. Repeat renal u/s in 3 weeks. 3. [**Last Name (un) **] f/u for diabetes. 4. PCP to follow [**Name9 (PRE) **] count for resolution of leukocytosis. Medications on Admission: Lantus 24 units Daily Novolog 6 units [**Hospital1 **] metformin 500 mg [**Hospital1 **] quinapril 10 mg daily omeprazole 20 mg daily Discharge Medications: 1. Outpatient Physical Therapy Patient requires outpatient physical therapy for strengthening and recovery of left leg function as well as overall deconditioning from an extended illness. 2. Outpatient Lab Work Weekly CBC with differential, ALT, AST, T Bili, ALK PHOS, BUN, and creatinine. Please fax to [**Hospital1 18**] Infectious disease R.Ns. at ([**Telephone/Fax (1) 4591**]. If any issues, phone# is ([**Telephone/Fax (1) 1354**]. 3. CeftriaXONE 2 gm IV Q24H RX *ceftriaxone 2 gram 2 grams intravenous daily Disp #*42 Gram Refills:*0 4. Glargine 34 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Quinapril 10 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Acetaminophen 650 mg PO Q6H:PRN pain 9. Docusate Sodium 100 mg PO BID 10. Senna 1 TAB PO BID constipation 11. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain Please do not drive, operate machinery, or take other sedating medications while on this medication. RX *oxycodone 10 mg 1 Tablet(s) by mouth every 6 hours Disp #*20 Tablet Refills:*0 12. Lancets,Thin *NF* (lancets) Freestyle Lite lancets: use to check blood sugar Miscellaneous four times a day RX *FreeStyle Lancets use to check fingersticks four times a day Disp #*1 Box Refills:*2 13. FreeStyle Lite Strips *NF* (blood sugar diagnostic) use to check fingerstick Miscellaneous four times a day RX *FreeStyle Lite Strips use to check fingerstick four times a day Disp #*1 Box Refills:*2 Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: PRIMARY: emphysematous pyelonephritis E. coli bacteremia diabetic ketoacidosis SECONDARY: diabetes mellitus hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred to [**Hospital1 18**] due to concerns that you had a kidney infection and possibly a pulmonary embolus (blood clot in the lungs). We made sure you do not have a pulmonary embolus, so you do not need to be on blood thinners. But you do have a kidney infection, and the E. coli bacteria have caused gas formation in the kidneys (emphysematous pyelonephritis). You will be treated with intravenous antibiotics for a total of [**3-20**] weeks, to be determined by Infectious Disease Outpatient Antibiotic [**Hospital **] clinic (appointment listed below). Note that you also have a Primary Care appointment (listed below) which you should keep. You will need a repeat renal ultrasound in 6 weeks (during the week of [**8-8**]) to confirm that the gas in the kidneys has decreased. Please remember to mention this to your Primary Care doctor. Also, you should mention your left leg/thigh pain with your doctor. The cause is unclear; we made sure you did not have a bleed or a blood clot but your doctor might consider performing an MRI to investigate a musculoskeletal cause. While you were here you were briefly in the medical ICU for diabetic ketoacidosis, which is acid build-up in the blood because of very elevated blood sugars. You required an insulin drip for a short amount of time but then were reasonably controlled on subcutaneous insulin. Your blood sugar elevation is likely due to your infection. You are being discharged on an increased insulin regimen, but it is possible that it will be able to be decreased as your infection resolves. Please follow-up with [**Last Name (un) **] diabetes (appointment listed below). You should check your fingersticks before meals and at bedtime. If you notice blood sugars of <80 or >300 please call [**Last Name (un) **] at ([**Telephone/Fax (1) 102677**] or on nights/weekends you can contact the covering physician [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 112215**]. We made the following changes to your medications: -START Ceftriaxone (total course 3-4 weeks, day 1 was [**2140-6-27**]) -START Tylenol and Oxycodone as needed for pain (do not drive, operate machinery, or use sedatives while you are on this medication) -INCREASE basal Lantus to 34 units a day -STOP Novolog -START Humalog sliding scale (please see attached) Followup Instructions: PRIMARY CARE Department: Primary Care Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6589**] for Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14875**] When: Monday [**2140-7-4**] at 7:45 AM Address: 1 COMPASS WAY, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],[**Numeric Identifier 25733**] Phone: [**Telephone/Fax (1) 25734**] Notes: Dr. [**Last Name (STitle) 6589**] works in the same practice as Dr. [**Last Name (STitle) 14875**]. After this visit you should make an appointment with your regular PCP. [**Last Name (un) **] DIABETES Thursday [**2140-7-7**] at 2:00 PM One [**Last Name (un) **] Place [**Location (un) 86**], [**Numeric Identifier 718**] ([**Telephone/Fax (1) 19850**] INFECTIOUS DISEASE OUTPATIENT [**Hospital **] CLINIC Department: INFECTIOUS DISEASE When: THURSDAY [**2140-7-7**] at 2:00 PM With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage ***Note: You are currently scheduled for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and Infectious Disease appointment at the same time. Infectious Disease will be calling you with a revised appointment time. If you do not hear back by Tuesday [**7-5**] please call them at [**Telephone/Fax (1) 457**] to reschedule.*** Completed by:[**2140-7-8**] Name: [**Known lastname 2534**],[**Known firstname **] Unit No: [**Numeric Identifier 18424**] Admission Date: [**2140-6-27**] Discharge Date: [**2140-7-1**] Date of Birth: [**2081-4-24**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4247**] Addendum: Clarification of pt's diagnoses and hospital course: Ms. [**Known lastname **] had a primary diagnosis of E. coli emphysematous pyelonephritis with septicemia. Although she had a blood stream infection, with the original source from the kidneys, she did not have sepsis, as she had only 1 of 4 possible findings in sepsis, which requires 2 or more of the 4 findings. She met only the criteria by elevated white blood cell count. She lacked fever / hypothermia, tachypnea (RR >20) or elevated HR (HR >90). Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: Emphysematous pyelonephritis with E. Coli Septicemia [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4249**] MD [**Male First Name (un) 4250**] Completed by:[**2140-9-1**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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5877

Discharge summary

report

Admission Date: [**2190-1-16**] Discharge Date: [**2190-1-21**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: GI bleed, AAA, pneumomediastinum, [**Doctor First Name **] [**Doctor Last Name **] tear, L hip fx Major Surgical or Invasive Procedure: ORIF [**2190-1-20**] with Dr. [**Last Name (STitle) **] History of Present Illness: 86 M w/ pmh of CAD s/p CABG, HTN, PMR on chronic steroids, known AAA, osteoporosis, prostate CA who presented to BINeedham on [**1-14**] after fall resulting in L hip pain. Pt stated he was in his USOH on [**1-14**] when he slipped and fell on the ice in his back yard, landing on his left hip and left elbow. He denies head trauma or LOC. He denied preceeding symptoms including chest pain, SOB, lightheadedness or palpitations. On presentation to [**Location (un) 620**] VS 97.7 BP 165/73 HR64 RR 16 02 100% RA. He was found to have a left intertrochanteric fracture on plain film. On [**1-14**] the patient experienced an episode of coffee ground emesis, he was evaluated by GI (Dr. [**Last Name (STitle) 23233**] and had an EGD which revealed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear which was cauterized, there were two non-bleeding AVMs seen in the duodenum. His Hct remained stable around 39 during his stay. He remained HD stable and maintained on nexium IV. The pt underwent an abd CT scan for history of AAA which showed slight interval enlargement of an infrarenal intraabdominal aortic aneurusm from 5cm in [**5-/2188**] to 5.4 cm. Pt also noted to have pneumomediastinum and gas within the distal esophagus and proximal gastric wall presumed to be related to M-W tear. + Distended bowel loops. He was started on Zosyn for the pneumomediastinum and kept NPO. He was seen by Dr. [**Last Name (STitle) **] regarding his AAA. He complained of and pain and distention. Attributed to his dilated loops of bowel, an NGT was placed. Given the GIB and AAA pt was transfered to [**Hospital1 18**] for for hip repair. On ROS pt currently c/o abd pain, points to lower abdomen. Describes as spasms that he has been having for the past 2 days since his fall. States he has not had a bowel movement since then, nor has he been passing gas. Slight HA, no vision changes (other than related to cataract surgery 4 days ago). Had n/v at OSH, none now. Denies any chest discomfort or SOB, mild stable DOE at home, no orthopnea or PND. + occ heartburn. No dysuria. No fevers or chills. ICU to ICU transfer for mgmt of GIB, and hip fx. Past Medical History: R eye cataract surgery on [**1-12**] CAD s/p MI and CABG (per grandson there was an episode of AF perioperative requiring transient coumadin/dig in [**2179**]) L CEA [**2179**] AAA (5cmx5.4 at BINeedham) Prostate Ca x ~1 year HTN PMR on chronic steroids Osteoporosis GERD Hyperlipidemia Hypothyroidism Social History: The patient lives with his daughter in a home. He quit tobacco in [**2179**] but had a 60pk/yr history prior to this. No alcohol use. Widowed. He was in the Army and worked as a firefighter. Family History: Parents died of stroke. Physical Exam: VS: Temp: 99.4 BP:136/71 HR:100 RR:15 O2sat91% RA --> 97-100% on 70% Face mask. GEN: pleasant, elderly man, NAD HEENT: Surgical R pupil with conjunctival hemorrhage, EOMI, anicteric, MMM, op without lesions, endentulous. NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: Coarse crackles CV: Regular, tachy, S1 and S2 wnl, no m/r/g, distant. No displaced PMI. ABD: +BS, + tympany, abd markedly distended. minimally tender, no rebound tenderness or guarding. EXT: no c/c/e, cool, 1+ TP pulses, + onychomycosis, swelling and tenderness L hip. Leg does not appear shortened, + internal rotation. SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. No focal deficits noted. Pertinent Results: [**1-16**] Hip film:FINDINGS: There is a comminuted fracture involving the intertrochanteric region of the left femur. Angulation. [**1-17**] CTA: 1. Small subsegmental pulmonary embolus within the left lower lobe. 2. Patchy opacities within the right upper lobe and left lower lobe which may represent aspiration. Consolidative process within the right lung apex which may represent aspiration versus atelectasis. Recommend followup to resolution in [**3-6**] weeks after appropriate antibiotic treatment. 3. Small bilateral pleural effusions and adjacent atelectasis marginally increased since prior exam. 4. Trace pneumomediastinum, improved compared to prior exam. 5. Compression fractures of the thoracic spine, likely chronic. [**1-19**] TTE: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2187-12-10**], estimated pulmonary artery systolic pressure is now higher. Brief Hospital Course: Briefly this is an 86M with PMH of CAD s/p CABG, PMR on steroids, osteoporosis and [**Hospital **] transfered from OSH with traumatic hip fx after developing UGIB. # Rhythm:On admission was in sinus tach, after trip to radiology for imagining went into AF with RVR intermitently with SVT. Overnight was persistently tachycardic, rare breaks into sinus, mostly AF/Aflutter. -pt on diltiazem drip, transitioned to PO metoprolol for rate control -TTE showed nl LV function, LA not enlarged -Pt on heparin gtt with transition to coumdin. -TSH elevated, FT4 WNL -CEs negative, no evidence for myocardial strain in setting of rate stress. #Hypoxemia. Per records and pt history there is no history of lung disease, pt is not on home 02. On arrival to ED at [**Location (un) 620**], was 100% on RA. On arrival to [**Hospital1 18**] was 91% on RA, 97-100% on 70% face mask. Started on heparin overnight both for AF and suspicion of PE. CTA showed small sub segmental LLL PE. -heparin gtt, transitioned to coumadin -LENIs showed no DVT #UGIB. Per OSH records, pt developed abdominal discomfort at around noon on [**1-15**] and proceeded to have coffee ground emesis. Underwent EGD which showed 2 small non-bleeding AVMs in bulb, [**Doctor First Name 329**]-[**Doctor Last Name **] tear with protruding vessel in distal esophagus, non-bleeding, was injected with epi and cauterized. Pt was started on IV PPI and kept NPO. Pt arrives at [**Hospital1 18**] with NGT in place. Hct had decreased from 44 to 38, was not transfused. Pt remained HD stable. On arrival to [**Hospital1 18**], Hct 42. Hct has stayed stable o/n, pt pulled out his NGT, has had no episodes of coffe ground emesis or abd pain. -HCT stable in house, no further evidence bleeding, pt transitioned to PO PPI #Hip Fx. s/p ORIF with Dr, [**Name (NI) **] on [**1-20**]. No complications. WBAT, working with PT prior to d/c. Will follow up with Dr. [**Last Name (STitle) **] in 2 weeks for f/u x-rays and suture removal. #Abd distention. Pt reports no bowel movements since before his fall, also denying passing gas. Had NGT tube placed at OSH for decompression in setting of abd distention and dilated loops of bowel on CT scan. Continues to have dilated, tympanitic abd, however BS are present, abd is non-tender. ? partial ileus in setting of opiod use. KUB showed impressive colon dilation with stool in rectal vault. Pt s/p rectal decompression overnight with lactulose enema and rectal tube with significant decrease in abd distention and discomfort. Now passing gas. #AAA. Noted to be mildly increased since [**2187**], now 5cm x 5.4 cm. Was evaluated at BINeedham by his vascular surgeon Dr. [**Last Name (STitle) **]. Plan to repair in [**Month (only) 958**], per their service pt is ok for orthopedic surgery. -o/p follow-up with Dr. [**Last Name (STitle) **] [**Name (STitle) 23234**] ok'd anticoagulation #Pneumomediastinum. Seen on CT at OSH, unclear etiology, possibly in setting of vomiting. On CTA at [**Hospital1 18**] there was interval resolution. # CAD:History of MI with CABG [**2179**]. -pt had been holding asa since before [**1-12**] for eye surgery. Continue to hold in setting of UGIB, planned ORIF. -On BB -Continue lipitor -EKG did not have evidence of acute ischemia, pt without symptoms concerning for ACS. CEs negative in setting of tachycardia. # Hyperlipidemia: Continue lipitor # HTN:Switched from Dilt to BB. #Fevers. Pt spiked fever on [**1-19**]/2 blood cultures grew cougulase negative staph. Treated with vancomycin. Surveillance cultures negative. Pt to continue vancomycin for 7 day course. #PMR. Low dose oral steroids #Hypothyroidism: Continue levothyroxine. TSH elevated, TFTs WNL. # Code Status:Per discussion with HCP pt is [**Name (NI) 835**] not DNR # Communication HCP is daughter and grandson, 1st call: [**Doctor First Name **] [**Doctor First Name **] (RN at [**Company 2860**]) Cell # [**Telephone/Fax (1) 23235**] home [**Telephone/Fax (1) 23236**] office [**Telephone/Fax (1) 23237**] 2nd call: Daughter [**First Name8 (NamePattern2) 622**] [**Known lastname 7710**] (out of town at the moment) [**Telephone/Fax (1) 23238**] [**Name (NI) **] [**Name (NI) 23239**], [**First Name3 (LF) **] in law, [**Telephone/Fax (1) 23240**]. Work [**Telephone/Fax (1) 23241**] Other grandson, [**Name (NI) **] [**Name (NI) **] home [**Telephone/Fax (1) 23242**], cell [**Telephone/Fax (1) 23243**], work [**Telephone/Fax (1) 23244**]. Dispo to rehab with ortho and PCP follow up. Medications on Admission: Medications: (on admission to [**Location (un) 620**]) Prednisone 2 mg [**Hospital1 **] Vit D 400 IU Tums 1 tab daily Diltiazem 120 mg daily Lipitor 10 mg daily ASA 81 mg daily (had been holding for cataract surgery) Prilosec 20 mg daily Paxil 2.5 mg [**Hospital1 **] Fosamax 70 mg q Friday Iron 325 daily Levothyroxine 25 mcg daily Ofloxacin 0.3% 1 drop R eye qid Econopred 1% eyedrops R eye 6X per day Diclofenac 0.1% 1 drop R eye [**Hospital1 **] Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: Left intertrochanteric hip fracture Upper GI bleed Atrial fibrillation Abdominal aortic aneurysm Bacteremia Secondary diagnoses: Gastroesophageal reflux Polymyalgia rheumatica Hypothyroidism Prostate CA Hyperlipidemia Discharge Condition: Stable Discharge Instructions: You were admitted after a hip fracture, you also had an episode of bleeding from your esophagus as well as a rapid irregular heart rate and an infection in your blood. Please take all medications as prescribed. You were started on a medication called coumadin or warfarin which is an anticoagulant for your atrial fibrillation, you will need to have your blood checked in 3 days to monitor these levels and dose your coumadin accordingly. You are on an IV antibiotic for your infection, you should take this for a total of 7 days. Please follow up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks of discharge. Please call your doctor or return to the emergency room if you experience bleeding, any chest pain, fevers, increased shortness of breath or for any other concerning symptoms. Followup Instructions: Please call your primary physician for an appointment within 2 weeks of discharge: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 17753**] Please call your orthopedic surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for a follow up appointment in two weeks for suture removal and follow up x-rays. [**Telephone/Fax (1) 1228**] You have the following scheduled appointments in our system. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2190-6-14**] 11:00 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2190-6-14**] 11:45 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "530.7", "285.1", "V58.65", "415.19", "E885.9", "441.4", "733.00", "820.21", "041.19", "560.1", "537.82", "V45.81", "518.1", "427.32", "244.9", "427.31", "725", "185", "401.9", "790.7" ]

icd9cm

[ [ [] ] ]

[ "79.35" ]

icd9pcs

[ [ [] ] ]

10712, 10778

5711, 10211

367, 425

11059, 11068

4001, 5688

11926, 12790

3192, 3217

10799, 10799

10237, 10689

11092, 11903

3232, 3982

10947, 11038

230, 329

453, 2637

10818, 10926

2659, 2963

2979, 3176

13,338

156,571

846

Discharge summary

report

Admission Date: [**2112-6-7**] Discharge Date: [**2112-6-22**] Date of Birth: [**2038-6-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: [**6-8**]: attempted laminectomy (aborted for bleeding) [**6-10**]: C4-T3 laminectomy, C4-T1 fusion [**6-14**]: C4-C7 anterior fusion History of Present Illness: 74M on coumadin for a fib s/p unwitnessed fall down several flights of stairs, +LOC. He was uncertain about any precipitating symptoms & does not remember event at all. He complained of LBP & R leg pain on arrival to ED & soon thereafter developed paresthesias of the arms, as well as weakness of the right foot while in the ED. Past Medical History: A fib (on coumadin) HTN COPD BPH DJD left bell palsy R hipo replacement Social History: No toxic habits Married Moved from [**Country 5881**] at young age Retired cook. Family History: noncontributory Physical Exam: AVSS, GCS 15 NCAT trachea midline, +C collar RRR CTA bilat soft obese nontender guaiac neg 5/5 strength x4, moving all extremities in trauma bay Pertinent Results: On arrival: INR 8.9 INJURIES: prevertebral, posterior paraspinal cervical hematomas cervical epidural hematoma, s/p cervical laminectomy [**6-10**] C spine fractures, s/p C4-C7 anterior fusion [**6-14**] T spine fractures (T2,3,11 vert bodies) Epidural hematoma (C5-T4 cord compression, T6-T12-no compression) R subclavian hematoma R retroperitoneal hematoma (psoas/iliacus) (?compression of femoral nerve) Hairline sacral fx Brief Hospital Course: [**6-6**]: Admitted to TSICU following fall. [**Date range (1) 5882**]: Reversal of anticoagulation & definitive repair of epidural hematomata [**6-17**]: Transfer to floor [**6-18**]: Cardiorespiratory arrest, reintubation & transfer back to TISCU [**6-22**]: Removal of care & declaration of death NEURO: Lost bilat arm & RLE strength in ED secondary to explanding cervical epidural hematoma. Brought to OR by spine team x3 ([**6-8**]: case aborted for excessive bleeding, [**6-10**]: laminectomy & posterior fusion, [**6-14**]: anterior fusion). Neurologically intact until [**6-18**] arrest, after which patient was unresponsive. Followed by neurology & ortho spine teams. CV: recurrent rapid a fib throughout ICU course, controlled with lopressor & diltiazem. followed by cards team. RESP: tolerated extubation easily following 3rd OR. Apneic after arrest event on [**6-18**]. HEME: followed by hematology for continued oozing during OR interventions despite reversal of anticoagulation. ID: treated with zosyn for aspiration pneumonia. see culture data for microbiological ID. Medications on Admission: coumadin, advair, atenolol, zestril, hydroxyzine, fluoxetine Discharge Medications: n/a Discharge Disposition: Extended Care Discharge Diagnosis: prevertebral, posterior paraspinal hematomas cervical epidural hematoma, s/p cervical laminectomy [**6-10**] C spine fractures, s/p C4-C7 anterior fusion [**6-14**] T spine fractures (T2,3,11 vert bodies) Epidural hematoma (C5-T4 cord compression, T6-T12-no compression) R subclavian hematoma R retroperitoneal hematoma (psoas/iliacus) (?compression of femoral nerve) Hairline sacral fx respiratory arrest A fib HTN COPD aspiration pneumonia Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2112-8-8**]

[ "V43.64", "E880.9", "E878.8", "401.9", "868.04", "496", "865.00", "348.1", "427.5", "807.00", "427.31", "998.11", "276.3", "V58.61", "806.06", "518.81" ]

icd9cm

[ [ [] ] ]

[ "80.51", "96.04", "84.51", "03.4", "81.03", "81.64", "03.09", "99.04", "81.02", "99.60", "96.72" ]

icd9pcs

[ [ [] ] ]

2907, 2922

1674, 2768

321, 456

3407, 3417

1222, 1651

3469, 3502

1025, 1042

2879, 2884

2943, 3386

2794, 2856

3441, 3446

1057, 1203

273, 283

484, 816

838, 911

927, 1009

47,245

138,046

54159

Discharge summary

report

Admission Date: [**2167-7-22**] Discharge Date: [**2167-7-26**] Date of Birth: [**2107-2-4**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: atypical GI symptoms Major Surgical or Invasive Procedure: Coronary artery bypass grafting x2 with left internal mammary artery graft to left anterior descending and reverse saphenous vein graft the marginal branch. History of Present Illness: 60 year old female with a history of diabetes, HLD, and anxiety who has had atypical GI complaints >1year, no symptoms since [**2166-11-21**]. Patient underwent ETT in [**Month (only) **] which was abnormal. She presents today for cardiac catherization. Catherization shows multivessel and left main disease. Cardiac surgery has been consulted for evaluation for surgical revascularization. Past Medical History: DM 2 hyperlipidemia rheumatic fever as a child anxiety Past Surgical History Cosmetic surgery [**5-30**] (eye lid lift) D&C x2 Social History: Race: Caucasian Last Dental Exam:edentulous Lives with: lives with husband. [**Name (NI) **] in college at BU Occupation: trained as a nurse/ currently works in private practice as a social worker [**Name (NI) 1139**]:[**9-4**] pack history/ quit at age 35 ETOH: 1-2 drinks per week Family History: Non contributory Physical Exam: Admission Physical Exam Pulse:89 bpm Resp: 18 O2 sat: 99% RA B/P Right: 119/74 Left: 135/80 Height:5ft 1 inch Weight:137lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema +1 Varicosities: None Neuro: Grossly intact Pulses: Femoral Right: dressing Left: +2 DP Right: +1 Left: +1 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: 0 Left: 0 Pertinent Results: [**2167-7-24**] 03:31AM BLOOD WBC-8.1 RBC-3.00* Hgb-9.8* Hct-26.4* MCV-88 MCH-32.7* MCHC-37.0* RDW-14.0 Plt Ct-117* [**2167-7-22**] 01:00PM BLOOD WBC-8.7# RBC-2.63* Hgb-8.3*# Hct-24.1* MCV-92 MCH-31.7 MCHC-34.5 RDW-13.0 Plt Ct-131* [**2167-7-22**] 02:24PM BLOOD PT-13.5* PTT-32.4 INR(PT)-1.2* [**2167-7-22**] 01:00PM BLOOD PT-13.5* PTT-29.3 INR(PT)-1.2* [**2167-7-24**] 03:31AM BLOOD Glucose-133* UreaN-9 Creat-0.5 Na-134 K-3.8 Cl-99 HCO3-29 AnGap-10 [**2167-7-22**] 02:24PM BLOOD UreaN-9 Creat-0.5 Na-139 K-3.9 Cl-110* HCO3-24 AnGap-9 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 110988**] (Complete) Done [**2167-7-22**] at 12:12:01 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2107-2-4**] Age (years): 60 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Chest pain. Coronary artery disease. Mitral valve disease. Shortness of breath. For CABG. ICD-9 Codes: 786.05, 786.51, 424.1, 424.0 Test Information Date/Time: [**2167-7-22**] at 12:12 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18397**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW1-: Machine: AW1 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.6 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.4 cm Left Ventricle - Fractional Shortening: 0.37 >= 0.29 Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Annulus: 1.9 cm <= 3.0 cm Aorta - Sinus Level: 1.9 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aortic Valve - Mean Gradient: 3 mm Hg Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - Pressure Half Time: 39 ms Mitral Valve - MVA (P [**11-22**] T): 5.6 cm2 Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 3.4 m/sec Mitral Valve - E/A ratio: 0.21 Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Moderate (2+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate (2+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Results were personally reviewed with the MD caring for the patient. Conclusions PreBypass: No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. LVEF 55% Dr. [**Last Name (STitle) **] was notified in person of the results. PostBypass: Ascending and descending aortic contours intact No change in MR [**First Name (Titles) **] [**Last Name (Titles) **] Preserved biventricular function Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2167-7-23**] 11:50 ?????? [**2159**] CareGroup IS. All rights reserved. Brief Hospital Course: On [**2167-7-22**] Ms.[**Known lastname **] was taken to the operating room and underwent Coronary artery bypass grafting x2(left internal mammary artery graft to left anterior descending and reverse saphenous vein graft the marginal branch) with Dr.[**Last Name (STitle) **]. Please refer to operative report for further details. She tolerated the procedure well and was transferred to the CVICU intubated and sedated in critical but stable condition. She awoke neurologically intact and was weaned to extubation. All lines and drains were discontinued in a timely fashion. POD#1 a right sided chest tubed was placed for a tension pneumothorax. Beta-blocker/Statin/Aspirin and diuresis were initiated. She continued to progress and was transferred to the step down unit for further monitoring on POD#2. Physical Therapy evaluated for strength and mobility. She failed to void and the foley catheter was reinserted for >900 cc. Detrol was started. The remainder of her postoperative course was uneventful. On POD#4 she was discharged to home with VNA. All follow up appointments were advised. Medications on Admission: Active Medication list as of [**2167-7-16**]: FISH OIL, CALCIUM 600 [**Hospital1 **] WITH 400 IU VIT D EACH PILL - (Prescribed by Other Provider) - Dosage uncertain LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day LORAZEPAM - 0.5 mg Tablet - [**11-22**] - 1 Tablet(s) by mouth qd prn METFORMIN - 850 mg Tablet - 1 Tablet(s) by mouth twice a day SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day ASPIRIN - (OTC) - 81 mg Tablet - 1 Tablet(s) by mouth once a day 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. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 10 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] vna Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass grafting x2 DM 2 hyperlipidemia rheumatic fever as a child anxiety Past Surgical History Cosmetic surgery [**5-30**] (eye lid lift) D&C x2 Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral anagesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: ?????? Monitor vitals signs including weight and temperature o Concerns - fever of 100.5 degrees Fahrenheit or higher o Concerns - weight increase more than two pounds in one day or five pounds in a week ?????? Monitor wound healing, teach wound care o Care ??????SHOWER DAILY - including first washing incisions gently with mild soap o Care - NO lotions, cream, powder, or ointments to incisions o Concerns - warmth, redness, swelling or increased tenderness/pain o Concerns - ANY fluid or drainage coming out of incisions ?????? Medication, diet and exercise teaching and compliance ?????? Follow-up appointment assistance and compliance. **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: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2167-8-13**] 2:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17194**], MD Phone:[**Telephone/Fax (1) 3070**] Date/Time:[**2167-9-1**] 10:30 Cardiology: Dr [**Last Name (STitle) **] on [**8-25**] at 1:15pm Completed by:[**2167-7-26**]

[ "300.00", "250.00", "272.4", "458.29", "V15.82", "414.01", "599.0", "512.0", "413.9" ]

icd9cm

[ [ [] ] ]

[ "36.11", "39.61", "36.15", "88.72", "34.04" ]

icd9pcs

[ [ [] ] ]

9591, 9646

6689, 7784

342, 501

9880, 10105

2109, 6666

10958, 11331

1392, 1411

8320, 9568

9667, 9859

7810, 8297

10129, 10935

1426, 2090

281, 304

529, 924

946, 1075

1091, 1376

8,682

185,138

2898

Discharge summary

report

Admission Date: [**2123-1-6**] Discharge Date: [**2123-2-4**] Date of Birth: [**2059-10-21**] Sex: F Service: NSU HISTORY OF PRESENT ILLNESS: This patient has a long history of lower back and leg pain and presented to consultation to Dr. [**Last Name (STitle) 1132**] for examination with complaints of worsening sensory loss on the right side of her body including her face. She underwent magnetic resonance imaging of the head which showed a 5mm aneurysm in the supraclinoid left internal carotid artery. She was brought to the neuroendovascular suite and underwent a diagnostic cerebral angiogram which showed a four by four by five millimeter aneurysm with a 3.5 millimeter neck of the supraclinoid left internal carotid artery segment. She was advised to return on [**2123-1-6**], to undergo a coiling of that aneurysm. PAST MEDICAL HISTORY: Anxiety/depression. She has been hospitalized for that in the past, most recently in [**2122-5-16**]. Status post bilateral hip and knee replacements. Osteoarthritis. Chronic low back pain and sciatica. History of T5 fracture, T4 through 5 disc with cord compression, cervical stenosis and prior lumbar surgeries. History of chest pain, and she has had atypical symptoms. Stress MIBI showed global hypokinesis with an ejection fraction of 43 percent, no ischemia. There is a question of mild to moderate pulmonary hypertension. SOCIAL HISTORY: The patient smokes one pack per day times fifty years. She does not drink alcohol for the last ten years. PHYSICAL EXAMINATION: Blood pressure 138/68, heart rate 75, oxygen saturation 95 to 96 percent in room air. In general, she is in no acute distress. Heart shows regular rate and rhythm, II/VI systolic murmur. Lungs distant breath sounds without any wheeze. Extremities - one plus ankle swelling. HOSPITAL COURSE: The patient was brought to the endovascular neurovascular angiography suite and underwent a stent mediated coiling of her left internal carotid artery aneurysm. Postoperatively in the interventional suite while waking up, she was noted to have a systolic blood pressure of 220 to 230 range accompanied by difficulty breathing following extubation as a result of her pulmonary disease and smoking history. She had been extubated but needed to be reintubated because she was unable to maintain an adequate breathing rate. Although her neurological examination was stable at this point, a stat head CT was performed since she was reintubated and there was no longer a neurological examination to follow. The head CT showed evidence of intraparenchymal blood with a subarachnoid component in a sulcal compartment. She was brought to the Post Anesthesia Care Unit and was noted to be awake, alert, following commands in all four extremities but slightly worse in her right hand at first which improved back to baseline. Her heparin was reversed with protamine and a post-protamine ACT checked which confirmed return to baseline. She was also making I can't breathe mouthing words around her endotracheal tube. At 9:00 p.m., she was noted to have developed a right hemineglect and right hemiparesis. The patient was brought emergently to the CT scanner where there was evidence of a large left- sided hemorrhage and expansion of the previous clot. She was rushed emergently to the operating room for a left decompressive craniotomy and left temporal lobectomy, partial. On the afternoon of [**2123-1-7**], a ventriculostomy drain was placed to rule out hydrocephalus. She had a low opening pressure of less than ten and her ICPs remained in that range throughout the day. Her head CT that day showed no rebleeding after the craniotomy and decompression. Postoperatively, the patient was brought to the Surgical Intensive Care Unit where she was kept intubated and sedated with strict blood pressure parameters, intubated, sedated, paralyzed with blood pressure parameters less than 140. Her pupils were noted on her first postoperative day to be 4.5 and reactive on the right and 4.0 and reactive on the left. A follow-up head CT on [**2123-1-7**], showed a left intraparenchymal hematoma evacuation and craniotomy with slight decrease in mass effect. She was started on Heparin, on Aspirin. She was kept sedated and kept her blood pressure less than 140 to 150. Her ventriculostomy drain was kept at ten above the tragus. Social services were involved with the patient and Dr. [**Last Name (STitle) 1132**] kept in contact with her separated husband who was her next of [**Doctor First Name **]. On her second postoperative day, she remained paralyzed and sedated. Her ICPs were in the eight to twenty range, eighteen mostly. Her hematocrit was 27.2. Her [**Location (un) 1661**]-[**Location (un) 1662**] drain was discontinued. She was given one unit of packed red blood cells. She was started on Mannitol 25 mg three times a day due for concerns of worsening edema on her latest head CT. Her head of bed was elevated at 45 degrees. She was also given Lasix in addition to Mannitol and Morphine drip was started for pain control. Her pCO2 goal was 30 to 35. On [**2123-1-10**], her CT was noted not to be significantly changed compared with the day before. There was a large left sided temporal intraparenchymal hemorrhage and moderate amount of mass effect, surrounding edema. There was no significant shift of normal midline structures. Her ICP remained in the three to twelve range. She was continued on sedation. Her hematocrit was 25.4. The Intensive Care Unit team had some resistance to giving blood for that hematocrit. She had an echocardiogram to rule out congestive heart failure which showed that her overall systolic ejection fraction was normal at 55 percent. There was mild pulmonary artery systolic hypertension. There was no pericardial effusion. The mitral valve was noted to be mildly thickened but no mitral regurgitation was seen. On [**2123-1-12**], the patient underwent a diagnostic cerebral angiogram which showed moderate vasospasm in the left middle cerebral artery with a patent stent without thromboemboli evidenced by angiogram. On neurologic examination, her pupils are bilaterally equal and reactive. With the recent find of left middle cerebral artery vasospasm, they recommended keeping her pCO2 at 35 to 40, keeping her drain at 10. Cerebrospinal fluid culture was sent given her cloudy appearance. Systolic blood pressure between 120 to 160 and Aspirin daily and hematocrit target of 30 percent. Her sedation was weaned and paralytic were shut off on the evening of [**2123-1-12**], into [**2123-1-13**]. She was also started on Nimodipine given her vasospasm 30 mg q4hours. She was started on Levaquin for a possible pneumonia. She began to spike fevers on [**2123-1-14**], and [**2123-1-15**], her Dilantin was discontinued with the thoughts that it could possibly be causing her drug fever. She was started on Keppra. On [**2123-1-14**], on examination, her eyes were open, her pupils were four and reactive. She was biting on her tube at the time. She did not have any movement of her extremities. She had electroencephalogram performed which showed encephalopathy. She continued to spike fevers 106 to 103 from [**2123-1-14**], to [**2123-1-17**]. Various cultures were sent off. She was started on Vancomycin to have broad coverage. She was noted to have gram positive cocci of her ventriculostomy drain from [**2123-1-12**]. On [**2123-1-17**], she received infectious disease consultation. Her cerebrospinal fluid was resent at that time. They recommended continuing on intravenous Vancomycin and to discontinue her ventriculostomy and place a lumbar drain as needed. She was treated with Levaquin for her pneumonia. Her cerebrospinal fluid that was sent on [**2123-1-17**], had no growth. Her examination on [**2123-1-19**], was that she was opening her eyes. She had minimal amount of her right upper extremity and no movement of her lower extremity. On [**2123-1-22**], she underwent percutaneous endoscopic gastrostomy and tracheostomy insertion without any problems. [**Name (NI) **] ventriculostomy drain was discontinued and the lumbar drain was inserted. Her cultures which remained positive for coagulase negative Staphylococcus in one out of four cultures. Head CT from [**2123-1-24**], showed slight increase in the amount of edema with mass effect and slight midline shift. Her lumbar drain was kept at 5 cc/hour. She was trialed on tracheostomy mask for three hours but became tachypneic and was back on continuous positive airway pressure. Her Levaquin was discontinued per infectious disease. On [**2123-1-27**], an inferior vena cava filter was placed. The patient was noted to be awake, alert, attempts to follow commands with her left hand, no movement of her right, moves her toes on her left side. On [**2123-1-28**], her lumbar drain was discontinued. Follow-up lumbar taps on [**2123-1-29**], showed an opening pressure of 18. The patient's neurologic status had not changed since her lumbar drain was discontinued and another repeat lumbar puncture on [**2123-2-2**], showed an opening pressure of 11. On [**2123-2-1**], the patient was transferred to the Step-Down Unit. Her neurologic examination is awake to stimulation. She moves her left side spontaneously, localizes briskly on the left upper extremity, slight withdrawal on her left lower extremity. Her craniectomy site was full but not tense. She needed to be suctioned every one to two hours. Her tube feedings are at goal at this time. DISCHARGE INSTRUCTIONS: She should wear a helmet when out of bed at all times due to the craniectomy site. She should follow-up with Dr. [**Last Name (STitle) 1132**] in the office in two weeks for decision about cranioplasty. Any signs of infection or changes in neurologic status should be reported to Dr.[**Name (NI) 14019**] office. Her last dose of Levaquin is scheduled for [**2123-2-2**]. She is not on any further antibiotics at this time. MEDICATIONS ON DISCHARGE: 1. Glycopyrrolate 1 mg p.o. four times a day. 2. Plavix 75 mg p.o. q72hours. 3. Fluticasone Propionate 110 mcg two puffs twice a day. 4. Aspirin 125 mg p.o. daily. 5. Keppra 1000 mg p.o. twice a day. 6. Heparin 5000 units three times a day. 7. Lansoprazole 30 mg daily. 8. Insulin sliding scale. 9. Beclomethasone two sprays four times a day. 10.Colace 100 mg p.o. twice a day. DISCHARGE DIAGNOSES: Status post left internal carotid artery aneurysm coiling with subarachnoid hemorrhage. Anxiety/depression. Status post bilateral hip and knee replacements. Osteoarthritis. Chest pain, global hypokinesis, mild to moderate pulmonary hypertension. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern1) 12790**] MEDQUIST36 D: [**2123-2-2**] 14:33:33 T: [**2123-2-2**] 19:58:46 Job#: [**Job Number 14020**]

[ "493.20", "486", "997.02", "437.3", "E879.8", "997.3", "788.20", "431" ]

icd9cm

[ [ [] ] ]

[ "01.39", "39.72", "31.1", "02.12", "43.11", "02.2", "96.6", "88.41", "38.7" ]

icd9pcs

[ [ [] ] ]

10469, 10972

10067, 10447

1854, 9587

9612, 10041

1557, 1836

163, 850

873, 1409

1426, 1534

11,809

110,140

5356

Discharge summary

report

Admission Date: [**2108-4-9**] Discharge Date: [**2108-4-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: weakness Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **]yo male with history of congestive heart failure, chronic kidney disease, gout, GERD, anemia, and possible MDS was admitted from the ED with weakness. . He initially presented to geriatrics clinic with 2-3 weeks of diarrhea and vomiting. Additional review of systems was notable for the following: poor intake, decreased appetite. He denied fevers, shaking chills, chest pain, shortness of breath, palpitations, abdominal pain, bright red blood per rectum, muscle aches, and pain. . Upon arrival in the ED, temp 98.3, HR 70, BP 75/45, and pulse ox 97%. His exam was notable for dry mucous membranes, irregular heart rate, and decreased skin turgor. His abdominal and pulmonary exams were unremarkable. He received levofloxacin 750 mg IV x 1, metronidazole 500mg IV x 1, potassium chloride 20mEq IV x 1, and 1L NS IVF. RUQ US demonstrated unchanged cholelithiasis and CXR was unremarkable. He was admitted to the [**Hospital Unit Name 153**] for further management of his hypotension and weakness. Upon arrival to the [**Hospital Unit Name 153**] he reports feeling much improved with improved strength. Past Medical History: 1. Congestive Heart Failure - [**8-21**] EF 20-30%, dilated RV, [**12-16**]+ MR, 1+ TR, dilated and hypokinetic RV - follows with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] 2. Atrial Fibrillation - follows with Dr. [**Last Name (STitle) **] - s/p BiV ICD - NSR on amiodarone therapy 3. Chronic Kidney Disease - Baseline Creatinine 2.3-2.8 - followed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**] 4. Gout 5. GERD 6. Osteoarthritis 7. Myelodysplastic Syndrome - followed with Drs. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] - baseline hematocrit 32 / baseline platelets 100-120 / baseline WBC [**3-18**] 8. BPH 9. Hypertension 10. s/p Appendectomy Social History: - Home: lives in an [**Hospital3 **] facility in [**Location (un) 583**]; supportive family with 1 daughter in CT, 1 daughter in [**Name2 (NI) **], and 1 son in [**Name2 (NI) **]; - Occupation:high school graduate and retired heating engineer - EtOH: Denies - Drugs: Denies - Tobacco: Quit smoking 20 years ago. Family History: Noncontributory Physical Exam: VS: T95, BP 104/46, HR 70, RR 23, O2sat 100% RA Gen: Elderly male, fatigued, no acute distress, resting comfortably in bed HEENT: Clear OP, dry mucous membranes NECK: Supple, No LAD, JVP elevated to 8cm CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, mild rales at bases b/l, no wheezes or rhonchi ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 intact. 5/5 strength throughout. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant . On transfer: VS: T96.2, BP 89/62, HR 68, O2sat 97%RA Brief Hospital Course: [**Age over 90 **] yo male with multiple medical problems including congestive heart failure, atrial fibrillation on coumadin, chronic kidney disease, and myelodysplastic syndrome was admitted to the [**Hospital Unit Name 153**] with hypotension in the setting of two weeks of diarrhea, treated with intravenous fluids. His course was notable for progressive renal failure and anuria. The patient and his family elected to focus on comfort; he was seen by the palliative consult team. His family spent the day with him on [**4-18**]; he died on [**2108-4-19**]. Medications on Admission: 1. Allopurinol 100mg PO qod 2. Amiodarone 200mg PO daily 3. Betamethasone cream daily 4. Calcitriol .25mcg PO q MWF 5. Colchicine .6mg PO qod 6. Aranesp 7. Furosemide 120mg PO tid 8. Lidocaine patch daily 9. Lisinopril 2.5mg PO daily 10. Lopressor 25mg PO bid 11. Nasonex 50mcg intranasally daily 12. Warfarin 2.5mg PO daily 13. Acetaminophen prn 14. Sarna 15. Omeprazole 20mg PO bid Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Renal failure Discharge Condition: Expired

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4407, 4416

3379, 3945

269, 275

4473, 4483

2681, 2698

4379, 4384

4437, 4452

3971, 4356

2713, 3356

221, 231

303, 1426

1448, 2335

2351, 2665

1,590

146,302

45469

Discharge summary

report

Admission Date: [**2111-1-27**] Discharge Date: [**2111-2-5**] Date of Birth: [**2056-2-3**] Sex: M Service: SURGERY Allergies: Levofloxacin / Codeine Attending:[**First Name3 (LF) 6346**] Chief Complaint: intraperitoneal hemorrhage and splenic hematoma Major Surgical or Invasive Procedure: none History of Present Illness: 54 year old male with history of NPH s/p VP shunt, CAD s/p MI with stent now with chronic abdominal pain since [**2109**] which worsened 2 days prior to admission in the LUQ. It was severe crampy abdominal pain which worsened after eating cereal. He did have emesis x1 which was bilous non-bloody and he has noticed distention and constipation. Admitted first to [**Hospital 1474**] hospital [**2111-1-24**] for rule out MI which was negative. He continued to have persistent abdominal pain and his Hemotocrit dropped from 30.6 to 19.1 which he recieved 4 units which then bumped his hemotocrit to 27. His last Bowel movement was sunday and he continues to have flatus. He was transferred on [**2111-1-26**] Past Medical History: -[**2109-12-13**] Cardiac Catheterization - LAD with proximal 40% and mid 70% stenosis. Ramus with a large mid 90% stenosis was stented with 2.5 x 23mm CYPHER DES and 3 x 13mm CYPHER DES with TIMI 3 flow. RCA was occluded in the mid segment and could not be engaged but was filled with left-right callaterals. -Bipolar - NPH status post Rigt VP shunt in [**6-26**] and revision [**9-26**] -Asthma -ADHD -High Cholesterol -HTN -PTSD -AAA - DJD PSH: [**Name (NI) 10259**], PTCA, VP shunt [**6-26**] ([**Hospital1 336**]), revision of VP shunt [**9-26**] ([**Doctor Last Name **]) Social History: (+) cigarette smoking -quit in [**11-25**] 60ppy history, [**12-24**] ppd on and off for 40 years Family History: (+) [**Name (NI) 41900**] CAD Father has CAD and CHF. Social History: Married for 15 years with two children 10 daughter and 14 son. Physical Exam: VS: T 97.5 BP 138/64 HR 83 RR 16 O2Sat 99% RA General: no acute distress, alert and oriented x 3 Neuro 5/5 strength. FROM HEENT: PERRLA, EOMI, CV II-XII grossly intact CV: regular rate and rhythm Lungs: Cleart to ausculation bilaterally Abdomen: soft, markedly distended, + taympanic LUQ, diffuse tenderness to palpation, no guarding Extremeties: No clubbing, edema, 2+ DP/PT pulses bilaterally Pertinent Results: [**2111-1-28**] CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: There are bibasilar opacities, most suggestive of atelectasis, as well as a small left basilar low density effusion. The liver appears normal. The patient is status post cholecystectomy. The pancreas, adrenal glands are within normal limits. There is a low density cystic lesion in the lower pole of the right kidney consistent with a simple renal cyst. There is a large subcapsular hematoma along the lateral aspect of the spleen, which measures approximately 12 x 9 cm in axial dimensions, likely with a small perisplenic component. The hematoma is of a high density suggesting recent hemorrhage, but on arterial and portal venous phase imaging, there is no evidence of active contrast extravasation. There is a ventriculoperitoneal shunt catheter terminating in the right mid abdomen. There is a small-to-moderate amount of low-density ascites throughout the abdomen. Although the presence of a small amount of hemorrhage within the fluid cannot be entirely excluded, appearance is most compatible with a fluid related to ventriculoperitoneal shunting. The stomach, small and large bowel are within normal limits. There is no lymphadenopathy, or free air. CT ANGIOGRAM: There is an accessory left hepatic artery emanating from the left gastric artery. There is a replaced right hepatic artery originating from the superior mesenteric artery. An accessory left renal artery serving the lower pole of the left kidney is noted. Immediately above the aortic bifurcation, and below the takeoff of the inferior mesenteric artery, the infrarenal shows focal ectasia up to 33 mm in diameter. The major mesenteric veins are patent. BONE WINDOWS: There are no suspicious lytic or blastic lesions. IMPRESSION: 1. Large subcapsular hematoma without evidence of active contrast extravasation. 2. Small amount of ascites within the pelvis, most likely related to the presence of a ventriculoperitoneal shunt catheter. 3. Ectactic infrarenal aorta measuring up to 33 mm in diameter. Shortly after the study, a preliminary [**Location (un) 1131**] was provided by Dr. [**First Name4 (NamePattern1) 5656**] [**Last Name (NamePattern1) **], which stated, "large high attenuation collection adjacent to spleen, appears to be subcapsular hematoma. No evidence of active extravasation of contrast. Large amount of free fluid seen within abdomen. Small right pleural effusion with associated atelectasis." Brief Hospital Course: [**Known firstname **] [**Known lastname 97020**] was transferred from [**Hospital 1474**] Hospital on [**2111-1-27**]. Hct was 26.3 after receiving PRBCs at the outside hospital. A repeat CT scan showed a large subcapsular hematoma without evidence of active contrast extravasation; and a small amount of ascites within the pelvis, most likely related to the presence of a ventriculoperitoneal shunt catheter. He was admitted to the ICU for serial exams and monitoring. He was placed on bedrest. At HD 5 his Hct was stable and he was transferred to the floor. He continued to complain of pain and abdominal distention. A bowel regimen was started. At HD 6 his activity was advanced. His urinary catheter was removed. The Hct was stable at 31.4. He remained distended and with abdominal pain. A CXR was completed for SOB/DOE which showed a left pleural effusion. At HD7 He was afebrile and ambulatory. Urine culture was positive for E. Coli. Bactrim was started. He had increased oxygen requirements with walking, and continued to complain of abdominal distention, pain, and difficulty eating due to abdominal pressure. PVCs were noted on telemetry. EKGs were obtained without evidence of acute event. He was maintained on telemetry with no acute events. His hemocrit continued to be stable up to his discharge on HD 10. He also did have three bowel movements on HD 9 after receiving lactulose. On HD 9 he felt that he had difficulty urinating. UA was sent which was negative and on prostate exam he did have a slightly enlarged prostate for which he was started on Flomax. On discharge he was tolerating a regular diet with a bowel movement the previous day and hematocrit stable. He was also advise to follow with his primary care physician about his chronic constipation and his starting Flomax. Medications on Admission: 1. Protonix 40mg PO daily 2. Plavix 75mg PO daily 3. ASA 81mg PO daily 4. Simvastatin 80mg PO daily 5. Lisinopril 10mg PO daily 6. Toprol 100mg PO BID 7. Albuterol 2 puffs [**Hospital1 **] Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day) for 4 weeks. Disp:*56 Tablet Sustained Release(s)* Refills:*0* 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*1* 9. Morphine 15 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours as needed for pain for 2 weeks. Disp:*20 Tablet(s)* Refills:*0* 10. Lactulose 10 g/15 mL Solution Sig: One (1) 10 g PO once a day as needed for constipation for 5 doses. Disp:*5 10 g packets* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: contained splenic hematoma Discharge Condition: Good Discharge Instructions: * Increasing pain or persistent pain that is not relieved by pain medications *Inability to urinate * Fever (>101.5 F) *Nausea or Vomiting that last longer than 24 hours * Inability to pass gas or stool * Other symptoms concerning to you Please take all your medications as ordered. No strenous activity for 2 months. NO CONTACT sports for 2 months. Followup Instructions: 1. Please follow up with Dr. [**First Name (STitle) 2819**] in 2 weeks. Call ([**Telephone/Fax (1) 35203**] to make an appointment. 2. Need to follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17887**] about starting flomax and to talk to her about your chronic constipation and abdominal pain. Call [**Telephone/Fax (1) 3183**] to make an appointment. Completed by:[**2111-2-5**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8087, 8142

4859, 6671

328, 335

8213, 8220

2375, 4836

8620, 9033

1810, 1864

6910, 8064

8163, 8192

6697, 6887

8244, 8597

1960, 2356

241, 290

363, 1076

1098, 1678

1880, 1945

74,454

116,702

8707

Discharge summary

report

Admission Date: [**2155-12-6**] Discharge Date: [**2155-12-6**] Date of Birth: [**2091-6-10**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: Headache Major Surgical or Invasive Procedure: None History of Present Illness: HPI: The pt is a 64 year-old man with a history of DM, HTN and chronic back pain who presents with headache and unresponsiveness, found to have a large cerebellar hemorrhage. Per his family, overnight last night he began to complain of a worsening headache, and became less responsive this morning, at which time EMS was called. On arrival EMS reported that he was awake, but only oriented to self, with possible decreased movement on the right compared to the left. En route to the hospital he developed agonal respirations, and by the time he arrived in the ED he was completely unresponsive, though was still breathing on his own. On arrival he was noted to have 2mm minimally reactive pupils, and no gag reflex. He was intubated for airway protection. He had a head CT which showed a large cerebellar hemorrhage with intraventricular extension. He was seen by Neurosurgery, who felt this was non-operative, at which point Neurology was consulted. He was also noted to be hypertensive to 213/103, for which he was started on a nicardipine drip. Patient intubated, unable to answer ROS. Past Medical History: -HTN -DM -Gout Social History: Lives in [**Location 745**] with his wife, son and daughter in law. Family History: Unknown Physical Exam: Vitals: P: 92 R: 13 BP: 152/67 SaO2: 100% intubated General: Intubated HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: obese, soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: occasional areas of scarring over distal lower extremities Neurologic: -Mental Status: Intubated, off propofol for ~2 hours, not responsive to verbal or painful stimuli. -Cranial Nerves: Pupils 2mm, sluggish, minimally reactive. Negative corneals, negative oculocephalics. Negative gag. -Motor/Sensory: Flaccid tone throughout, though with occasional fine amplitude rhythmic shaking of his shoulders, that is suppressible. No response to painful stimuli in upper extremities, triple flexion in bilateral lower extremities. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 3 3 3 3 1 Plantar response was extensor bilaterally. Pertinent Results: Admission Labs: 144 | 114 | 15 ---------------< 151 3.3 | 17 | 0.6 Ca: 6.6 Mg: 1.3 PO4: 2.4 ALT: 16 AST: 30 AlkP: 68 TBil: 0.6 Trop: <0.01 PT: 13.6 PTT: 23.3 INR: 1.2 17.1 8.1 >--------< 135 49.1 U/A: negative Imaging: NON-CONTRAST HEAD CT: There is a large intraparenchymal hematoma within the posterior fossa, measuring 4.0 x 7.3 cm axially. There is extension into the ventricular system, including the fourth, third, and lateral ventricles. There is extensive mass effect, with herniation of the tonsils inferiorly through the foramen magnum, and upward transtentorial herniation with effacement of the basal cisterns. The brainstem is compressed anteriorly. There is additional subarachnoid hemorrhage seen within the basal cisterns. There is no further intraparenchymal hematoma supratentorially. There is no subdural or epidural hematoma. The bones are unremarkable, and the visualized paranasal sinuses are clear. IMPRESSION: Large posterior fossa intraparenchymal hematoma measuring up to 4 x 7.3 cm, actually, with extension into the ventricles. Additional subarachnoid hemorrhage is seen in the basal cisterns. There is extensive mass effect, with upward transtentorial herniation causing effacement of the basal cisterns, compression of the brainstem anteriorly, and downward tonsillar herniation through the foramen magnum.Dilated temporal horns indicate developing hydrocephalus. CXR: FINDINGS: An endotracheal tube is in position with tip approximately 8 cm above the carina. Lung volumes are low. There is likely some atelectasis at the bases and in the right middle lobe; however, no definite opacity to suggest pneumonia is seen, though the right infrahilar region is not well evaluted. No pleural effusion or pneumothorax is identified. An NGT is in place with tip out of view of the radiograph, below the diaphragm. IMPRESSION: Status post endotracheal tube placement with tip approximately 8 cm above the carina. Brief Hospital Course: Mr. [**Known firstname **] [**Known lastname 30485**] is a 64 year-old man with a history of HTN, DM, gout and chronic back pain presenting with severe headache followed by unresponsiveness, found to have a large cerebellar hemorrhage with intraventricular extension. On discovery of the hemorrhage, he was initially evaluated by Neurosurgery, however given the extent of the hemorrhage, he was determined not to be a surgical candidate. He was initially intubated for airway protection, and placed on a nicardipine drip for blood pressure control, and admitted to the NeuroICU. After the rest of his family arrived, further discussion was held with the family regarding his overall poor prognosis given the extent of the hemorrhage and low likelihood of meaningful recovery. The family stated that their father would not desire to be on extended life support and the decision was made to make him CMO. The priest was called to administer last rites, afterwhich the patient was extubated, and died shortly thereafter. Medications on Admission: Unknown - thought to include lisinopril and prednisone Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "780.01", "274.9", "431", "401.9", "250.00", "348.4", "V49.86" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

5930, 5939

4772, 5796

325, 331

5991, 6001

2786, 2786

6054, 6176

1598, 1607

5901, 5907

5960, 5970

5822, 5878

6025, 6031

2273, 2767

1622, 2157

277, 287

359, 1458

3051, 4749

2803, 3041

2172, 2256

1480, 1496

1512, 1582

31,693

174,262

53466

Discharge summary

report

Admission Date: [**2115-5-15**] Discharge Date: [**2115-5-26**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: Rectosigmoid colon cancer Major Surgical or Invasive Procedure: 1. Exploratory laparotomy 2. Low anterior resection 3. Hartmann's end colostomy 4. Feeding transgastric jejunostomy 5. Splenic flexure takedown History of Present Illness: [**Known firstname **] is an 88-year-old female with a history of lower abdominal pain, heme positive stool who initially did not want evaluation and workup but then conceded to a sigmoidoscopy. Sigmoidoscopy demonstrated a large rectosigmoid mass that was biopsied and showed high-grade dysplasia with likely adenocarcinoma. CT scan showed a large mass in the pelvis. She was seen in the hospital and as an outpatient and offered low anterior resection with possible colostomy. Risks and benefits of the procedure were discussed. Consent was reviewed and signed. Past Medical History: MONOCLONAL GAMMOPATHY DEMENTIA HYPERTENSION ? of ANGINA, STABLE- PERSANTINE THALLIUM NEGATIVE [**4-18**] OSTEOARTHRITIS BACK PAIN- S/P LUMBAR DISC [**Doctor First Name 147**]. S/P ARTHROPLASTY KNEE, TOTAL REPLACEMENT, BILAT HEADACHE ESOPHAGITIS, REFLUX OSTEOPOROSIS ? of GOUT- LEFT GREAT TOE ATOPIC DERMATITIS S/P INGUINAL HERNIA REPAIR, BILAT S/P TOTAL HYSTERECTOMY [**2075**] S/P REMOVE GALLBLADDER S/P REMOVAL OF APPENDIX ? of POLYMYALGIA RHEUMATICA SHOULDER PAIN, RIGHT, CHRONIC RESTLESS LEG SYNDROME . MEDS: ATENOLOL TAB 100MG one tab po qd \ FOSAMAX TABS 70 MG 1 tab po qweek PROTONIX 40 MG Daily MULTIVITAMIN one po qd CALCIUM CARB CHW 500MG 2-3 per day METROCREAM 0.75 % CREAM apply qd DOXEPIN HCL 50 MG CAPS 1 cap po qhs TRAMADOL HCL 50 MG 2 tabs po qd 4- 6 hours prn--not using FUROSEMIDE TAB 20MG po qam LISINOPRIL 5 MG TABS po qhs REQUIP 2 MG TABS po 1 hour before bedtime . NKDA Social History: Married. Two sons who live in the area. Currently at [**Location (un) 8220**] NH. Pt is a holocaust survivor. Family History: unknown Physical Exam: AVSS Gen: nad CV: RRR Chest: CTAb Abd: S/ND, appropriately tender, surgical incision intact with no signs of infection, stoma pink Ext: WWP, non-tender Pertinent Results: [**2115-5-15**] 05:34PM BLOOD WBC-5.8 RBC-3.42* Hgb-10.5* Hct-30.9* MCV-90 MCH-30.7 MCHC-34.0 RDW-15.5 Plt Ct-314# [**2115-5-16**] 01:29AM BLOOD WBC-8.2 RBC-3.34* Hgb-10.4* Hct-29.9* MCV-90 MCH-31.2 MCHC-34.9 RDW-15.9* Plt Ct-330 [**2115-5-17**] 04:50AM BLOOD WBC-8.7 RBC-3.17* Hgb-9.9* Hct-28.6* MCV-90 MCH-31.2 MCHC-34.5 RDW-16.0* Plt Ct-312 [**2115-5-18**] 05:20AM BLOOD WBC-6.6 RBC-3.17* Hgb-10.2* Hct-28.8* MCV-91 MCH-32.0 MCHC-35.3* RDW-15.8* Plt Ct-334 [**2115-5-19**] 06:00AM BLOOD WBC-4.9 RBC-3.13* Hgb-9.7* Hct-29.0* MCV-93 MCH-30.9 MCHC-33.3 RDW-16.0* Plt Ct-305 [**2115-5-15**] 05:34PM BLOOD Glucose-146* UreaN-13 Creat-0.8 Na-140 K-3.9 Cl-108 HCO3-25 AnGap-11 [**2115-5-16**] 01:29AM BLOOD Glucose-124* UreaN-15 Creat-1.0 Na-139 K-4.1 Cl-107 HCO3-24 AnGap-12 [**2115-5-17**] 04:50AM BLOOD Glucose-102 UreaN-17 Creat-1.0 Na-139 K-3.9 Cl-106 HCO3-25 AnGap-12 [**2115-5-18**] 05:20AM BLOOD Glucose-133* UreaN-14 Creat-0.9 Na-139 K-3.2* Cl-104 HCO3-26 AnGap-12 [**2115-5-19**] 06:00AM BLOOD Glucose-123* UreaN-13 Creat-0.7 Na-141 K-4.2 Cl-104 HCO3-29 AnGap-12 [**2115-5-20**] 05:25AM BLOOD Glucose-120* UreaN-15 Creat-0.7 Na-141 K-3.9 Cl-104 HCO3-29 AnGap-12 [**2115-5-19**] 06:00AM BLOOD ALT-7 AST-20 AlkPhos-71 TotBili-0.4 [**2115-5-20**] 05:25AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.8 Brief Hospital Course: 88F with pre-operative diagnosis of rectosigmoid cancer admitted for scheduled, elective sigmoid colectomy. Informed consent was obtained. Pt tolerated the procedure well but was kept intubated and admitted to the ICU overnight for anesthesia concerns and the pt being slow to wake after general anesthesia. Pt did well overnight in the ICU with no issues. On POD1 she was extubated with no complications. Her NGT was also removed. She was transferred to the floor. Her bowel functions slowly returned to function and her diet was advanced from sips to clears to regular diet as well as her tubefeeds via the j-tube were advanced which she was tolerating well. She had several episodes of emesis but a f/u KUB showed the G-J tube to be in place. The G-tube balloon was reduced by 10cc for the possibility that that could be causing some mild obstruction. She had had no episodes of vomiting for greater than 24hrs on the day of discharge. The geriatric service was consulted and assisted us with her care in terms of medications and sleep aids. Of note, she continued to be somewhat sleepy during her post-operative course. The geriatric service felt that this might be due to her haldol, trazodone and/or remeron but they had no definite explanation. Haldol and trazodone were held and her remeron was reduced then also d/c'ed. Once all of these medications were discontinued, she was much more alert and oriented equivalent to her baseline. Physical and occupational therapy evaluated the patient and deemed her in need of rehab placement. Of note, her stool was sent for c.diff which came back positive. Although she was afebrile and she did not have a white count, she was started on flagyl given the positive cultures for a course of 14 days. On the day of discharge she was afebrile, VSS, incision CD&I, and tolerating feeds and regular diet. Medications on Admission: Lopressor 150', Mirtazapine 15', Prilosec 20', Trazadone 75', Ca 500''', Vit D, Colace 100', Fe, MVI Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 6. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO every 4-6 hours as needed for pain. 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. 10. Lactobacillus Acidophilus Capsule Sig: One (1) Capsule PO twice a day for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Rectosigmoid colon cancer Discharge Condition: stable Discharge Instructions: Call or come back in if you experience fevers, chills, [**Hospital6 **], vomiting, increasing redness, increased swelling, bleeding or purulent discharge from your incision, increasing pain, or any other concerns. You should only take pain medications as needed. Take stool softeners to prevent constipation. . It is okay to shower but do not soak your wound. Do not immerse your wound in water for at least 4 weeks postoperatively. Do not lift greater than [**10-2**] lbs for 4 weeks. Followup Instructions: Follow-up with Dr. [**First Name (STitle) 2819**] in [**6-27**] days. Please call his office to verify your appointment: ([**Telephone/Fax (1) 6347**]

[ "154.0", "733.00", "401.9", "560.1", "290.3", "008.45", "E939.0", "569.83", "294.8", "280.0", "273.1" ]

icd9cm

[ [ [] ] ]

[ "48.62", "46.39", "96.6" ]

icd9pcs

[ [ [] ] ]

6571, 6637

3605, 5465

287, 432

6707, 6716

2288, 3582

7251, 7406

2092, 2101

5616, 6548

6658, 6686

5491, 5593

6740, 7228

2116, 2269

222, 249

460, 1026

1048, 1945

1961, 2076

1,244

160,739

4290

Discharge summary

report

Admission Date: [**2103-8-2**] Discharge Date: [**2103-8-16**] Date of Birth: [**2033-3-26**] Sex: M Service: CHIEF COMPLAINT: GI bleed, acute MI. HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old man with coronary artery disease, status post CABG, end stage renal disease on hemodialysis and CHF with an EF of approximately 35% at baseline. He was admitted to [**Hospital **] Hospital on [**2103-7-31**] after an episode of chest pain and shortness of breath at hemodialysis. He reportedly had a similar episode on [**2103-7-28**] at hemodialysis. ECG at that time showed a left bundle branch pattern. Troponins of 0.17 and 2.01 were obtained. He was started on Heparin for presumed acute coronary syndrome. At 6:30 the following morning on [**2103-8-1**] he became diaphoretic and briefly lost consciousness. A code was called at that time and the patient was resuscitated. He had melena and coffee ground emesis with a hematocrit dropping from 33.5 to 26.9. He became bradycardic to the 40's, was given Atropine and was intubated. CK rose to 727 and troponin I of 34 at that time. An EGD was performed and no ulcer was visualized secondary to not being able to enter the duodenum. Repeat echo showed an EF of 25% with 3-4+ MR. [**Name13 (STitle) **] was given 6 units of packed red cells, 4 units FFP, started on Levophed for hemodynamic support and transferred to the [**Hospital1 69**] for further management. PAST MEDICAL HISTORY: Coronary artery disease status post CABG, end stage renal disease secondary to glomerulonephritis on hemodialysis, ischemic cardiomyopathy, COPD, history of supraventricular tachycardia, laryngeal carcinoma status post XRT to larynx, benign prostatic hypertrophy, ventral hernia. MEDICATIONS: Outpatient medications are as follows: Digoxin 0.125 mg po q d, Iron Sulfate 325 mg po q d, Nephrocaps, Aspirin 81 mg po q d, Phos-Lo 2-3 tabs with meals, Paxil 10 mg po q d, Rocaltrol 0.25 mg po q d, Prevacid 15 mg po q d, Zestril 5 mg po q d, Cardura 2 mg po q d, Flovent and AeroBid inhalers, Klonopin 0.5 mg [**Hospital1 **] prn. Medications on transfer to [**Hospital1 69**]: Albuterol, Flovent, Prevacid, Cardura, Klonopin, Lisinopril, Paxil, Rocaltrol, Digoxin, Ferrous Gluconate, Aspirin, Phos-Lo and Nitroglycerin. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a retired teacher. He is married and lives with his wife, they are raising their granddaughter. [**Name (NI) **] ethanol use. He quit smoking approximately 7 years ago. PHYSICAL EXAMINATION: The patient was intubated at time of transfer with a Propofol drip. Blood pressure was 84/37, heart rate in the 80's. Oxygen saturation was 92-94% on 50% FIO2. His HEENT exam was unremarkable. Mucus membranes were moist. Pupils were equal, round and reactive to light. OGT and EDT were both present. JVD could not be actually assessed. The lungs had coarse breath sounds throughout. Heart was regular rate and rhythm, 2/6 systolic murmur was noted at the apex. His abdomen was soft, nontender, non distended. Extremities were without edema. LABORATORY DATA: On admission, WBC 19.4, hematocrit 37.7, platelet count 207,000, sodium 141, potassium 6.3, chloride 105, CO2 18, BUN 79, creatinine 6.7, INR 1.5, PTT 50.3, EKG showed sinus rhythm at a rate of 69, left bundle branch block with 2-[**Street Address(2) 2051**] depressions in V5 and V6. Chest x-ray showed right pleural effusion with right lower lobe infiltrate. HOSPITAL COURSE: The patient was admitted to the CCU for further management after cardiac catheterization. 1. Cardiac: Cardiac catheterization showed two patent grafts but could not identify blood flow to the left circumflex territory. No interventions were done at this time. The patient was quickly weaned off pressors on [**8-8**]. During hemodialysis the patient went into atrial fibrillation with rapid ventricular rate. He was rate controlled with Diltiazem as the family requested the avoidance of beta blockers. He was subsequently loaded on Amiodarone and spontaneously converted to normal sinus rhythm. On [**2103-8-9**] the patient had a 10 beat and then a subsequent 5 beat run of ventricular tachycardia. He was seen by EP at that time, however, due to a national state of emergency, further EP evaluation could not be performed as an inpatient. Instead, he will have a complete EP study with possible placement of an ICD as an outpatient. In the interim, the patient has been given an event recorder. 2. Pulmonary: The patient was noted to have an aspiration pneumonia on chest x-ray and elevated white count at time of admission. He was treated with a 14 day course of Levofloxacin and Flagyl. He was extubated on the third and was subsequently noted to have some wheezes. He was initially treated with Albuterol nebs and then switched over to Combivent MDI and restarted on his at home medications. 3. GI: The patient's hematocrit was stable throughout this hospitalization. He was started on a proton pump inhibitor. Initially he had some heme positive discharge from his NG tube. On [**8-13**] he had two episodes of emesis that were heme positive. Since then his hematocrit has continued to be stable. However, it was decided to defer further evaluation of this until the patient was an outpatient as proper evaluation cannot occur during the peri MI period because this places him at greatly increased risk. His H. pylori status was noted to be negative. He will follow-up with GI as an outpatient. 4. Renal: At the time of admission the patient was given Calcium Gluconate and Kayexalate for hyperkalemia. He was then hemodialyzed on his regular schedule without further incident. 5. Neuro: The patient initially had decreased levels of consciousness after extubation, only being oriented to person. With continued PT and recuperation, the patient became alert and oriented times three. 6. Fluids, Electrolytes & Nutrition: The patient was noted to have difficulty swallowing shortly after extubation. A video swallow study showed deep laryngeal penetration of thick and thin liquids. He subsequently tolerated a moist solid with liquids thickened to nectar consistently diet. DISCHARGE MEDICATIONS: ASA 81 mg po q d, Paxil 10 mg po q d, Cardura 1 mg po q h.s., Protonix 40 mg po q d, Captopril 50 mg po tid, Flovent 2 puffs [**Hospital1 **], Serevent 2 puffs [**Hospital1 **], Combivent MDI 2 puffs qid prn, Digoxin 0.125 mg po q d, Amiodarone 400 mg po q d, Iron Sulfate 325 mg po q d, Phos-Lo three tablets po tid with meals, Nephrocaps, Klonopin 0.5 mg po bid prn, Trazodone 25 mg po q h.s. prn. The patient was discharged to [**Hospital 1319**] Rehab in stable condition. DISCHARGE DIAGNOSIS: 1. GI bleed. [**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 9348**] MEDQUIST36 D: [**2103-8-16**] 16:10 T: [**2103-8-17**] 10:11 JOB#: [**Job Number 18584**]

[ "428.0", "410.71", "585", "496", "997.1", "424.0", "427.31", "507.0", "414.01" ]

icd9cm

[ [ [] ] ]

[ "37.22", "96.6", "88.53", "96.72", "88.56", "39.95" ]

icd9pcs

[ [ [] ] ]

6266, 6745

6766, 7058

3521, 6242

2570, 3503

148, 169

198, 1458

1481, 2342

2359, 2547

8,978

103,447

2393

Discharge summary

report

Admission Date: [**2106-3-26**] Discharge Date: [**2106-4-12**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest tightness Major Surgical or Invasive Procedure: s/p cardiac catheterization s/p CABGx2 [**3-29**] LIMA-LAD, SVG-OM History of Present Illness: Mrs. [**Known lastname **] is an 80 yo woman with a known h/o CAD who has had PCI to her RCA, presented to the ED with SOB and chest tightness on [**3-26**]. Past Medical History: CAD s/p RCA PCI PVD s/p R popliteal PCI HTN anxiety HOH collagenous colitis hypercholesterolemia glaucoma macular degeneration s/p bilateral cataract surgery Social History: Mrs. [**Known lastname **] lives at home with her husband. She denies tobacco or EtOH. Pertinent Results: [**2106-4-9**] 07:08AM BLOOD WBC-11.0 RBC-3.87* Hgb-11.8* Hct-35.2* MCV-91 MCH-30.5 MCHC-33.6 RDW-15.1 Plt Ct-433 [**2106-4-9**] 07:08AM BLOOD Plt Ct-433 [**2106-4-9**] 07:08AM BLOOD PT-12.9 PTT-27.0 INR(PT)-1.1 [**2106-4-9**] 07:08AM BLOOD Glucose-91 UreaN-23* Creat-1.0 Na-137 K-4.5 Cl-102 HCO3-24 AnGap-16 Brief Hospital Course: Mrs. [**Known lastname **] presented to [**Hospital1 18**] on [**3-26**] with c/o chest tightness and shortness of breath. Her cardiac catheterization showed a normal ejection fraction and significant 2 vessel disease. She was taken to the operating room on [**3-29**] with Dr. [**Last Name (STitle) **] on [**3-29**] for CABGx2. She tolerated the procedure well and was transferred to the ICU in stable condition. She was weaned and extubated from mechanical ventilation without difficulty and transferred to the regular floor on POD#2. On POD#2 she required PRBC transfusion and had several episodes of atrial fibrillation. She was started on amiodarone and began to develop periods of bradycardia. On the morning of POD#5 she developed HTN, SOB and rales. She was treated with diuretics and IV nitroglycerine and the decision was made to transfer her to the ICU for close monitoring. Her EKG was without ischemic changes, and echocardiogram did not show any wall motion abnormality or pericardial effusion. Her symptoms of heart failure resolved with continued diuresis and she was transferred back to the regular floor. Her beta blockers were discontinued due to her bradycardia, however she continued to have episodes of atrial fibrillation. On POD#10 an electrophysiology consult was obtained due to continues episodes of rapid atrial fibrillation and it was recommended to decrease her dose of amiodarone and restart a low dose of atenolol. She was started on Coumadin for anticoagulation, and by POD#14, her INR was 2.1 and she was cleared for discharge to home. Medications on Admission: lisinopril 2.5mg qd atenolol 25 mg qd zocor 10 mg qd ativan prn asprin 325 mg qd imdur 60mg qd trusopt eye gtts occuvite paxil 10mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Dorzolamide HCl 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 7 days. Disp:*14 Capsule, Sustained Release(s)* Refills:*0* 5. 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* 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a day. 11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: then check with Dr.[**Name (NI) 12389**] office for continued dosing. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Coronary Artery Disease Hypertension s/p CABG PVD anxiety HTN collagenous colitis Discharge Condition: good Discharge Instructions: you may take a shower and wash your incisions with mild soap and water do not swim or take a bath for 1 month do not drive for 1 month do not apply lotions, creams, ointments or powders to your incisions do not lift anything heavier than 10 pounds for 1 month Followup Instructions: Follow up with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 457**] in [**1-17**] weeks follwo up with Dr. [**Last Name (STitle) **] in [**3-19**] weeks Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD follow up in [**1-17**] weeks Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2386**] follow up with Dr. [**Last Name (STitle) **] in [**2-18**] weeks ([**Telephone/Fax (1) 12390**] Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2106-5-13**] 3:15 Provider: [**First Name11 (Name Pattern1) 278**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 394**], O.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2106-7-13**] 1:30 Completed by:[**2106-4-12**]

[ "427.31", "428.0", "412", "414.01", "272.0", "401.9", "272.4", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "36.12", "88.53", "37.22", "88.56" ]

icd9pcs

[ [ [] ] ]

4310, 4396

1178, 2763

284, 353

4522, 4528

845, 1155

4836, 5816

2948, 4287

4417, 4501

2789, 2925

4552, 4813

229, 246

381, 540

562, 721

737, 826

22,024

149,586

5782

Discharge summary

report

Admission Date: [**2131-6-13**] Discharge Date: [**2131-6-16**] Date of Birth: [**2089-3-6**] Sex: F Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 2704**] Chief Complaint: CHIEF COMPLAINT: vaginal bleeding Major Surgical or Invasive Procedure: Placement and subsequent removal of temporary pacing wire Pacemaker placement History of Present Illness: HPI: 42 yo F with PMH of Freidrich's Ataxia, muscular dystrophy, afib who presents with vaginal bleeding and clots. She notes that her menses began about 7 days ago and she states that she had increased bleeding compared to normal. For the last 3-4 days she notes blood clots as well. Her husband who changes her diaper notes that the bleeding has been much worse than usual. She notes some lightheadedness. Denies acute change in vision, palpitations, chest pain, SOB, n/v, diaphoresis. She does have a history of uterine fibroids. Past Medical History: PMH: Friedreich's ataxia Muscular dystrophy DM insulin dependent from age 31 atrial fibrillation/flutter hypothyroidism gastroparesis major depression urinary incontinence HTN systolic CHF with LVEF 40-45% Uterine fibroid CKD baseline Cr 1.2 s/p spinal fusion for scoliosis s/p CCY Social History: married and lives at home. Her husband cares for her along with a PCA. No tobacco history. No alcohol or IVDU. Family History: brother died of [**Name (NI) 22988**]. mother died of lung cancer (was a smoker). 3 cousins with [**Name (NI) 22988**]. Physical Exam: PE: vitals: T 98.2, BP 102/58, HR 58, RR 20, O2sat 97% RA General: obese female in NAD, lying in bed. A&O x3 HEENT: NCAT, anicteric sclera, non-injected conjunctiva. dry MM, OP clear without erythema or exudate. PERRL. EOMI. neck supple CV: RRR, no m/r/g Lung: CTAB no w/r/r Abdomen: +BS, soft, NTND Ext: no e/c/c. both legs flexed at knees and hips Neuro: speech slow but clear. Patient can not move legs and limited arm movements (baseline per patient and husband) Pertinent Results: [**2131-6-13**] 03:15PM PT-42.0* PTT-30.2 INR(PT)-4.8* [**2131-6-16**] 07:40AM PT-20.9* PTT-27.0 INR(PT)-2.0* [**2131-6-14**] 12:08PM Digoxin-0.8* Transvaginal ultrasound [**2131-6-13**] 1. Fibroid uterus. Allowing for differences in technique, no significant interval change in size of multiple fibroids. 2. Relatively normal appearance of the endometrium. Please note, the LMP is unknown. Brief Hospital Course: In summary, this is a 42 female with [**Last Name (un) 22989**] ataxia/Musc Dystrophy, cardiomyopathy with EF 20%, afib/flutter s/p DC cardioversion on coumadin with uterine fibroids and menorrhagia in setting of elevated INR who was transferred to the CCU for bradycardia and hypotension. Bradycardia/afib: Patient has tachy-brady syndrome and had long pause in setting of digoxin/amiodarone/carvedilol use and hypokalemia. However, she has had no recent change in medications. She was transferred to the CCU and a temporary wire was placed. Responded well to brief peripheral dopamine and atropine. Now appears to be in sinus rhytm/afib and has fluctuated as an outpatient despite cardioversion. All medications were held and patient underwent electrophysiology study with permanent pacemaker placement for her tachy-brady syndrome. Amiodarone dosage was decreased to 200mg daily and carvedilol 6.25 TID continued. Patient was continued on coumadin 2mg and set up for INR follow up. Hypotension: Likely related to acute bradycardia. Admission hypotension likely related to blood loss. Responded well to IVF. Hypotension resolved after IVF and rate control was acheived. CHF/Cardiomyopathy: EF 20% per last TTE. Followed by Dr. [**First Name (STitle) 437**]. Related to underlying muscular dystrophy. No current signs of decompensation. Digoxin and ACE were held in setting of bradycardia and hypotension. Home lasix of 80mg po daily and digoxin 0.125mg were continued. Menorrhagia/Fibroids: Related to fibroids given vaginal U/S. Nothing to suggest abnormal uterine bleeding per GYN. Hct stablized slightly below her baseline. INR corrected with FFP/Vit K. Uterine bleeding resolved during hospital stay. Patient was instructed to follow up with GYN as an outpatient for further management of her uterine fibroids. [**Last Name (un) 22989**] Ataxia: Currently stable. Pt is wheelchair bound. Outpatient regimen of pain control and muscle relaxants was tailored on this admission. Tizanadine was discontinued due to its interaction with amiodarone. Amiodarone causes decreased clearance of tizanadine and increases the sedative effects. Patient instructed to discuss use of tizanadine with PCP. Diabetes Type I: Secondary to Friedreichs Ataxia. Patient was contined on home doses of NPH with RISS, QID fingersticks. Hypothyroidism: Continued home dose Levoxyl. TSH elevated, may be amiodarone related as Free T4 was normal. Depression: Continued on home Lexapro dosage. Medications on Admission: Medications: 1.Amiodarone 400 mg PO DAILY 2.Aripiprazole 10 mg PO DAILY 3.Carvedilol 6.25 mg PO BID 4.Coenzyme Q10 900 mg daily 5.Coumadin 2mg on Wed and 3mg all other days 6.Digoxin 0.0625 mg PO DAILY 7.Escitalopram Oxalate 20 mg PO DAILY 8.Ferrous Sulfate 325 mg PO DAILY 9.Furosemide 80 mg PO DAILY 10.Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose 11.Levothyroxine Sodium 125 mcg PO DAILY 12.Lisinopril 5 mg PO DAILY 13.Lyrica *NF* 75 mg Oral daily 14.Magoxide 400mg 15.Myrapex 0.125 daily 16.Potassium liquid 15ml [**Hospital1 **] 17.Tizanidine HCl 4 mg PO BID 18.Tolterodine 2 mg PO BID 19.Topiramate (Topamax) 25 mg PO QAM 20.Topiramate (Topamax) 50 mg PO QPM 21.TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Discharge Medications: 1. Keflex 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:*6 Tablet(s)* Refills:*0* 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Coenzyme Q10 300 mg Capsule Sig: Three (3) Capsule PO once a day. 7. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day. 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO daily (). 13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Topiramate 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 16. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 17. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 18. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO daily (). 19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: max 4 g daily. 20. INSULIN Please resume your home insulin dosing regimen of insulin sliding scale with NPH 28 U in the morning and 10 units in the afternoon. 21. Outpatient Lab Work Please go to the [**Hospital 191**] [**Hospital3 271**] on Monday, [**6-18**] for an INR check. 22. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 23. Potassium Chloride 20 mEq Packet Sig: Twenty (20) mEq PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Chronic atrial fibrillation on coumadin Uterine bleeding secondary to fibroids Tachy-brady syndrome status post pacemaker placement Secondary: Dilated cardiomyopathy Chronic kidney disease Friedreich's ataxia Muscular dystrophy Insulin dependent diabetes mellitus Gastroparesis Urinary incontinence Discharge Condition: afebrile, normotensive, comfortable on room air Discharge Instructions: You have been evaluated for your vaginal bleeding due to fibroids. Your INR was also high (your blood was too thin) when you were admitted. You should resume your coumadin this evening at a dose of 2 mg daily. We would like you to have your INR drawn on Monday, [**6-18**] at the [**Hospital 191**] [**Hospital3 **]. Also during your hospitalization, you were found to have a low heart rate which required a pacemaker. You should not raise your arm above the level of your shoulder. You will return to Device Clinic next week to have your pacemaker checked. You should not shower for the next week; you may take sponge baths. You should continue your usual dose of digoxin and carvedilol. Please take only 200 mg of amiodarone daily (down from your prior dose of 400 mg daily). You should also not take your tizanidine until you speak with Dr. [**Last Name (STitle) **] next week. Please call your doctor or return to the emergency room should you develop any of the following symptoms: fever > 101, chills, pain in your pacemaker pocker or increasing swelling redness at the pacer site, difficulty breathing, confusion, nausea or vomiting, chest pain, continue vaginal bleeding, lightheadedness, or any other concerns. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please do not elevate left arm greater than 90 degrees for one month. Please do not shower for one week. Followup Instructions: Please return to the Device Clinic to have your pacemaker investigated at the end of next week. The office number is [**Telephone/Fax (1) 59**]. Please contact them for an appointment. You need to follow up with Dr. [**Last Name (STitle) **] within the next 1 week. Please call [**Telephone/Fax (1) 250**] for an appointment. Please discuss continuing your tizanidine with him before you restart this medication. Please get your INR checked on Monday through the [**Hospital 191**] [**Hospital3 **]. Please keep these other already-scheduled appointments. Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2131-6-27**] 1:20 Provider: [**Name10 (NameIs) 191**] CLINICAL PHARMACIST Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2131-6-28**] 1:40 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2131-6-28**] 2:45

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Discharge summary

report

Admission Date: [**2135-12-7**] Discharge Date: [**2135-12-15**] Date of Birth: [**2074-7-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1257**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: Intubation RIJ CVL placement History of Present Illness: This is a 61 yom with hx of Atrial Fibrillation not on Coumadin, Seizure disorder, Depression, hx of squamous cell carcinoma of left tonsil and oropharynx, hx of aspiration PNA with hx of trach, hx of extensive truncal and LE burn wounds s/p skin grafting who was brought to the ED on [**2135-12-7**] from his Nursing home for hypoxemia. Per report, patient was found in his room with oxygen saturation of 85% on 2L NC, BP 112/74, HR 56, RR 12. EMS placed patient on NRB with O2 sat in 90s, BP noted to be 70/45, patient received IVF bolus, and nebs treatment with improvement. Lasix was then given for bibasilar crackles heard on lung exam. . In the ED, initial VS: Temp 100.6, HR 92, BP 104/62, RR 19, 99% NRB. Patient became hypotensive with SBP 60s along with afib with RVR to 170s. Levophed was started and then changed to Neo given his tachycardia. A RIJ CVL was placed for access. 3.5L IVF were given. patient was noted to be more somnolent and was intubated prior to admission to MICU. CXR in the ED showed ?Left mid lung zone opacity concerning for PNA. He was started on Vanco/Zosyn for treatment of sepsis/PNA. . In the MICU, abx were changed from from linezolid/zosyn/cipro to linezolid/cefepime on [**2135-12-8**]. Patient was in and out of Afib, so was started on dilt. Later afib episodes with controlled with metoprolol 5mg IV, which help him convert to sinus w/in 1 hour. He was weaned off pressors on [**2135-12-10**], and successfully extubated on [**2135-12-11**], the day prior to transfer to the floor. Of note, patient continued to be in afib with RVR overnight on [**12-11**] to 170s; pt was refusing to take PO dilt during the day; responded to IVFs and IV dilt 20 and IV metoprolol 5; then spontaneously converted back to NSR. . Also in the MICU, gen [**Doctor First Name **] evaluated patient on [**2135-12-11**] for Stg I-II sacral decub in setting of remote skin grafts after burns, they recommended switching dressing to xeroform and reconsulting plastic surgery. Plastic surgery was seeing patient prior to transfer to the floor. Recs pending. Also, GGT was found to be elevated so liver US was ordered, read pending on transfer. . Upon transfer, paitent's vital signs were: afebrile at 98.6F, HR 77, BP 126/63, RR 19, 98% on RA. He denied shortness of breath or chest pain or palpitations. He had no pain anywhere else. He did complain of leg spasms that has been bothering him for the past 3 years since the fire accident. He was otherwise very comfortable. He denied sore throat and said he has been eating some solids since extubation. He denied abdominal pain, diarrhea, constipation, nausea or vomiting. He had no fever or chills. He said his mind didn't work well now, and that he is worried about losing his nursing home bed and would have nowhere to go after this hospitalization. Past Medical History: Squamous Cell Carcinoma of left tonsill and oropharynx s/p chemo therapy in [**2135-6-19**], followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 103064**] at [**Hospital1 2025**] s/p Extensive truncal burns s/p skin grafting [**2132**] B/L BKA [**9-/2133**] Paroxysmal Atrial Fibrillation (lone afib on aspirin) Seizure disorder Depression hx of Aspiration PNA s/p trach hx of C.diff hx of VRE ?DVT Social History: The patient lives at [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing home. 20pk year smoking history, quit 3 years ago at the time of the burns. Alcohol- at least 1 pint of hard liquor a day until 3 years ago when he stopped after his burns. Cocaine as a teenager. Family History: Mother died of cancer at age 56, he is unclear which cancer Physical Exam: Vitals - T:97.2 BP:111/63 HR:66 RR:18 02 sat:99% on RA GENERAL: NAD, pleasant HEENT: Pupils equal and round, reactive to light, NCAT, MMM CARDIAC: +S1/S2, no M/R/G, RRR LUNG: Mild expiratory ronchi in anterior lung fields ABDOMEN: +BS, NT/ND EXT: +b/l BKA, +small clean based ulceration on left stump DERM: Extensive burn wounds over torso and b/l LE with healed skin grafting. +sloughed decubitus ulcers with clean base on back measuring 24x24 inches, Stage II Pertinent Results: ADMISSION LABS: [**2135-12-7**] 02:10AM BLOOD WBC-20.9* RBC-2.57* Hgb-7.0* Hct-23.4* MCV-91 MCH-27.4 MCHC-30.1* RDW-13.8 Plt Ct-278 [**2135-12-7**] 02:10AM BLOOD Neuts-84.4* Lymphs-13.2* Monos-2.2 Eos-0.1 Baso-0.1 [**2135-12-7**] 02:10AM BLOOD PT-19.7* PTT-39.4* INR(PT)-1.8* [**2135-12-8**] 07:00AM BLOOD Fibrino-656* [**2135-12-7**] 02:10AM BLOOD Glucose-84 UreaN-36* Creat-2.0* Na-142 K-3.6 Cl-108 HCO3-25 AnGap-13 [**2135-12-7**] 02:10AM BLOOD ALT-11 AST-16 CK(CPK)-211* AlkPhos-331* TotBili-0.2 [**2135-12-11**] 02:43AM BLOOD GGT-135* [**2135-12-7**] 02:10AM BLOOD Lipase-9 [**2135-12-7**] 02:10AM BLOOD CK-MB-3 cTropnT-0.16* proBNP-1697* [**2135-12-7**] 09:52AM BLOOD Calcium-6.9* Phos-3.6 Mg-1.7 [**2135-12-7**] 02:10AM BLOOD TSH-0.22* [**2135-12-13**] 06:00AM BLOOD TSH-1.1 [**2135-12-13**] 06:00AM BLOOD T4-PND Free T4-0.98 [**2135-12-7**] 09:52AM BLOOD Calcium-6.9* Phos-3.6 Mg-1.7 [**2135-12-10**] 04:57AM BLOOD Cortsol-10.1 [**2135-12-10**] 10:11AM BLOOD Cortsol-9.1 [**2135-12-10**] 10:59AM BLOOD Cortsol-24.0* [**2135-12-10**] 10:10AM BLOOD Valproa-50 ----------------- DISCHARGE LABS: PT: 14.6 PTT: 29.9 INR: 1.3 Alk Phos: 245 GGT:150 Ca: 8.5 Mg: 1.8 P: 2.6 WBC: 3.5 Hct: 28.3 Platelets: 180 Na: 138 K: 3.5 Cl: 102 CO2: 31 BUN: 10 Cr: 0.7 Glu: 79 ----------------- STUDIES: EKG [**2135-12-7**]: atrial fibrillation with RVR . CXR [**2135-12-7**]: Multifocal pneumonia. . LENIS [**2135-12-7**]: No evidence of DVT. . CXR [**2135-12-8**]: Unchanged right lung opacities worrisome for infectious process with worsening of the left retrocardiac atelectasis. . CXR [**2135-12-9**]: 1. Interval improvement in the right basal and left mid lung opacities, suggesting resolving infections. 2. Lines and tubes in place. . CXR [**2135-12-11**]: Interval improvement in bilateral pulmonary infiltrates. . CXR [**2135-12-12**]: Evaluation of the study is limited, the lateral aspect of the left hemithorax was not included in the film. Cardiac size is normal, right IJ catheter tip is in the cavoatrial junction. Multifocal opacities bilaterally in the lungs larger in the left mid lung are unchanged from prior. If any there is a small right pleural effusion. There is no evident pneumothorax. . TTE [**2135-12-9**]: The left atrium is mildly dilated. 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 aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal regional and global biventricular systolic function. No significant valvular abnormality seen. . RUQ US [**2135-12-12**]: 1. No intrahepatic or extrahepatic biliary duct dilatation is seen. 2. Several small calculi are seen within the lumen of the gallbladder. 3. Mild mural thickening at the gallbladder fundus with areas of ringing artifact, suggestive of adenomyomatosis. . MRI L and S spine [**2135-12-13**]: 1. Large soft tissue ulcer and scar overlying the inferior sacrum and coccyx without clear extension to bone. 2. Focal, small area of bone marrow edema and enhancement in the posterior elements of the sacrum at the level of S3. This may represent a small focal area of osteomyelitis but is not specific. Brief Hospital Course: 61 yom with hx of Atrial Fibrillation not on Coumadin, Seizure disorder, Depression, hx of Squamous cell carcinoma of left tonsil and oropharynx, hx of Aspiration PNA with hx of trach, hx of Extensive truncal and LE burn wounds s/p skin grafting, hx of VRE who was brought in from his Nursing home for hypoxemia. . # Pneumonia: Patient was treated with 8 day course of antibiotics (linezolid and cefepime). He was extubated on [**2135-12-11**], and on transfer out of the MICU to the regular floor, he was satting well on room air. Given his history of aspiration pneumonia in the past per [**Hospital1 2025**] records, this pneumonia was most likely aspiration-related. Patient's diet was maintained on mechanical softs/nectar pre-thickened liquids. . # Atrial Fibrillation: Patient developed atrial fibrillation in the MICU, in the setting of infection and levophed use. Last afib episode was on the night of [**2135-12-11**]. He responded well to PO diltiazem and metoprolol. Patient's TSH was low at 0.22, so we discontinued Synthroid 25mcg daily. Patient need to follow up with his PCP to have thyroid hormone re-checked. Since CHADS score is 0, patient was continued on aspirin 325mg daily. . # Decub ulcers: Patient has stage I and II decub ulcers on the back. Patient was seen by vascular surgery and [**Date Range **] care services. He underwent MRI pelvis to assess for osteomyelitis, which showed a focal, small area of bone marrow edema and enhancement in the posterior elements of the sacrum at the level of S3. This may represent a small focal area of osteomyelitis but is not specific. After discussing with radiology, plastic surgery and consulting infectious disease, we determined that this radiological finding has low likelihood of being osteomyelitis, and it would casue more harm than benefit to have it biopsied. Prophylactic antibiotics are not indicated, and patient should get a follow up MRI in [**6-20**] weeks to assess the size of this focal edema and enhancement. . # [**Date Range 409**] care for Decub ulcers and BKA stumps: The following was the [**Date Range **] care instructions: Pressure relief per pressure ulcer guidelines. Support surface: [**Doctor First Name **] Air low air loss, Turn and reposition every 1-2 hours and prn, Moisturize B/L stumps and periwound tissue left stump [**Hospital1 **] with Aloe Vesta Moisture Barrier Ointment. Left stump and coccyx/gluteal tissue: Commercial [**Hospital1 **] cleanser or normal saline to irrigate/cleanse all open wounds. Pat the tissue dry with dry gauze. Left stump: Apply Adaptic, dry gauze, Kerlix wrap, change daily. Coccyx/gluteal tissue: Apply Critic Aid Moisture Barrier Ointment to the periwound tissue with each DRG change. Apply Aquacel AG dressings over the open sites to absorb moisture and decrease local bacteria bioburden Cover with large sofsorb dressings. No tape on skin, position in place, Change dressing daily and prn. When patient begins to stool, will need to evaluate for containment and readjust placement of dressings. Monitor hydration due to increased fluid loss from coccyx/gluteal wounds (similar to burn fluid loss). Support nutrition and hydration. Notify MD [**First Name (Titles) **] [**Last Name (Titles) **] care nurse [**First Name (Titles) **] [**Last Name (Titles) **] or skin deteriorates. . # Elevated Alk phos and GGT: Alk phos 245 (highest 394), GGT 150 on discharge. Pt is not complaining of any RUQ pain. ALT, AST and bilirubin were normal. RUQ US showed absence of intra- and extra-hepatic duct dilatation. On reviewing [**Hospital1 2025**] records, it appeared that patient has a history of elevated alk phos which typically resolves without intervention. Patient should follow up with PCP on these lab abnormalities. . # Elevated INR: Patient was found to have an elevated INR, up to 2.8, while in ICU. Patient received vitK to reverse this coagulopathy. On the day of discharge, INR was 1.3. Patient not on coumadin, so this is most likely due to mal-nutrition. . # Hypothyroidism: TSH was low at 0.22, so we discontinued home Synthroid 25mcg daily given his atrial fibrillation. Patient needs to have PCP follow up to have thyroid hormone re-checked in [**2-16**] weeks. . # Seizure disorder: Home Depakote was continued. . # Chronic pain: Home methadone and percocet were continued. . # Constipation: patient was on aggressive bowel regimen during this hospital stay. He had a rectal tube in during the first part of his hospital stay, which was pulled out two days prior to discharge. Patient had formed BMs on discharge. . # FEN: Patient was on mechanical soft/nectar pre-thickened liquids diet. His electrolytes were monitored and repleted PRN. . # PPX: PPI, heparin SQ when INR trended down, bowel regimen . # ACCESS: RIJ CVL, which was pulled on the day of discharge. . # CODE: Full Medications on Admission: Synthroid 25mcg daily Prilosec 20mg daily Finasteride 5mg daily Methadone 30mg daily Depakote 500mg [**Hospital1 **] Neurontin 300mg PO TID Polyethylene Glycol 17gm daily Tyelenol 325-650mg PRN Enoxaparin 40mg SQ Daily MOM 30ml at 8pm Dulcolax 10mg supp per rectum PRN Fleet enema PRN Compazine 5mg prior to taking methadone Percocet 1 tab PO q4h PRN Ativan 1mg daily PRN Metoprolol 6.25mg PO BID ASA 325mg PO Daily 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. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 3. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Methadone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Ativan 1 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 12. Metoprolol Tartrate 25 mg Tablet Sig: 6.25 MG PO twice a day: hold if SBP<90 or HR<50. 13. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for headache. 14. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous once a day. 15. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal once a day as needed for constipation. 16. Milk of Magnesia 800 mg/5 mL Suspension Sig: One (1) PO once a day: at 8pm daily. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: Aspiration pneumonia Stage I, II decub ulcers Paroxysmal atrial fibrillation s/p severe burns and BKA Squamous cell carcinoma of the tongue and oropharynx s/p chemotherapy in [**2135-6-19**] Discharge Condition: Afebrile, not requiring oxygen. Tolerating PO diet well. Discharge Instructions: It was a pleasure to be involved in your care, Mr. [**Known lastname 103065**]. You were admitted to [**Hospital1 69**] because of pneumonia. You were initially admitted to the medical intensive care unit, and was intubated because of difficulties with breathing. You were successfully extubated on [**2135-12-11**] and your pneumonia was treated with a full course of antibiotics. You responded to treatment very well, and you did not require any oxygen suplementation when you were transferred to the regular floor. As you probably know, the reason for your repeated pneumonia is because of aspiration. Please adhere to the diet recommendation of mechanical softs and nectar prethickened liquids. For the ulcers on your back, you were seen by plastic surgery, infectious disease service and [**Year (4 digits) **] care service. Because these ulcers are from lying on your back, please try to lie on your sides when you are in bed to prevent worsening of these ulcers. You were found to have some abnormalities in your liver function tests. We ultrasounded your liver, which showed no significant abnormalities. Please follow up with primary care doctor to have the tests rechecked. Your medications were not changed. - please discontinue levothyroxine and have your thyroid function re-checked in the nursing home or when you see your primary care doctor If you develop shortness of breath, severe cough, high fevers, chills, heart palpitations, abdominal pain, or any other symptom that concerns you, please call your doctor or come to the emergency department immediately. Followup Instructions: You missed your appointment with your oncologist, Dr. [**Last Name (STitle) 103064**], on [**12-7**] because you were admitted, we tried to make another appointment for you, but couldn't get hold of Dr. [**Name (NI) 103066**] secretary after multiple tries. We asked the phone operator to stat page the secretary but did not hear anything from them. Please make an appointment to see him at the Center for Head and Neck Cancers on [**Street Address(2) 38740**], Yawkey building at [**Hospital1 2025**]. Please call [**Telephone/Fax (1) 12267**] to make an appointment. We also tried to make an appointment for you to see your primary care doctor, Dr. [**Last Name (STitle) 36712**]. However, on multiple attempts, we were only able to talk to Dr.[**Name (NI) 103067**] telephone answering service who stat paged the staff but we never heard anything from them. Please call [**Telephone/Fax (1) 37824**] to make an appointment to see Dr. [**Last Name (STitle) 36712**]. You need to have your liver function tests, coagulation tests, thyroid function tests re-checked and have another MRI pelvis to follow up. In the [**Hospital1 2025**] discharge summary from [**2135-11-28**], you were asked to make an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for ENT follow up. We called and tried to make the appointment for you, but the staff was out for lunch when we called. We were not able get an appointment for you before you left with ambulance. Please call [**Telephone/Fax (1) 103068**] to make an appointment.

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

15016, 15170

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29672

Discharge summary

report

Admission Date: [**2118-5-16**] Discharge Date: [**2118-5-20**] Date of Birth: [**2042-12-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3705**] Chief Complaint: Altered mental status, hypothermia, dyspnea Major Surgical or Invasive Procedure: [**2118-5-16**] Intubation [**2118-5-17**] Extubation [**2118-5-16**] R IJ central venous line placement History of Present Illness: 73yo M with h/o COPD, CHF, HTN, is brought to the hospital for change in mental status. Patient was en route to his pulmonary follow up appointment when he was found by the transporters to be confused with oxygen saturation of 85% on RA. The transportation service brought him directly to the Emergency Department. . In the Emergency Department, patient was minimally responsive wtih initial vitals of T 98.2 HR 80 BP 164/68 RR 18 SPO2 100% on 15L . He was given a trial of Narcan to which he did not respond. He was not protecting airway and was subsequently intubated w/o difficulty. After intubation he had repeated episodes of hypotension requiring 2L IVF, CVL placement, and dopamine. ABGs show hypercarbic respiratory failure. CT Head w/o acute change. Broad spectrum antibiotics (ceftriaxone, unasyn, and vancomycin) were started for possible infection in setting of hypotension. . He was transferred to the ICU where the dopamine was weaned off. He was treated empirically for COPD exacerbation with solumedrol and levaquin. Patient was able to be extubated the following day and was transferred to the floor. He is currently on his home oxygen requirement (2L NC). . On arrival to floor patient denies any complaints. States he feels well and would like to go home. His mildly labored respirations are reportedly "better than his normal". He denies any abdominal pain, nausea, vomiting, diarrhea, fever, chills, or chest pain. He is unable to recall the events leading to his admission. He denies recent illness or changes in medications. He denies any history of similar presentations. Past Medical History: (per [**2115**] D/C summary, OMR notes and rehab report) 1. Severe COPD on home O2 continuously 2. CHF 3. HTN 4. BPH 5. Hypothyroid 6. Afib 7. ? MI 8. h/o TB [**2058**]'s 9. ? seizure disorder 10. Severe left carotid stenosis 11. Mixed personality disorder with narcissistic and oppositional traits 12. Depression 13. Etoh abuse Social History: He is currently living at the [**Hospital 2251**] Nursing Home ([**Telephone/Fax (1) 71095**]) but has a history of homelessness. Previously worked for Budweiser driving trucks. 6 children; mostly living in NH. 60pk/yr smoking history and currently still smoking 8 cigarettes per day. He denies any alcohol use in the last two years. Denies drugs. Family History: Noncontributory Physical Exam: On arrival to ICU: VITAL SIGNS: T 98.1 BP 150/72 HR 75 RR 17 O2 96% on PEEP 8 and FiO2 50% AC 500 X 16 GENERAL: Intubated and sedated HEENT: Normocephalic, ecchymoses below bilateral eyes No conjunctival pallor. No scleral icterus. Pupils pinpoint. MMM. ETT in place. RIJ in place. CARDIAC: Distant heart sounds, reg, no g/m/r, nl S1, S2 LUNGS: CTAB, good air movement biaterally, no wheezes ABDOMEN: NABS. Soft, NT, mildly distended. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: Pinpoint pupils, upgoing toes, sedated on versed GU: foley catheter placed that is draining blood-tinged urine On arrival to the medicine floor: VITAL SIGNS: T 97.8 BP 120/57 HR 62 RR 18 O2 97% on 2L GENERAL: NAD, awake and watching television, cooperative HEENT: Normocephalic, ecchymoses below bilateral eyes, No conjunctival pallor. No scleral icterus. PERRL. MMM. NECK: FROM, bandage over prior RIJ site c/d/i CARDIAC: Distant heart sounds, reg, no g/m/r, nl S1, S2 LUNGS: mild respiratory effort, able to complete sentences, nasal cannula in patient's mouth, CTAB, good air movement bilaterally, no wheezes ABDOMEN: NABS. Soft, NT, mildly distended. EXTREMITIES: Cool, dry, trace BLE edema R>L (chronic), no calf pain, 1+ dorsalis pedis pulses. SKIN: No rashes/lesions, + symmetric echymosis under eyes NEURO: No focal deficits, CN 2-12 grossly intact Pertinent Results: [**2118-5-16**] 03:48PM BLOOD WBC-6.5 RBC-4.22* Hgb-11.2* Hct-37.0* MCV-88 MCH-26.6* MCHC-30.4* RDW-15.2 Plt Ct-185 [**2118-5-16**] 03:48PM BLOOD Neuts-85.0* Lymphs-10.2* Monos-3.3 Eos-1.2 Baso-0.3 [**2118-5-16**] 03:48PM BLOOD PT-13.8* PTT-25.9 INR(PT)-1.2* [**2118-5-16**] 03:48PM BLOOD Glucose-104 UreaN-19 Creat-0.7 Na-140 K-5.1 Cl-91* HCO3-44* AnGap-10 [**2118-5-16**] 03:48PM BLOOD ALT-12 AST-15 CK(CPK)-49 AlkPhos-56 TotBili-0.4 [**2118-5-16**] 03:48PM BLOOD cTropnT-<0.01 [**2118-5-16**] 03:48PM BLOOD Albumin-3.8 Calcium-9.5 Phos-3.4 Mg-1.7 [**2118-5-16**] 03:48PM BLOOD TSH-0.18* [**2118-5-17**] 04:18AM BLOOD T3-78* Free T4-1.6 [**2118-5-16**] 03:48PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2118-5-16**] 03:47PM BLOOD pO2-77* pCO2-117* pH-7.26* calTCO2-55* Base XS-19 Intubat-NOT INTUBA [**2118-5-18**] 11:05AM BLOOD Type-MIX pO2-61* pCO2-55* pH-7.46* calTCO2-40* Base XS-12 Comment-GREEN TOP [**2118-5-16**] 04:03PM BLOOD Lactate-0.9 [**2118-5-17**] 12:36AM BLOOD freeCa-1.20 . MICRO [**2118-5-16**] Blood cx: NGTD [**2118-5-16**] Urine cx: yeast 10-100,000 CFU [**2118-5-17**] Sputum cx: Proteus species GRAM STAIN (Final [**2118-5-17**]): [**10-23**] PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2118-5-19**]): SPARSE GROWTH OROPHARYNGEAL FLORA. UNABLE TO RULE OUT HAEMOPHILUS DUE TO OVERGROWTH OF SWARMING PROTEUS SPECIES. PROTEUS SPECIES. SPARSE GROWTH. . ECG: SR (78), nl axis, no LVH, < [**Street Address(2) 4793**] depressions in V4-V6 (new). TWI in aVL (old). IMAGING: [**5-16**] Port CXR: Endotracheal tube is in place, tip just below the thoracic inlet, roughly 7 cm above the carina. Cardiomediastinal contours are unchanged allowing for portable supine technique. Irregular densities throughout the right hemithorax consistent with parenchymal calcifications related to prior granulomatous infection are not significantly changed. There is no new airspace opacity. There is no definite pleural effusion, though the left CP angle is excluded. There is no pneumothorax. Multiple old healed rib fractures are stable bilaterally. IMPRESSION: No acute cardiopulmonary process. . [**5-16**] CT head w/o contrast: wet read No acute hemorrhage. Stable lacunar infarcts. Mucosal thickening and soft tissue in the left maxillary sinus, likely infectious. MRI is more sensitive for acute infarcts. . [**5-16**] CTA Chest/Abd/Pelvis: wet read No PE. Mucous plugging with associated volume loss of right lower lobe. No colitis. Circumferential thickening of bladder wall--could be due to underdistention or acute/acute on chronic cystitis; correlate with UA. . [**2118-5-17**] EEG: IMPRESSION: This is an abnormal portable EEG recording due to the slow background suggestive of a moderate to severe encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. There were no lateralized or epileptiform features seen in this recording. . [**2118-5-19**] CXR: The ET tube tip was removed as well as the NG tube and the right internal jugular line. Cardiomediastinal silhouette is stable. The lungs are significantly hyperinflated due to severe emphysema but overall there is improved aeration of the lung bases. Bilateral old rib fractures are noted. There is no interval development of pleural effusion or pneumothorax. . Brief Hospital Course: ASSESSMENT AND PLAN: 75 M w/ pmh of COPD on home O2, presents en-route to pulmonary appointment w/ hypercarbic respiratory failure. #. Hypercarbic respiratory failure: Unclear precipitant, i.e, did altered mental status cause hypercarbia or did hypercarbia cause altered mental status? Patient is on depakote and olanzapine which are sedating but these are not new medications. No narcotics in his medication list and he did not respond to narcan in the ED. Toxicology screens were negative. Patient's hypercarbia may be due to relapsing COPD exacerbation as it appears from his notes that he has recently been treated w/ a steroid taper (unclear when he started/stopped it). Has a RLL mucus plug but no obvious infiltrates on current imaging. Does have a history of alcohol abuse but no h/o of liver disease. No obvious electrolyte abnormalities apart from elevated bicarb. In the ICU patient was started empirically on levaquin and methylprednisolone. He responded well and was extubated. Patient is currently on home oxygen requirement. Plan to continue empiric treatment for COPD exacerbation. Patient completed at 5 day course of levaquin during this hospitalization for complicated COPD exacerbation. Patient to continue steroid taper and scheduled nebulizer treatments. Patient was counseled on smoking cessation. Currently not interested in quitting. Continue to use caution with supplemental oxygen. Titrated supplemental oxygen to maintain oxygen saturations > 92%. . #. Altered mental status: Unclear precipitant. Head CT w/o trauma or acute process. Electrolytes and LFTs were unremarkable. Patient did not respond to narcan as described above. Urine and serum toxicology screens were negative with the exception of benzos (given for intubation). EEG was performed which suggested toxic-metabolic encephalopathy. Hypercarbia is likely primary contributor to his confusion and somnolence. Mental status resolved with resolution of his respiratory failure. Patient currently alert and oriented. Does not show evidence of confusion in conversation. Would continue to hold unnecessary sedating medications such as trazadone. . #. Psych: Patient has history of personality disorder, depression, and etoh abuse. Patient currently appears stable. Continue home medications of citalopram, risperidone, and depakote. Hold trazadone and other prn sedating medications if possible. . # CAD/CHF: Not an active issue. Patient is without chest pain and appears euvolemic on exam. No events on telemetry. Patient continued on daily aspirin, plavix, statin, beta blocker and acei. . #. Anemia: Normocytic, no active bleeding. Decreased hematocrit during admission likely dilutional. Hct is slowly trending up at time of discharge. Currently Hct 32. Recommend monitoring hematocrit within the next week. . #. Hematuria: Secondary to traumatic foley placement. Hematuria resolved after removal of foley catheter. . #. Question of Cystitis on CT pelvis: UA w/ borderline UTI on arrival. CBC w/o WBC elevation but mild L-shift. Urine culture positive for yeast. Foley catheter was dicontinued and urinary symptoms resolved. . #. DM2: On sliding scale regular at rehab. Blood sugar likely to be elevated in the setting of steroids. Would continue diabetic diet with frequent finger sticks while on steroid taper. Continue sliding scale insulin. . #. HTN: Antihypertensives were being held in setting of post-intubation hypotension. Hypotension had resolved prior to arrival to floor. Patient restarted on home metoprolol and lisinopril prior to discharge. . #. Afib: Per medical record history. In sinus rhythm throughout admission. Not anticoagulated. No events on telemetry. . # FEN: Cardiac, diabetic diet, magnesium oxide supplementation . # CODE STATUS: Full for Rehab report . # EMERGENCY CONTACT: [**Name (NI) **] [**Name (NI) 71096**] (cousin) [**Telephone/Fax (1) 71097**]. [**Name (NI) **] (son) [**Telephone/Fax (1) 71098**] . # DISPOSITION: HOME to [**Hospital **] NURSING HOME . Medications on Admission: [**First Name8 (NamePattern2) **] [**Hospital 2251**] Nursing and Rehab Center List Oscal Duoneb Metoprolol 75 [**Hospital1 **] Risperidal 0.5 [**Hospital1 **] Foradil 1 cap [**Hospital1 **] singulair 10 mg daily Hytrin 2 mg po qhs trazodone 25 mg qhs Proscar 5 mg qhs Omeprazole 20 mg daily NTG sl prn Albuterol nebs Ertapenem 1 g IV daily X 5 days ([**Date range (1) 71099**]) Florastar 250 mg po bid Regular insulin SS Prednisone taper? Fosamax Mag oxide 400 mg daily Spiriva ASA 81 Plavix 75 mg daily Zocor 20 mg daily Lisinopriil 20 mg [**Last Name (un) **] Citalopram 30 mg daily Depacote 750 qam . PRNS tylenol MOM bisacodyl [**Name2 (NI) **] enema prune juice Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for candidal infection. 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Divalproex 250 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO QAM (once a day (in the morning)). 6. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Risperidone 1 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO twice a day: For total of 75 mg po bid. 11. Prednisone 10 mg Tablet Sig: See below Tablet PO once a day for 8 days: Please take 4 tablets daily for two days. Followed by 3 tablets daily for two days. Followed by 2 tablets daily for two days. Followed by 1 tablet daily for two days. For a total of 8 days of treatment. 12. Foradil Aerolizer 12 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation twice a day. 13. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 14. Florastor 250 mg Capsule Sig: One (1) Capsule PO twice a day. 15. Proscar 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. Hytrin 2 mg Capsule Sig: One (1) Capsule PO at bedtime. 17. Os-Cal 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO three times a day. 18. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 19. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 20. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual q 5 minutes as needed for chest pain: Not to exceed three doses. If chest pain persists after three doses of ntg please call 911. 21. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation q4h prn as needed for shortness of breath or wheezing. 22. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 23. Fosamax Oral 24. Insulin regimen Please continue home insulin regimen with finger stick monitoring qachs while on steroids. 25. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 26. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. 27. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) dose PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital **] nursing home Discharge Diagnosis: Primary Diagnosis Hypercarbic respiratory failure secondary to COPD exacerbation Secondary Diagnosis Diabetes Mellitus type 2 Anemia Hematuria secondary to trauma Tobacco abuse Discharge Condition: Hemodynamically stable; maintaining oxygen saturations > 94% on 2L NC, patient able to ambulate with minimal assistance. Discharge Instructions: You were brought to the hospital with new onset of somnolence and confusion. In the Emergency Department, you were found to have low oxygen levels and decreased responsiveness and required intubation. You were transferred to the ICU where you were treated with steroids and antibiotics. Your symptoms improved and you were safely extubated. You were transferred to the medicine floor where you were monitored overnight without events. . The following changes were made to your home medications: 1) START prednisone taper 2) STOP trazadone and it may have contributed to your somnolence . Please continue all other home medications as previously directed. . Please notify your physician or return to the hospital if you experience increased shortness of breath, dizziness, confusion, weakness, fever, chills, or any other symptom that is concerning to you. Followup Instructions: Please follow up with your primary care provider within one week of discharge to monitor your symptoms.

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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33356

Discharge summary

report

Admission Date: [**2151-3-29**] Discharge Date: [**2151-4-3**] Date of Birth: [**2073-7-26**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: ACS, cardiogenic shock Major Surgical or Invasive Procedure: central line cardiac catheterization MVR possible CABG History of Present Illness: 77 year old female w/ a h/o [**First Name3 (LF) **], hypercholesterolemia, DM, PMR on steroids who is transferred from [**Hospital 2079**] hospital w/ ACS in cardiogenic shock. She initially presented to [**Hospital 2079**] hospital w/ 2 days of CP and SOB. Family describes "chest congestion" starting at ~7 pm on the night of presentation to Southshore ([**2151-3-28**]) which was significantly worse than recently (had been complaing of chest congestion x 2 wks) now associate with SOB. Husband called 911 and she was brought to [**Hospital 2079**] hospital. In the Southshore ED, patient found to have ST depressions in V2-V6 and isolated STE in V1. She was also found to have pulmonary edema and was managed w/ BiPAP and diuresis. This am, patient was evaluated by Cardiology and was found to be hypotensive in cardiogenic shock. Cr rising w/ poor UOP despite diuresis. Cardiac enzymes were found to be elevated: CK 198->431->951-> 5403, MB 37->86->192->915, Trop 0.37->0.95->1.46->17.16. She was started on heparin gtt, integrillin, Plavix 300mg x1. She underwent cardiac cath showing TO LAD, 90% circ, tortuous RCA with L->L collaterals as well as R->L collaterals to septum. IABP placed and patient was intubated, Patient was briefly in asystole by report but converted with CPR and was placed on Levophed via a peripheral IV. 2 PIV's in place. Stat bedside ECHO showed moderate to severe MR and MR w/ apical and lateral HK. . Upon arrival to the CCU, patient is intubated and sedated but moving all extremities. She continues to have a high levophed requirement to maintain her pressures. She was taken emergently to the cardiac cath lab where her LAD TO was confirmed as well as her 90% circ w/ L->L collaterals and RCA w/ aneurysm vs. dissection and R->L collaterals. She received 2 BMS->Circ. The LAD was crossed but given likely chronicity of her TO, it was not opened. . Recent events discussed with patient's family. Family notes that since THR in [**10/2150**], patient has complained of increased fatigue. Has also had slow, slurred speech since that time. Family notes DOE w/ [**2-4**] of a mile over the last year. She must stop after a few steps on the stairs to rest. Patient also complained of "chest congestion" over the last few weeks which had recently improved. She also complained of "indigestion". Associated w/ recent chest congestion, patient also had orthopnea symptoms which improved w/ pillows. Past Medical History: # hypertension # hypercholesterolemia # diet controlled DM (family denies) # Polymyalgia Rheumatica # s/p R THR [**10/2150**] # s/p appendectomy in her 30s # s/p umbilical hernia repair Social History: Patient lives in [**Location 77420**] with husband. She has 3 daughters in the area as well as a son. She used to smoke [**3-7**] cigs/day x 20 yrs but quit 20 yrs ago. No EtOH use. Family History: No significant family h/o CAD or SCD Physical Exam: VS: T 100.3, BP 84/60, HR 74, RR 17, O2 99% on AC400x16,PEEP5, FiO2 100% Gen: pale, ill appearing female, intubated and sedated HEENT: NCAT. Sclera anicteric. PERRL. Neck: Supple with JVP of to angle of mandible. CV: RR, normal S1, S2. No S4, no S3. II/VI sys murmur at base Chest: Course breath sounds bilaterally w/ basilar crackles bilaterally. Abd: Decreased BS. Soft, NTND, No HSM or tenderness. No abdominal bruits. Groin: IABP in R groin. Arterial sheath and PA catheter in L groin. Ext: Cool extremities. Blue, cyanotic appearing L hand. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+; Femoral 2+; DP dopp Left: Carotid 2+; Femoral 2+; DP dopp Pertinent Results: COMMENTS: 1. Successful stenting of the LCX with two bare metal stents 3.0 X 18 mm and 2.5 X 12 mm Vision stents in a non-overlapping fashion with no residual stenosis (see PTCA comments for detail). 2. Engagement of the proximal cap of the chronic total LAD occlusion with Shinobi wire. 3. RCA angiography showing two proximal and mid vessel 60% lesion an a distal pseudoaneurysm with possible dissection. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe systolic and diastolic ventricular dysfunction. 3. Cardiogenic shock requiring IABP support. 4. Successful stenting of the LCA with two bare metal stents ------- TTE [**3-30**] The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with inferolateral akinesis, as well as inferior and lateral hypokinesis (LCx distribution). The remaining segments exhibit compensatory hyperkinesis (LVEF = 35-40%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. There is a partial rupture of the posterolateral papillary muscle with associated eccentric, anteriorly-directed jet of severe (4+) mitral regurgitation. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD. Partial papillary muscle rupture with severe mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension ---------------- TTE [**3-31**] after surgery Prebypass: moderate global LV hypokinesis (30-35%), severe mitral regurgitation with eccentric jet, partial rupture of posteromedial papillary muscle and chordae tendinae, moderate 2+ tricuspid regurgitation. Right ventricular free wall appears normal. There is evidence mildly calcified aortic leaflets but no evidence of aortic stenosis. Descending and ascending aorta within NL limits. Postbypass: overall LV function globally depressed (30-35%). Minimal improvement compared to prebypass. Prosthetic mitral valve leaflets well positioned and adequate movement of the leaflets. . No appreciable mitral regurgitation. Moderate tricuspid regurgitation as seen in the prebypass period.. RV free wall unchanged and normal. Descending and ascending aorta within normal limits and without evidence of dissection. [**2151-4-3**] 09:24PM BLOOD WBC-7.5# RBC-1.14*# Hgb-3.5*# Hct-10.9*# MCV-96# MCH-30.7 MCHC-32.2 RDW-15.7* Plt Ct-29*# [**2151-4-3**] 09:24PM BLOOD Neuts-73.2* Bands-0 Lymphs-16.3* Monos-9.5 Eos-0.2 Baso-0.8 [**2151-4-3**] 09:24PM BLOOD Plt Ct-29*# [**2151-4-3**] 05:19AM BLOOD Glucose-142* UreaN-51* Creat-0.9 Na-146* K-3.9 Cl-113* HCO3-24 AnGap-13 [**2151-4-2**] 08:53AM BLOOD ALT-57* AST-53* LD(LDH)-714* AlkPhos-65 Amylase-264* TotBili-0.8 [**2151-4-2**] 08:53AM BLOOD Lipase-99* [**2151-3-31**] 03:30AM BLOOD CK-MB-76* MB Indx-13.9* cTropnT-8.97* [**2151-4-3**] 05:19AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.2 [**2151-3-30**] 03:02AM BLOOD %HbA1c-4.9 Brief Hospital Course: SUMMARY OSH AND CCU COURSE 77 y/o F with a history of type II diabetes, [**Month/Day/Year **], dyslipidemia, PMR with increasing fatigue since undergoing THR in 9/[**2150**]. Patient had complaints of increasing DOE and orthopnea 2 weeks prior to admission. She was only able to climb a few steps on the stairs before stopping for rest. 2 days PTA patient also complained of "chest congestion" and "indigestion", on the day of admission patient c/o of worsening chest congestion and dyspnea. Husband called 911 and on [**3-28**] she presented to [**Hospital 2079**] hospital ED, in the Southshore ED patient??????s ECG showed ST depressions in V2-V6 and isolated STE in AVR. Cardiac enzymes revealed tropT 0.37, CK 198 and MB 37. She was started on heparin gtt, integrillin, Plavix 300mg x1. She was also found to have pulmonary edema and was managed w/ BiPAP and diuresis. Next morning patient was evaluated by Cardiology and found to be hypotensive, with rising creatinine, poor UOP despite dieresis. Cardiac enzymes rising CK 198->431->951-> 5403, MB 37->86->192->915, Trop 0.37->0.95->1.46->17.16. She underwent cardiac cath at [**Hospital1 34**] which showed a totally occluded LAD, 90% occluded left circ, tortuous RCA with evidence of L->L collaterals as well as R->L collaterals to septum. IABP placed and patient was intubated, Patient was briefly in asystole by report but converted with CPR . Levophed was started via a peripheral IV. Stat ECHO showed moderate to severe MR and MR w/ apical and lateral HK., EF 40-45%. Patient was then transferred to [**Hospital1 18**]. Upon arrival to the CCU, patient is intubated and sedated with a high levophed requirement to maintain her pressures, ECG showed ST depressions in V3-4, TWI V5-6. She was taken emergently to the cardiac cath lab which showed 2 sequential 90% left circ lesions which were stented with 2 non overlapping BMS, no residual stenosis with TIMI 3 flow afterwards, pressor requirements decreased with improvement in MAP. Her totally occluded LAD was probed, were able to break the cap but the wire was not easily advanced confirming the chronicity.RCA angiography showed two proximal and mid vessel 60% lesions with ? of aneurysm vs. dissection and multiple septal collaterals to LAD. On return from cath lab pressor requirements were decreased and patient was diuresed, PEEP increased to [**Month (only) **]. preload( [**Month (only) **] venous return from inc. thoracic pressures) and afterload. Next morning TTE showed EF 35-40% with inferolateral akinesis in LCx distribution, found to have a partial rupture of the posterolateral papillary muscle with severe (4+) mitral regurgitation. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Patient taken to surgery this morning. Cardiac enzymes trending down (tn 24 to 15, ck 4000 to 1500, mb 500 to 200) # CAD/Ischemia: ECG w/ evidence of anterolateral ischemia. ? whether due to collaterals from circ vs. RCA. Substantial infarct w/ CK-MB of 960. Now s/p BMS x 2 to LCx and no intervention on RCA. Decreased pressor requirements post PCI. - cont asa, plavix - cont heparin gtt - high dose statin - cycling cardiac enzymes - IABP - discuss adding beta blocker . # Pump: EF 40-45% w/ apical lateral HK at OSH. Now in cardiogenic shock. Suspect worsening of EF. Elevated filling pressures on RHC w/ PCW of 30. - off levophed - cont IABP 1:1. Will add ace inhibitor once weaning - going for surgery this morning, held off further diuresis overnight - add beta blocker once off vasopressors - TTE in am. If significant anteroapical AK or severely depressed EF will consider continuation of heparin beyond 48 hours w/ transition to coumadin . # Rhythm: - atrial tachycardia likely secondary to ischemia and severe MR causing left atrial stretch, held on further diuresis - MVR this morning - on heparin gtt . # Resp: significant A-a gradient on initial ABG w/ pO2 122 on 100% FiO2. Improved with PEEP to 10mg which decreases preload and afterload - repeat ABG - weaned oxygen overnight - cont vent support on AC for now - tx for possible aspiration pna as below - diuresis as tolerated . # ARF: unknown baseline but labs at OSH w/ Cr 0.9->1.8. Likely [**3-6**] poor forward flow in the setting of cardiogenic shock. - creatinine trending down - BUN elevated, component secondary to steroids - if continues to worsen can consider urine lytes/eos . # ID: leukocytosis on OSH labs. Potentially secondary to stress demargination in the setting of significant MI. Must also consider aspiration event in the setting of cardiac arrest at OSH. CXR w/ possible infiltrate in RUL and RLL. - check sputum and urine cx's - blood cultures if spikes, afebrile - empirically cover for aspiration w/ levo/flagyl x 7 days as WBC count and fever will be difficult to interpret in the setting of stress dose steroids and large MI . # [**Month/Day (2) **]: hypotensive currently in cardiogenic shock. - holding home dose atenolol - stress dose steroids as below . # polymyalgia rheumatica: on prednisone daily at home but unknown dose. Cannot check [**Last Name (un) 104**] stim. - stress dose steroids with methylpred 40 mg IV Q8H, taper down - rapid taper w/ stabilization of BP . # DM: documented diet controlled DM although family denies. - HbA1C <5 - ISS . # FEN: NPO for now. Once stable will start TFs - [**Hospital1 **] lytes once diuresis begun . # Prophylaxis: heparin gtt. PPI IV. bowel regimen . # Code: FULL. Confirmed w/ HCP Underwent MVR/cabg x1 with Dr.[**Last Name (STitle) **] on [**3-31**]. Pt. already intubated and had IABP prior to OR. Transferred to the CVICU in fair condition on epinephrine, nitroglycerin, insulin and propofol drips. Abx continued for presumed pre-op PNA. ENT consulted for epistaxis. IABP removed and epinephrine drip weaned to off on POD #2. Amiodarone started for Afib. At 9PM on POD #3, she became acutely hypotensive and non-responsive. CPR started, and chest opened at the bedside. Moderate amount of blood around the heart noted.Open cardiac massage performed for asystole.Unable to pace the heart. No obvious sites of bleeding identified. Patient pronounced at 9:50 PM.Family notified. Permission for autopsy granted. Medications on Admission: atenolol 50 mg daily prednisone 5mg daily advil [**Hospital1 **] prn fosamax Qwk Discharge Disposition: Expired Discharge Diagnosis: CAD s/p MVR/cabg x1 cardiogenic shock acute MI ruptured papillary muscle with severe 4+ MR [**First Name (Titles) **] [**Last Name (Titles) **] A fib elev. lipids polymyalgia rheumatica DM Discharge Condition: expired Completed by:[**2151-6-24**]

[ "428.0", "427.31", "784.7", "272.0", "287.5", "401.9", "250.00", "785.51", "414.11", "V43.64", "998.11", "584.9", "725", "424.0", "997.1", "429.6", "428.31", "496", "410.71", "414.01" ]

icd9cm

[ [ [] ] ]

[ "00.66", "35.23", "96.72", "37.91", "89.60", "36.11", "37.23", "36.06", "00.40", "21.01", "39.61", "88.56", "00.46", "99.04", "97.44", "99.05" ]

icd9pcs

[ [ [] ] ]

13744, 13753

7354, 13612

343, 399

13986, 14024

4044, 4452

3282, 3320

13774, 13965

13638, 13721

4469, 7331

3335, 4025

281, 305

427, 2857

2879, 3067

3083, 3266

18,915

163,648

18745

Discharge summary

report

Admission Date: [**2176-8-13**] Discharge Date: [**2176-8-19**] Date of Birth: [**2176-8-13**] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 41776**] is a former 35 and [**2-6**] week male admitted for respiratory distress management. PRENATAL SCREENS: Mother is a 29 year old gravida III, para I-II with prenatal screens as follows: O positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, GBS unknown. Estimated date of confinement [**2176-9-16**]. History is notable for lupus, on Baby Aspirin until two weeks prior to delivery. Noted to have thrombocytopenia. The mother was on bedrest for the previous twelve weeks from delivery, known to have uterine thinning after previous cesarean section. Plan for repeat cesarean section on the morning of delivery due to risk for uterine rupture. The baby emerged vigorous with [**Name (NI) **] of eight at one minute and eight at five minutes, received blow by oxygen for central cyanosis, developed respiratory distress, grunting, flaring and retracting and was transferred to the Newborn Intensive Care Unit for further evaluation. PHYSICAL EXAMINATION: On admission, temperature was 98.7, heart rate 150, respiratory rate 40, main blood pressure 58, saturation greater than 95% with blow by oxygen. Anterior fontanelle soft and flat, no dysmorphism. Features consistent with 35 weeks despite LGA weight of 3340 grams which in the greater than 90th percentile, length 48 centimeters, greater than 50th percentile, head circumference 34.5, 75th to 90th percentile. Discharge weight 2990 grams. Bilateral breath sounds, coarse, with poor aeration and tachypnea and grunting, flaring and retracting. The heart rate was regular rate and rhythm without murmur. The abdomen was soft, nontender, three vessel cord, no hepatosplenomegaly. Genitourinary - appropriate for gestational age male. Hips stable. HOSPITAL COURSE: 1. Respiratory - The baby required intubation, received two doses of Surfactant and transitioned to CPAP by day of life two. His initial capillary blood gas on ventilatory settings of 25/6 times 25 greater than 35% was 7.23, 64, 28, minus 2. On day of life two, the infant transitioned from CPAP to nasal cannula oxygen and then by day of life four, he was in room air. He remained in room air with no further respiratory distress. Baseline respiratory rate was 40 to 60s. He has not exhibited any apnea or bradycardia of prematurity. 2. Cardiovascular - The baby has been cardiovascularly stable with no murmur. Baseline blood pressure 60 to 70s over 30 to 40s with mean in the 40 to 50s. 3. Fluids, electrolytes and nutrition - The baby initially had a peripheral intravenous started of D10W. His initial dextrose stick was 58. He has always been greater than 50 in his dextrose sticks. He was started on enteral feedings on day of life two once his respiratory status stabilized. He advanced to full feedings without difficulty. At the time of discharge, he is feeding Enfamil 20 ad lib, taking in greater than 100cc per kilogram per day. He is voiding and stooling. He had initial electrolytes on day of life one with sodium 140, potassium 4.3, chloride 105, CO2 22. 4. Gastrointestinal - The baby has had several bilirubin levels drawn. On day of life three, he was 9.3/0.3/9.0. On day of life five, 9.2/0.4/8.8. On day of life six prior to discharge, he was 10.0/0.4/8.6. He is voiding, looks slightly jaundiced and will be seeing his pediatrician in two days. He did not require any phototherapy. 5. Hematology - The baby did not require any blood products during this admission. Admission hematocrit was 43.5. 6. Infectious disease - At the time of admission because of his prematurity and respiratory distress, he had a blood culture and a complete blood count sent. His white blood cell count was 11.0 with 11 polys, 0 bands, 77 lymphocytes, platelet count 336,000, hematocrit 43.5. He was started on Ampicillin and Gentamicin at 48 hours. The baby was clinically well, and cultures remained negative and antibiotics were discontinued. He has not had any further issues of infection. 7. Neurology - The baby is appropriate for gestational age not requiring head ultrasound based on gestational age of greater than 32 weeks. 8. Sensory - Audiology hearing screen was performed with automated auditory brainstem responses and results were within normal limits. 9. Ophthalmology - Examination not indicated based on gestational age of greater than 32 weeks. 10. Psychosocial - Parents are in visiting daily, look forward to [**Known lastname **] transition home. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home with family. PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 1169**] [**Last Name (NamePattern1) **], telephone number [**Telephone/Fax (1) 51364**], fax [**Telephone/Fax (1) 51365**]. CARE RECOMMENDATIONS: 1. Continue ad lib feedings of Enfamil 20 with iron ad lib. 2. Medications - None at the time of discharge. 3. Car seat position screening passed prior to discharge. 4. State Newborn Screening sent on [**2176-8-18**], results pending. 5. Immunizations Received - None at the time of discharge. Parents would like to have first hepatitis B vaccine given in pediatrician's office after discharge. 6. Immunizations Recommended: Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: a. Born at less than 32 weeks. b. Born between 32 and 35 weeks with plans for Day Care during RSV season, with a smoker in the household or with preschool siblings. c. With chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. FOLLOW-UP APPOINTMENT: Primary pediatrician, Dr. [**First Name8 (NamePattern2) 1169**] [**Last Name (NamePattern1) **], on [**2176-8-21**]. DISCHARGE DIAGNOSES: 1. 35 and [**2-6**] week premature male. 2. Status post respiratory distress syndrome. 3. Status post rule out sepsis with antibiotics. 4. Large for gestational age. Of note, the father of the baby has malignant hyperthermia. [**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**] Dictated By:[**Last Name (NamePattern1) 36251**] MEDQUIST36 D: [**2176-8-19**] 17:25 T: [**2176-8-19**] 18:53 JOB#: [**Job Number 51366**]

[ "765.28", "V30.01", "V50.2", "769", "V29.0", "766.1", "782.4", "765.19", "V29.3" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "64.0", "96.71" ]

icd9pcs

[ [ [] ] ]

4768, 4969

6239, 6758

1999, 4710

4991, 5395

1230, 1982

5424, 6076

6100, 6218

173, 1207

4735, 4744

81,245

167,691

45609

Discharge summary

report

Admission Date: [**2200-7-28**] Discharge Date: [**2200-8-15**] Date of Birth: [**2132-7-30**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Erythromycin Base / Demerol Attending:[**First Name3 (LF) 6075**] Chief Complaint: abdominal pain, nausea/vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 67 yo woman with PMHx sig. for ovarian cancer, radiation enteritis, and frequent admissions for SBOs (last admission in early [**Month (only) 205**]) who presents for nausea/vomiting and abdominal pain for the past 24 hours. She notes her belly has been "gurgling" loudly for a few days prior to the onset of pain. he describes the pain at 8/10 in severity like a band across her mid-abdomen. It does not radiate. She reports that her diarrhea is slightly improved but still quite frequent at [**5-5**] BMs/day. The DTO has helped. She [**Month/Year (2) **] fevers or chills. She reports that her PO intake has been quite poor because when she eats she has either nausea, pain or diarrhea. She has continued to loose weight. She does not tolerate ensures/boost. These symptoms are the exact symptoms she gets with her previous SBOs. . In ED, vitals were 97.3 70 123/95 22 100% ra. KUB was non specific. Mg was 1.0. Patient given dilaudid 1mg IV x1, compazine 10mg IV x1, Mg 4g IV x1, and 1L of NS. On transfer from ED to floor, vitals were T 97.2 p 62 bp 163/96 rr 15 sa 02 98%. . On floor, patient was somnolent, but arousable and followed commands. She had a bowel movement on arrival to the floor. ROS: [**Month/Year (2) 4273**] [**Month/Year (2) **], chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - multiple admissions for partial SBO, usually managed conservatively, most recently [**2200-6-8**] - [**2200-6-15**] - multiple small bowel obstructions - Recent hip fracture [**1-28**] MSSA osteomyelitis on [**2200-3-31**], on daptomycin for 6 weeks, recently discharged from rehabilitation in early [**Month (only) **] -h/o MRSA bacteremia ([**4-4**]), ([**6-4**]), ([**11-4**]), complicated by L2-L3 discitis/osteomyelitis, failed 4 month course of vancomycin, resoved with surgical intervention with L2, L3 partial corpectomy/debridement on [**2199-11-19**] followed by 3 month course of vancomycin - C.diff colitis [**2200-4-7**], neg C.diff toxin [**2200-6-11**] -C.parapsilosis line-associated BSI ([**8-/2199**]) -P.vulgaris pyelonephritis w/ bilat hydronephrosis dx [**12/2199**], treated with meropenem-->ciproflox -Ovarian cancer: Dx in [**2175**], stage IV metastatic to liver, s/p TAH-BSO, adriamycin, and XRT -Chemotherapy-associated cardiomyopathy, last ECHO in [**11-4**] with EF of 50% -Iron deficiency anemia -Hyperlipidemia -Chronic kidney disease -Osteoporosis -Hypothyroidism -h/o RUE brachial thrombus, PICC associated, in [**2199-4-11**] -Depression -tonsillectomy, adenoidectomy -appendectomy Social History: Patient lives with her husband, has 2 grown sons, and 3 grandchildren. She was a nurse until 6 months ago. She is a remote smoker. No etoh, recreational drug use. Walks with a walker at baseline secondary to hip pain. Family History: Breast cancer in maternal grandmother. Prostate cancer in maternal grandfather. Physical Exam: VS - Temp 95.5 F, BP 138/90, HR 82, R 18, O2-sat 100% RA Gen: cachetic woman, NAD, does appear older than age HEENT: PERRLA, EOMI, MM slighty dry, sclera anicteric Neck: no cervical or supraclavicaluar LAD Cardiovascular: RRR, normal s1/s2, no murmurs, rubs, or gallops Respiratory: CTAB no w/r/c Abd: normal active bowel sounds, firm with voluntary guarding, diffusely tender, no rebound, non distended Extremities: No c/c/e, 2+ DP and radial pulses bilaterally Neurological: somnolent but arousable, CN II-XII intact, moving all extremities, will follow commands. Pertinent Results: [**2200-8-1**] 06:29AM BLOOD IgG-800 IgA-110 IgM-53 [**2200-8-9**] 02:36AM BLOOD Triglyc-131 HDL-35 CHOL/HD-3.5 LDLcalc-60 [**2200-8-9**] 02:36AM BLOOD %HbA1c-5.5 eAG-111 [**2200-8-14**] 05:27AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.2* [**2200-8-8**] 06:16PM BLOOD CK-MB-3 cTropnT-0.01 [**2200-8-3**] 01:31PM BLOOD ALT-8 AST-15 LD(LDH)-269* AlkPhos-121* TotBili-0.3 [**2200-8-15**] 05:07AM BLOOD Glucose-84 UreaN-12 Creat-1.5* Na-136 K-4.0 Cl-107 HCO3-22 AnGap-11 [**2200-8-13**] 05:01AM BLOOD Ret Aut-1.1* [**2200-8-15**] 05:07AM BLOOD PT-27.4* INR(PT)-2.7* [**2200-8-15**] 05:07AM BLOOD WBC-10.5 RBC-2.91* Hgb-8.4* Hct-25.9* MCV-89 MCH-28.9 MCHC-32.5 RDW-15.3 Plt Ct-545* IMAGING: EKG - NSR 60, nl axis and intervals. +PVC. LVH with reciprical changes in ST seg in V1, V4 & V5 c/w prior. KUB - [**2200-7-28**] - IMPRESSION: No evidence of intestinal obstruction or perforation. Repeat upright views recommended to exclude intramural gas in the upper abdomen. [**2200-8-8**] CTA Head and Neck 1. Well-defined defect in temporal branch of left MCA at M1-M2 junction, likely secondary to embolism or thrombus. There is distal reconstitution via collaterals. 2. Large area of ischemia with a small area of evolving infarct in the left MCA territory. 3. Stable enlarged left parotid gland. [**2200-8-9**] MRI Head FINDINGS: There are foci of restricted diffusion seen in the left basal ganglia and subinsular region extending to the periventricular white matter. Small foci of restricted diffusion are also seen in the left thalamus and left posterior temporal region. Mild periventricular changes of small vessel disease are seen. There is no evidence of midline shift, mass effect, or hydrocephalus. There is no evidence of acute or chronic blood products. IMPRESSION: Acute left-sided infarcts as described above, predominantly involving the left insular region and basal ganglia region. [**2200-8-11**] ECHO No evidence of a patent foramen ovale/atrial septal defect seen after intravenous injection of agitated saline at rest and with maneuvers. [**2200-8-11**] U/S Neck IMPRESSION: Limited internal jugular vein ultrasound demonstrates no thrombus bilaterally. Brief Hospital Course: 67 year-old female with ovarian cancer s/p chemoradiation, radiation enteritis c/b frequent SBOs admitted [**2200-7-28**] with abdominal pain. Hospital course complicated by sialadenitis and CVA. 1. Abdominal pain: The patient reported the symptoms were similar to her previous partial small bowel obstructions. No evidence of SBO. Symptoms improved rapidly with bowel rest, intravenous fluids, anti-emetics, and pain control. Abdominal pain recurred, with diarrhea, a few days into the hospital course; given history of C. difficile, she was treated empirically with vancomycin PO. Antibiotics stopped after C. difficile toxin returned negative. 2. Sialadenitis/neck cellulitis: The patient developed left neck swelling at the angle of the jaw and a surrounding erythema of the skin. Ultrasound showed sialadenitis. The swelling tenderness and cellulitis initially improved with intravenous vancomycin and metronidazole, but acutely worsened on hospital day 8. CT neck was without evidence of abscess or obstructing stone. ENT was consulted, and recommended broadening coverage with ciprofloxacin and frequent use of sialogogues. Infection subsequently improved. As directed by infectious disease consult service, she was discharged with additional 7 days of therapy on levofloxacin and flagyl until [**2200-8-22**]. 3. Acute ischemic stroke: On hospital day 11 patient was found unresponsive with stable vital signs. She was mute and had gaze deviation to the left. A code stroke was called. Emergent CT scan revealed left MCA occlusion. Symptoms improved prior to administration of tPA. She was transferred to the ICU for further management. In the ICU patient was stable, and pressures were allowed to autoregulate. MRI was done which showed acute infarcts in the left temporal, left insular, and left thalamus. Exam was significantly improved and she was transferred to the floor. On the floor she was started on Coumadin, with INR's difficult to regulate likely due to drug-drug interactions with Flagyl. 4. History of right septic hip: Prior to hospitalization patient was planned for THR. Given antibiotic initiation for above infection could affect hip aspirate results, the orthopedic team requested aspiration of the hip under flouroscopic guidance prior to initiation of antibiotics. This was done on [**2200-7-31**] and revealed no growth. She should follow up with Dr. [**Last Name (STitle) 1005**] in the next 3-4 weeks for further management. 5. Acute on chronic renal failure: The patient's Cr increased to 1.7 with pre-renal labs and history. It returned to her baseline of 1.3-1.4 with intravenous hydration. 6. Anemia: She received 2 units of PRBC during this admission given fatigue. Please consider colonoscopy or EGD for further evaluation. Despite her anemia she had a retic count of 1.1. Contact: Dr. [**Known lastname 97260**] ([**Telephone/Fax (1) 97272**] Medications on Admission: 1. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for perineal pruritis. 2. Butorphanol Tartrate 10 mg/mL Spray, Non-Aerosol Sig: [**1-30**] spray Nasal every four (4) hours as needed for pain. 3. Sertraline 100 mg Tablet Sig: 1.5 Tablets PO once a day. 4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO once a day. 5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day as needed for leg swelling. - not taking recently 7. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO q3h as needed for pain. 9. Opium Tincture 10 mg/mL Tincture Sig: One (1) drop PO once a day as needed for diarrhea. Discharge Medications: 1. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 3. Sodium Chloride 0.9 % 0.9 % Solution Sig: Ten (10) ML Injection PRN (as needed) as needed for line flush: Flush with 10mL daily and PRN per lumen. Disp:*300 ML* Refills:*2* 4. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for perineal pruritis. Disp:*1 tube* Refills:*2* 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: [**Month (only) 116**] cause drowsiness. Do not drive when taking this medication. Disp:*20 Tablet(s)* Refills:*0* 7. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 8. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for Nausea. Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0* 9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: Abdominal pain Acute kidney injury on chronic kidney disease Sialadenitis Acute ischemic stroke (left middle cerebral artery) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Neuro: no focal deficits Discharge Instructions: You were admitted to [**Hospital1 69**] on [**2200-7-28**] with abdominal pain, nausea, vomiting, and dehydration. You improved with intravenous fluids and resting your stomach. Your symptoms may be due to intermittent small bowel obstruction. You also recieved a blood transfusion to help your fatigue. During the hospital stay you developed sialadenitis/parotitis, which is an infection of the glands in your face. You were treated with 3 antibiotics for this. You will also need to see an infectious disease doctor. On your expected day of discharge you developed symptoms of a stroke with weakness, and inability to speak. An MRI showed a bloickage in one of the main arteries supplying the left side of your brain, however you quickly recovered. You likely had a small clot which passed on its own and was dissolved. We made the following changes to your medications: We started you on Coumadin to prevent further clots, you should not take this medicine on your day of discharge [**8-15**] due to an INR of 2.7 (your goal is [**1-29**]), but it has been rising quickly. You will take 2mg as prescribed starting on [**8-16**]. Followup Instructions: You have an appointment to receive hip XRays [**Month/Year (2) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2200-8-19**] 9:25 You have an appointment with an Orthopaedic Surgeon [**Name6 (MD) **] [**Name8 (MD) 2229**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2200-8-19**] 9:45 You have an appointment with an ENT Doctor [**Last Name (Titles) **], [**First Name7 (NamePattern1) 10827**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Doctor Last Name **] & [**Doctor Last Name 3880**] LLC/ ENT Address: [**Location (un) 3881**], [**Apartment Address(1) 3882**], [**Location (un) **],[**Numeric Identifier 3883**] Phone: [**Telephone/Fax (1) 2349**] Appointment: [**Last Name (LF) 2974**], [**2201-8-22**]:45 *Please arrive by 11:15* You have an Appointment with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3649**] on [**8-25**] at 2:00 [**Telephone/Fax (1) 3070**] You have an appointment with an Infectious Disease [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 97273**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2200-8-29**] 12:00 You have an appointment with a Stroke Neurologist Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**] on [**2200-9-23**] at 3:30. Phone [**Telephone/Fax (1) 1694**]

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icd9cm

[ [ [] ] ]

[ "38.93", "81.91" ]

icd9pcs

[ [ [] ] ]

11673, 11692

6185, 9112

335, 342

11862, 11862

3994, 6162

13235, 14604

3309, 3390

10005, 11650

11713, 11841

9138, 9982

12071, 12923

3405, 3975

12952, 13212

264, 297

370, 1816

11877, 12047

1838, 3058

3074, 3293

4,499

120,260

25173+25174

Discharge summary

report+report

Admission Date: [**2197-9-18**] Discharge Date: [**2197-9-27**] Date of Birth: [**2121-4-6**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 3223**] Chief Complaint: Upper respiratory tract obstruction (foreign body) Cardio resp. arrest / ressucitation Abdominal distension Major Surgical or Invasive Procedure: 1. Esophagogastroduodenoscopy. 2. Exploratory laparotomy. 3. Debridement and closure of gastric perforation History of Present Illness: 78-year-old woman who was observed to choke on her food. Multiple attempts at the Heimlich maneuver were attempted. The patient then became apneic and went in cardiorespiratory arrest. Closed chest cardiac massage and mouth to mouth assisted breathing were initiated. A piece of meat could be extracted by hand from her upper respiratory tract. Ressucitation manoeuvers were succesful and patient was transferred to the ED at [**Hospital1 18**] where she presented with a distended abdomen and abdominal pain. A chest x-ray showed a very large amount of free air under the diaphragm. There was no indication of mediastinal air at all. The patient was taken emergently to the OR for explorative laparotomy. Past Medical History: Hypertension, depression, hiatal hernia S/p appendectomy Social History: OH: moderate consumption Family History: Noncontributory Physical Exam: Vitals: 36.1, 65, 119/61, 24, 92% (RA) General: no apparent distress Neck: supple Lungs: clear to ascultation bilaterally Heart: normal S1S2, regular rate and rhythum Abdomen: soft, grossly distended, nonlocalized tenderness, no hernias, prior appendectomy incision on the right Extremities: no clubbing, cyanosis or edema Neurologic: alert and oriented X3, no focal deficits On discharge: Alert, oriented, NAD; slightly depressed mood; 99.3 63 116/84 18 97 2L CTA bilat RRR, no abnormal sound or murmur [**Last Name (un) **] soft, non tender, non distended Wound: dry, clean, no drainage Extremities normotherm, no cyanosis, no clubbing Neuro: no focal deficit Pertinent Results: [**2197-9-21**] 06:02AM BLOOD WBC-12.2* RBC-2.68* Hgb-8.8* Hct-25.8* MCV-96 MCH-32.6* MCHC-34.0 RDW-13.8 Plt Ct-215 [**2197-9-21**] 06:02AM BLOOD PT-14.5* PTT-34.4 INR(PT)-1.4 [**2197-9-21**] 06:02AM BLOOD K-3.4 [**2197-9-25**] 06:05AM BLOOD K-4.3 [**2197-9-25**] 06:05AM BLOOD Mg-1.8 Brief Hospital Course: The patient was admitted on [**2197-9-18**] for an emergent esophagogastroduodenoscopy, exploratory laparotomy, and debridement and closure of gastric perforation. The operation went well with no complications. She was admitted to the surgical intensive care unit postoperatively as she was difficult to wean from extubation. She was sedated on a propofol drip. She was started on Vancomycin, Levofloxacin, Flagyl, and Diflucan for broad spectrum empiric coverage. Her pain was well controlled with Morphine. She was afebrile with stable vital signs and was extubated without incident on POD0. The cardiology team evaluated the patient for assymptomatic, hemodynamically stable bradycardia and agreed to start low dose Metoprolol for blood pressure control in spite of the bradycardia. On POD1, Vancomycin was discontinued. She was transferred to the floor. Her nasogastric tube was putting out minimal drainage. On POD2, her central venous line was discontinued. She ambulated without issues. On POD3, her NG tube was removed. Physical therapy was initiated for mobility and balance training. On POD4, she was started on sips of thick clears. Home medications were resumed. Her IV fluids were discontinued. On POD6, antibiotics were discontinued (total 7-day course). As the patient's history reveals three episodes of difficult swallowing in less than 2 weeks prior to the event, a bed-side swallow evaluation was ordered and demonstrated oral/pharyngeal/esophageal dysphagia. Her diet was advanced to thin liquids w/ ground solids. On POD7, a brain MRI was normal, excluding prior CVAs. A video swallow showed slight tongue weakness and esophageal motility dysfunction with abnormal emptying and tertiary contractions. The GI consultant/Dr [**Last Name (STitle) **] recommended to continue the Protonix treatment and potentially perform an EGD once the surgical wound has healed. Patient's diet was changed to regular w/ soft consistency and thin liquids. Patient is discharged on POD8 to a rehabilitation center for mobilization/physical therapy in good condition, afebrile. She will be follwe up by Dr [**Last Name (STitle) 519**] on [**2197-10-9**] and further GI follow up will be organized then. Medications on Admission: Lisinopril 20', norvasc 10', lexapro 40', trazodone Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours). 2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as needed. 8. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 3765**] - [**Location (un) 1514**] Discharge Diagnosis: Gastric perforation S/p foreign body obstruction of the upper resp. tract, cardiorespiratory arrest, Heimlich and ressucitation manoeuvers Discharge Condition: Good Discharge Instructions: Please consult the emergency room in case of fevers (>101.4), nausea, vomiting, abdominal pain, or redness, swelling or draiange at wound site. Take pain medication as needed for pain. Do not drive while taking narcotic medication! Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) 519**] on Monday [**2197-10-9**] at 10.00 AM. His office is located in [**Hospital Ward Name 23**] building, floor 3 ([**Telephone/Fax (1) 6554**]). Dr.[**Name (NI) 1745**] office will then organize your GI follow up with Dr [**Last Name (STitle) 3271**]. Please also schedule an appointment with your PCP [**Name Initial (PRE) 176**] 2 weeks of your discharge from the hospital. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2197-9-27**] Admission Date: [**2197-9-18**] Discharge Date: [**2197-9-27**] Date of Birth: [**2121-4-6**] Sex: F Service: [**Last Name (un) **] ADDENDUM: This is an addendum to the previously dictated discharge summary for the above-mentioned dates of admission. I would note that the patient was found to have a persistent bibasilar infiltrate on her chest films. She was treated with 1 week of broad-spectrum antibiotics for a presumed aspiration pneumonia related to her original esophageal obstruction. Therefore, please add to the discharged diagnoses aspiration pneumonia. [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**] Dictated By:[**Last Name (NamePattern4) 17555**] MEDQUIST36 D: [**2197-11-17**] 21:51:25 T: [**2197-11-18**] 14:28:33 Job#: [**Job Number 63107**]

[ "787.2", "998.2", "863.0", "997.1", "427.89", "401.9", "E915", "934.9", "507.0" ]

icd9cm

[ [ [] ] ]

[ "44.61", "45.13" ]

icd9pcs

[ [ [] ] ]

6025, 6099

2393, 4611

378, 490

6282, 6289

2083, 2370

6570, 8039

1363, 1380

4713, 6002

6120, 6261

4637, 4690

6313, 6547

1395, 1772

1786, 2064

231, 340

518, 1225

1247, 1305

1321, 1347

3,683

109,908

20568+20569+57178

Discharge summary

report+report+addendum

Admission Date: [**2102-4-4**] Discharge Date: [**2102-4-17**] Date of Birth: [**2055-6-22**] Sex: M Service: OME The patient's date of discharge is pending. This dictation covers the hospital course from admission, [**2102-4-4**] until [**2102-4-17**]. The remainder of the hospital course will be dictated by the next intern taking over care for this patient. CHIEF COMPLAINT: AML with increased blasts on a CBC. HISTORY OF PRESENT ILLNESS: This is a 46 year old male who developed dyspnea on exertion, palpitations and left abdominal pain and was diagnosed with pancytopenia in [**2100-11-17**]. Bone marrow aspirate was consistent with myelodysplastic syndrome, MDS. He was started on Procrit at the time and Aranesp and treated with arsenic which was discontinued in [**2101-9-17**]. White blood cell count increased to 300,000 with 87 percent myeloblasts and he was treated with leukophoresis followed by induction chemotherapy 7 Plus 3, in [**2102-1-16**], without infectious complications. A repeat bone marrow biopsy on [**2101-2-8**], showed hypercellular marrow with myeloid maturation and diffuse reticular fibrosis. He was given another course of chemotherapy in [**2102-2-16**], and went home on [**2102-3-6**]. He received platelets and blood transfusions during this time. On [**2102-4-3**], he saw Dr. [**Last Name (STitle) **] in Clinic where he was noted to have increasing blast count. He was asked to come into the hospital for admission of chemotherapy. His appetite has been good and he has had improving energy recently. He denies fevers, chills, nausea, vomiting, shortness of breath, cough, chest pain, diarrhea or dysuria and his weight has increased by five pounds in the past week. PAST MEDICAL HISTORY: AML as described above with induction chemotherapy 7 plus 3 in [**2102-1-16**]. Vocal cord polyps removed in [**2077**]. History of optic disc elevation, right greater than left. MEDICATIONS: 1. Valtrex one gram q. Day. 2. Diflucan 100 mg p.o. q. Day. 3. Ciprofloxacin 500 mg p.o. q. Day. 4. Neupogen. 5. Neumega 7 cc subcutaneously q. Day. 6. Procrit subcutaneously weekly. ALLERGIES: No known drug allergies. FAMILY HISTORY: Father with alcoholic cirrhosis. No history of malignancy. SOCIAL HISTORY: He is married and lives with his wife in [**Name (NI) 1727**]. Quit alcohol at 28 years old. Quit tobacco approximately five months ago. Quit marijuana approximately one year ago. Exposure to barium and lead in the past. PHYSICAL EXAMINATION: In general, well dressed, well nourished man in no apparent distress appearing slightly fatigued. Vital signs are temperature of 98.3 F.; heart rate 95; blood pressure 160/80; respiratory rate 20; saturation of 100 percent on room air. HEENT: Pupils equal, round and reactive to light. Extraocular muscles intact. Oropharynx is clear. Chest is clear to auscultation bilaterally with no wheezes, rales or rhonchi. Heart is regular rate and rhythm, normal S1, S2, II/VI systolic murmur, question flow murmur. Abdomen soft, nontender, nondistended, positive bowel sounds, positive hepatosplenomegaly. Extremities with no clubbing, cyanosis; one plus pitting edema bilateral lower extremities. Neurological: Five out of five strength in all extremities. Cranial nerves II through XII intact. Back tender over the bone marrow biopsy sites. No hematoma. PERTINENT LABORATORY DATA: Hematocrit is 24.0; white blood cell count is 4.7 with 51 percent polys, 2 bands, 34 lymphs, 19 monos, one eo, 29 percent blasts. Platelets of 195. INR is 1.3, fibrinogen 297, LDH 393, uric acid 6.8, creatinine 0.8, potassium 3.9, ANC is 959, ALT 73, AST 30, alkaline phosphatase 86. HOSPITAL COURSE: 1. ONCOLOGY: The patient presented with AML with increasing blasts on smear. The patient underwent chemotherapy with the FLAG protocol, which included Fludarabine, Ara-C and GCSF. The patient had an echocardiogram on presentation which was normal. He had an uncomplicated course during his hospitalization stay. He got GCSF continual and his hematocrit continued to drop during the hospitalization course. 2. HEMATOLOGY: The patient's transfusion hematocrit threshold was 25.0. He was given blood transfusions in- house to maintain a hematocrit of greater than 25 as well as platelet transfusions to be greater than 10. He had an episode where he required steroids, Decadron times one, prior to platelet transfusion as this had been occurring during his previous hospitalization stay at an outside hospital. 3. INFECTIOUS DISEASE: The patient was maintained on Bactrim, Diflucan and Acyclovir for prophylaxis. Levaquin was added once his ANC was less than 500. 4. DIET, FLUID, ELECTROLYTES AND NUTRITION: The patient was maintained on a neutropenic diet. When counts decreased, then he was maintained on intravenous fluids. Once his hydration reached an equilibrium after chemotherapy, he was switched to KVO during the day and maintenance fluids at night times one liter. 5. ACCESS: The patient had a left Portacath already in place on admission. He received a right triple lumen catheter at the Interventional Radiology in the right subclavian. He had some pain associated at the site and got Oxycodone as needed. 6. VERTIGO: The patient experienced a one time episode of vertigo while getting blood and while getting high dose ARA-C. Otoscopic examination was unremarkable. He had an MRI with gadolinium which was negative for any abnormalities except for mastoid and sphenoid fluid. Vertigo resolved. 7. OPHTHALMOLOGY: The patient had a history of a visual field cut defect and optic disc swelling right greater than left. The patient had Ophthalmology consulted in- house. They recommended an orbital MRI to rule out leukemic infiltrate. The patient had a fine cut MRI of the orbits which was negative for a leukemic infiltrate or mass effect. Followup of a lumbar puncture that was performed in the patient prior to admission was obtained from the outside hospital and was negative for malignant cells or any infectious process. The remainder of the [**Hospital 228**] hospital course will be dictated in a future discharge addendum summary by the next intern taking care of this patient. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 55010**] Dictated By:[**Last Name (NamePattern1) 12481**] MEDQUIST36 D: [**2102-4-17**] 14:31:07 T: [**2102-4-17**] 19:02:19 Job#: [**Job Number **] Admission Date: [**2102-4-4**] Discharge Date: Date of Birth: [**2055-6-22**] Sex: M Service: OME The patient's date of discharge is pending. This dictation covers the hospital course from admission, [**2102-4-4**] until [**2102-4-17**]. The remainder of the hospital course will be dictated by the next intern taking over care for this patient. CHIEF COMPLAINT: AML with increased blasts on a CBC. HISTORY OF PRESENT ILLNESS: This is a 46 year old male who developed dyspnea on exertion, palpitations and left abdominal pain and was diagnosed with pancytopenia in [**2100-11-17**]. Bone marrow aspirate was consistent with myelodysplastic syndrome, MDS. He was started on Procrit at the time and Aranesp and treated with arsenic which was discontinued in [**2101-9-17**]. White blood cell count increased to 300,000 with 87 percent myeloblasts and he was treated with leukophoresis followed by induction chemotherapy 7 Plus 3, in [**2102-1-16**], without infectious complications. A repeat bone marrow biopsy on [**2101-2-8**], showed hypercellular marrow with myeloid maturation and diffuse reticular fibrosis. He was given another course of chemotherapy in [**2102-2-16**], and went home on [**2102-3-6**]. He received platelets and blood transfusions during this time. On [**2102-4-3**], he saw Dr. [**Last Name (STitle) **] in Clinic where he was noted to have increasing blast count. He was asked to come into the hospital for admission of chemotherapy. His appetite has been good and he has had improving energy recently. He denies fevers, chills, nausea, vomiting, shortness of breath, cough, chest pain, diarrhea or dysuria and his weight has increased by five pounds in the past week. PAST MEDICAL HISTORY: AML as described above with induction chemotherapy 7 plus 3 in [**2102-1-16**]. Vocal cord polyps removed in [**2077**]. History of optic disc elevation, right greater than left. MEDICATIONS: 1. Valtrex one gram q. Day. 2. Diflucan 100 mg p.o. q. Day. 3. Ciprofloxacin 500 mg p.o. q. Day. 4. Neupogen. 5. Neumega 7 cc subcutaneously q. Day. 6. Procrit subcutaneously weekly. ALLERGIES: No known drug allergies. FAMILY HISTORY: Father with alcoholic cirrhosis. No history of malignancy. SOCIAL HISTORY: He is married and lives with his wife in [**Name (NI) 1727**]. Quit alcohol at 28 years old. Quit tobacco approximately five months ago. Quit marijuana approximately one year ago. Exposure to barium and lead in the past. PHYSICAL EXAMINATION: In general, well dressed, well nourished man in no apparent distress appearing slightly fatigued. Vital signs are temperature of 98.3 F.; heart rate 95; blood pressure 160/80; respiratory rate 20; saturation of 100 percent on room air. HEENT: Pupils equal, round and reactive to light. Extraocular muscles intact. Oropharynx is clear. Chest is clear to auscultation bilaterally with no wheezes, rales or rhonchi. Heart is regular rate and rhythm, normal S1, S2, II/VI systolic murmur, question flow murmur. Abdomen soft, nontender, nondistended, positive bowel sounds, positive hepatosplenomegaly. Extremities with no clubbing, cyanosis; one plus pitting edema bilateral lower extremities. Neurological: Five out of five strength in all extremities. Cranial nerves II through XII intact. Back tender over the bone marrow biopsy sites. No hematoma. PERTINENT LABORATORY DATA: Hematocrit is 24.0; white blood cell count is 4.7 with 51 percent polys, 2 bands, 34 lymphs, 19 monos, one eo, 29 percent blasts. Platelets of 195. INR is 1.3, fibrinogen 297, LDH 393, uric acid 6.8, creatinine 0.8, potassium 3.9, ANC is 959, ALT 73, AST 30, alkaline phosphatase 86. HOSPITAL COURSE: 1. ONCOLOGY: The patient presented with AML with increasing blasts on smear. The patient underwent chemotherapy with the FLAG protocol, which included Fludarabine, Ara-C and GCSF. The patient had an echocardiogram on presentation which was normal. He had an uncomplicated course during his hospitalization stay. He got GCSF continual and his hematocrit continued to drop during the hospitalization course. 2. HEMATOLOGY: The patient's transfusion hematocrit threshold was 25.0. He was given blood transfusions in- house to maintain a hematocrit of greater than 25 as well as platelet transfusions to be greater than 10. He had an episode where he required steroids, Decadron times one, prior to platelet transfusion as this had been occurring during his previous hospitalization stay at an outside hospital. 3. INFECTIOUS DISEASE: The patient was maintained on Bactrim, Diflucan and Acyclovir for prophylaxis. Levaquin was added once his ANC was less than 500. 4. DIET, FLUID, ELECTROLYTES AND NUTRITION: The patient was maintained on a neutropenic diet. When counts decreased, then he was maintained on intravenous fluids. Once his hydration reached an equilibrium after chemotherapy, he was switched to KVO during the day and maintenance fluids at night times one liter. 5. ACCESS: The patient had a left Portacath already in place on admission. He received a right triple lumen catheter at the Interventional Radiology in the right subclavian. He had some pain associated at the site and got Oxycodone as needed. 6. VERTIGO: The patient experienced a one time episode of vertigo while getting blood and while getting high dose ARA-C. Otoscopic examination was unremarkable. He had an MRI with gadolinium which was negative for any abnormalities except for mastoid and sphenoid fluid. Vertigo resolved. 7. OPHTHALMOLOGY: The patient had a history of a visual field cut defect and optic disc swelling right greater than left. The patient had Ophthalmology consulted in- house. They recommended an orbital MRI to rule out leukemic infiltrate. The patient had a fine cut MRI of the orbits which was negative for a leukemic infiltrate or mass effect. Followup of a lumbar puncture that was performed in the patient prior to admission was obtained from the outside hospital and was negative for malignant cells or any infectious process. The remainder of the [**Hospital 228**] hospital course will be dictated in a future discharge addendum summary by the next intern taking care of this patient. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 55010**] Dictated By:[**Last Name (NamePattern1) 12481**] MEDQUIST36 D: [**2102-4-17**] 14:31:07 T: [**2102-4-17**] 19:02:19 Job#: [**Job Number **] Name: [**Known lastname 10302**],[**Known firstname 651**] Unit No: [**Numeric Identifier 10303**] Admission Date: [**2102-4-4**] Discharge Date: [**2102-8-12**] Date of Birth: [**2055-6-22**] Sex: M Service: OMED Allergies: Cefepime Attending:[**First Name3 (LF) 2083**] Chief Complaint: M7 AML Major Surgical or Invasive Procedure: 1. Bone marrow biopsies [**2102-4-3**] & [**2102-5-3**] 2. Chest tube placement [**2102-5-5**] 3. VATS [**2102-5-5**] 4. Pericardiocentesis [**2102-7-27**] Brief Hospital Course: BRIEF SUMMARY: Mr. [**Known lastname **] is a 46yo male with M7 AML, refractory to induction w/ 7+3, then MEC, then FLAG. Developed fever and pulm infiltrate in weeks prior to transplant, s/p nondiagnostic VATS. Eventually defervesced on Ambisome, Imipenem and Voriconazole. s/p matched unrelated allo transplant [**2102-5-29**] due to escalating blasts after conditioning w/ Cytoxan/Busulfan. Post transplant course complicated by febrile neutropenia, respiratory failure requiring intubation, [**Last Name (un) 6169**]-occlusive disease w/ hepatic failure, acute renal failure, graft vs. host disease, seizures, small intracranial hemorrhage, transient episode of bradycardia/asystole of unclear etiology, and pericardial effusion. Slowly recovered after extubation on [**6-28**] with mild residual confusion/delerium, stable [**Last Name (un) 6169**]-occlusive disease, recovery of renal function. Pt continued to improve until discharge on [**2102-8-12**]. DETAILED HOSPITAL COURSE: 1. ONCOLOGY: Mr. [**Known lastname **] presented with AML with increasing blasts on smear. The patient underwent chemotherapy with the FLAG protocol, which included Fludarabine, Ara-C and GCSF. Pt had a normal echocardiogram on presentation. He remained neutropenic and pancytopenic on day 15 after therapy, and prophylactic antibiotics were started (Levaquin). He was also given G-CSF, however he remained pancytopenic. He was given multiple PRBC and platelet transfusions. A repeat bone marrow biopsy was performed on [**5-3**] that showed markedly hypocellular marrow with increased lymphocytes, plasma cells, and with background eosinophilic debris. Obvious leukemic infiltration was not present, however in the absence of a cellular marrow smear it is difficult to ascertain complete absence of myeloblasts. The patient's originaly scheduled MUD-BMT for [**5-7**] was postponed secondary to the ID issues outlined below, and due to the non-diagnostic bone marrow biopsy. His ANC trended up to 350 by [**5-9**], and 750 by [**5-12**], which was unfortunately due to increasing blasts to 37, and relapsed AML. However, his blasts gradually began to decrease again and were stable at <10, with platelet counts in the 50s, and it was decided to proceed to MUD transplant. He had a line placed on [**5-19**] for initiation of the preparatory regimen with busulfan/cytoxan, started on [**5-23**], which he tolerated well with mild nausea and some diarrhea. He started cyclosporine infusion [**5-29**] for GVHD prophylaxis, and stem cell infusion began [**5-30**]. Methotrexate was not started secondary to his pleural effusion, which drained 700cc of bloody fluid on thoracentesis on [**6-22**]. Concurrent with the start of chemotherapy, Mr. [**Known lastname 10304**] ANC decreased from a peak of 720 on [**5-28**] to zero on [**6-5**]. It rose again from 250 to 1100 on [**6-13**], and has been > 1000 since. Bactrim was d/c'd [**6-22**] for falling ANC to 840, and restarted in [**Month (only) 4278**] once ANC was consistently >1000. Pt's course was complicated by several problems outline below, including graft vs. host disease and cyclosporine toxicity (see below). Pt was transferred from the ICU to the Bone Marrow Transplant service on [**7-11**]. His GVHD was ultimately controlled on steroids and cyclosporin, which was gradually increased to maintain a serum level between 450-500. Discharge cyclosporin dose was 324gms/day on 25mg Prednisone [**Hospital1 **] to prevent GVHD. 2. HEMATOLOGY: The patient's transfusion hematocrit threshold was 25.0. He was given blood transfusions in-house to maintain a hematocrit of greater than 25 as well as platelet transfusions to be greater than 10. He had an episode where he required steroids, Decadron times one, prior to platelet transfusion as this had been occurring during his previous hospitalization stay at an outside hospital. While in the ICU, his platelets were persistently low. There were no schistocytes on a smear, and a HIT ab was negative. His low platelets could be secondary to splenomegaly. 3. INFECTIOUS DISEASE: The patient was intially started on Bactrim, Diflucan and Acyclovir for prophylaxis. Levaquin was added once his ANC was less than 500. On [**2102-4-24**] the patient spiked to 102.4 and Cefepime was added. He had been complaining of some left ear pain and sore throat at the time, as well as a productive cough. A CT of the sinuses on [**4-26**] did not demonstrate sinusitis, but did show 2 nodular opacities in the L lung apex. A CT of the chest on [**4-26**] showed several ill-defined nodules in both upper lobes, mostly centrally located, with a single ill-defined nodule in the RML. Ambisome was started on [**4-27**] for presumed pulmonary aspergillosis. Additionally, he continued to spike and was found to have [**12-25**] blood culture bottles positive for diphtheroids on [**4-24**], sensitive to vancomycin. Vancomycin and flagyl were added to the regimen on [**4-27**]. He was seen by ID on [**4-28**], who recommended discontinuing the fluconazole. A repeat CT scan on [**4-30**] showed worsening of the lung lesions, and ID recommended discontinuing flagyl and cefepime, and starting meropenem, in addition to a pulmonary consult. Meropenem was changed to imipenem on [**5-1**] for better [**Month/Year (2) 10305**] coverage. Additionally, his R IJ TLC had become edematous, warm, and tender, and was taken out [**2102-5-1**] - cultures of the tip were negative, and his L subclavian portacath was removed [**2102-5-2**] also because of concerns for infection. He had a BAL on [**5-1**] which was negative for PCP, [**Name10 (NameIs) 10305**], fungus, AFB. A CT scan on [**5-3**] showed rapid progression of bilateral nodular masses which were then quite extensive in the upper lobes, L>R, as well as interval increase in small bilateral pleural effusions, and thus voriconazole was added to the antibiotic regimen. Galactomannin on [**4-27**] was negative. The patient had a VATS on [**5-5**], the biopsy of which showed patchy acute and organizing pneumonitis with patchy accumulation of intraalveolar macrophages and fibrin, without evidence of malignancy, viral inclusions, or granuloma. Gram's stain, GMS, and AFB were all negative. He had a L chest tube in place for 24 hours after the procedure. He continued to spike fevers up to 102, and had a repeat chest CT scan on [**5-10**] that showed continued increase in the size of the bilateral consolidations most prominent in the upper lobes, which was felt to be most consistent with continued progression of an infectious process such as aspergillus, [**Month/Year (2) 10305**], or PCP. [**Name10 (NameIs) **] was also a slight interval increase in size of the L pleural effusion, which then appeared partially loculated, and the patient clinically worsened with new O2 requirement. Atrovent NEBs were started for wheezing. He temporarily improved, with decreased O2 requirement, but continued to have a productive cough. His sputum cultures were persistently negative. PFTs on [**5-10**] demonstrated a mild restrictive ventilatory defect with reduced diffusing capacity suggestive of an interstitial process. Vancomycin was discontinued on [**5-17**], as the patient had been adequately treated for his corynebacterium bacteremia (>14 days). On [**5-16**] the patient developed orthopnea. A repeat CXR showed worsening of the L pleural effusion with LLL consolidation and RLL consolidation. A repeat CT scan on [**5-21**] showed interval decrease in size of the bilateral consolidations most prominently seen in the upper lobes, with interval increase in size of left sided pleural effusion, with interval resolution of the small right sided pleural effusion. Symptomatically, however, he had improved, and was up walking around in the hallways, without O2 requirement. He had a diagnostic and therapeutic thoracentesis on [**5-23**] that did not show any organisms. His fever curve trended down on [**5-10**], and he was afebrile through his reinfusion on [**5-30**]. On [**6-2**] there was noted to be some erythema surrounding his TLC, therefore vancomycin was added. On [**6-4**] (day 5 s/p MUD) the patient spiked a fever of 103 and flagyl was added for presumed C. Diff. A CT of the sinuses was repeated, which demonstrated new opacification of the posterior left sphenoid sinus, which appeared consistent with mucosal thickening. A CT of the chest/abd/pelvis at the same time showed persistent multifocal pulmonary opacities, most extensive in the upper lobes, slight decrease in the size of left pleural effusion, with persistent loculation in the upper left hemithorax, hepatosplenomegaly, and no evidence of colitis or enteritis. Levofloxacin was added at this time. The patient spiked up to 104.5 on [**6-5**] with rigors, at which time cefepime was also added and imipenem discontinued as it was thought he may have developed imipenem resistant organisms. The patient was then on ambisome, cefepime, acyclovir, vancomycin, flagyl, and levaquin. A nasal swab at this time was negative for parainfluenza, adenovirus, RSV. A sputum gram stain on [**6-6**] demonstrated gram positive cocci in pairs and clusters, however he was already on vancomycin. The patient was transferred to the ICU on [**6-9**] secondary to hypotension requiring pressor support, which was weaned off within 24 hours. However, on [**6-12**] Mr. [**Known lastname 10304**] temp increased to 101.7 and he again became hypotensive requiring pressors. At this time he was on Meropenem (no imipenem secondary to concern for seizure potential), levaquin, flagyl, ambisome, and vancomycin. IV Bactrim was started on [**6-13**] for stenotrophomonas coverage after he spiked a temp of 102.4 and became hypotensive requiring further pressors, however it was discontinued when his blood cultures came back negative and his platelets dropped. Pt continued to be treated for aspiration pneumonia/bacterial sepsis, and was extubated on [**6-28**]. Pt's respiratory function and presumed pulmonary aspergilliosis improved on ambisome. Thoracentesis was performed on [**7-4**] and drained 600cc of fluid, which was culture negative. Pt continued to have persistent fevers. Pt [**Name (NI) 10306**] was changed on [**7-5**] d/t gram positive cocci bacteremia, treated with Vanco. Cerbralspinal fluid culture was without growth. No evidence of herpes encephalitis on MRI. C Dif x 3 were negative. Levaquin was discontinued on [**7-21**] as the patient had been afebrile for many days, without positive blood cultures. On [**7-24**] Mr. [**Known lastname **] had a temperature of 100.5 axillary. Blood and urine cultures were drawn but were negative, and a CT of the thorax was performed to evaluate the status of the pulmonary nodules. Cefepime was started on [**7-25**], however was changed to aztreonam secondary to development of a rash that had also been previously noted with cefepime. Additionally, a CMV viral load came back with 1470 copies, therefore gancyclovir was started. The CT thorax showed possible new lung nodules, however it was not clear as the study was difficult to compare to the previous CT scan. Ambisome was changed to voriconazole. The patient defervesced by [**7-26**], presumably secondary to the gancyclovir, and has been afebrile since. CMV viral load was negative on [**7-31**]. Pt will be d/c'd on IV caspofungin and PO valgangciclovir, the latter to be continued until day 100 s/p MUD. Pt also d/c'd on Bactrim, which was temporarily stopped d/t falling counts, to prophylact against PCP and [**Name9 (PRE) 10307**] (pt is IgG +). 4. CARDIOVASCULAR: On [**4-27**] the patient complained of some chest pain and continued to spike a fever, therefore an echo was performed on [**4-28**] to assess for pericarditis, which was normal, without evidence of effusion or vegetations. EF 60%. CK was within normal limits. On [**6-9**], at the time of development of his [**Last Name (un) 6169**]-occlussive disease, with rapid development of ascites and massive fluid overload with presumed redistribution hypovolemia and decreasing urine output, Mr. [**Known lastname **] became hemodynamically unstable and had to be transfered to the ICU for pressor support and closer monitoring. In the ICU he received aggressive volume repletion and a couple of short course of pressors. Additionally, he had to be intubated on [**6-10**] secondary to seizures with respiratory rate into the 40s and labored breathing. Extubation failed on [**6-12**], but was successful on [**6-16**]. On [**6-16**] the patient was noted to have two 4 second sinus pauses on tele, the first in the context of a hiccup, the second without clear preceeding event. He responded to atropine, and it was felt to be likely vagal in nature. An EKG while in the ICU demonstrated decreased amplitude, however an echocardiogram on [**6-9**] did not demonstrate an effusion. On [**7-4**], pt was bradycardic and had 17 seconds of asystole which spontaneously resolved. His metoprolol was held, pacer pads were left on his chest, and atropine was kept at his bedside. Pt's bradycardia/asystole were again thought to be vagal. Head CT ruled out brain stem lesion. Pt had no repeat episodes of pauses off metoprolol. Echo on [**7-6**] showed moderate pericardial effusion, increased in size, but no evidence of tamponade physiology. The patient developed tachycardia up to 150 just after receiving his dose of pentamidine on [**7-19**]. An EKG at the time showed NSR, and he was given 5 mg IV Lopressor x 1 which brought his heart rate down to 110. That night he was again found to be tachycardic up to 160. An EKG at the time showed atrial flutter. He was given IV Lopressor x 2 and his rate came down to 110 with the second dose. He was seen by cardiology and started on metoprolol 12.5 mg [**Hospital1 **]. A repeat echo will be performed should the patient go back into a-flutter, to investigate the status of his pericardial effusion. He has been in NSR since, with a rate between 100-110. His clonidine patch was tapered to 0.2 mg on [**7-22**], however his pressures were slightly higher to the 160s and 170s, therefore metoprolol was increased from 12.5 mg [**Hospital1 **] to 25 mg [**Hospital1 **] on [**7-24**]. His clonidine patch was further tapered and hydralazine prn was d/c'd. Pt d/c'd on metoprolol and nifedipine SA. A CT scan done on [**7-25**] to evaluate Mr. [**Known lastname 10304**] pulmonary nodules demonstrated an increased size of his effusion. An echo was done on [**7-26**] that showed a large pericardial effusion with right ventricular invagination, right atrial collapse, and impending tamponade, therefore on [**7-27**] the patient had a pericardiocentesis that removed 500 cc of serosanguinous fluid. The fluid was sent for culture and cytology - no evidence of infection or malignant cells were found. The fluid was characteristic of an exudate. A suveillance echos, the latest on [**8-10**], showed a stable small to moderate pericardial effusion. He was hemodynamically stable after his pericardiocentesis. 5. [**Last Name (un) **] Occlusive Disease: On [**5-6**] the patient was noted to have a rising total bilirubin to 2.6 with abdominal distention and a palpable liver edge. Additionally, his INR rose to 2.0. He received 4U FFP. A RUQ US on [**5-9**] showed hepatosplenomegaly, as well as a large amount of sludge within the nondistended and otherwise unremarkable gallbladder. On [**5-14**], his total bilirubin decreased to 0.8 and his coags normalized. On [**6-6**], Day 7 s/p MUD, Mr. [**Known lastname **] developed hyperbilirubinemia, with RUQ pain and tenderness, and icterus, worrisome for rapidly progressive VOD. Despite this, an US on [**6-7**] did not show ascites, and the liver appeared unchanged in size, and there was no reversal of blood flow. His INR climbed to 2.4 that night, with elevated PT and PTT, and total bili of 5.3. His platelets were 11 (up from 6 the day before) and he had an episode of epistaxis. His fibrinogen was 491, however his D-dimer was 1513, and there was concern for DIC. He developed shortness of breath that was thought to be secondary to rapid abdominal distention. He also developed bilateral pedal edema, facial edema, and IVF were changed to keep vein open. He was started on a defibrotide protocol on [**6-7**], and ambisome was decreased due to potential hepatotoxicity. His total bilirubin, however, rapidly climbed, his edema increased, and his urine output decreased. On [**6-9**] he had to be transfered to the ICU secondary to hemodynamic instability with blood pressures falling to 90/30, and heart rates into the 140s. His bilirubin was 17 on transfer, climbing to a peak of 23 by [**6-10**]. On [**6-11**], however, it began trending down again. He was given lactulose for presumed hepatic encephalopathy. Pt was on defibrotide per protocol, was d/c'd after liver size seems improved, and lfts's trend down/stabilize and U/S of Liver [**2102-7-12**] showing hepatopetal flow. Normal flow [**7-14**] U/S and CT. On [**7-29**] Mr. [**Known lastname **] was noted to have an acute elevation of his LFTs - AST 65, ALT 107, ALP 469, LDH 234. An US of his RUQ showed a new small to moderate amount of ascites surrounding the liver, with patent hepatic vasculature. Voriconazole was stopped secondary to concern for hepatotoxicity, and changed to caspofungin. Cyclosporine was restarted due to concern for GVHD. Pt's transaminitis likely d/t voriconazole in setting of cyclosporine, and improved by d/c. 6. DIARRHEA: The patient had loose bowel movements from [**Date range (1) 10308**] that were negative for C. Diff. The diarrhea seemed to resolve until the night before his reinfusion when he had 2 loose bowel movements. After reinfusion, his diarrhea worsened, and he had 4-5 episodes of diarrhea on day 3. The patient had diarrhea, thought to be secondary to graft versus host disease, that was responsive to solumedrol. He did not have any diarrhea while in the ICU on Solumedrol and cyclosporine. CMV viral load titers were negative. C. Diff was persistently negative. He was treated with solumedrol that was slowly tapered as the diarrhea resolved. He was started on Budesonide on [**7-19**]. Pt remained diarrhea-free on steroids and cyclosporine through discharge. 7. RENAL: At the same time that his bilirubin trended up, day 7 s/p MUD transplant, his creatinine was also noted to be rapidly increasing. It had reached 2.4 by the time of transfer to the ICU on [**6-9**], thought to be VOD associated hepatorenal syndrome. His creatinine reached a max of 3.3 on [**6-10**] and he received a very brief CVVH through his Hickmann catheter. Thereafter it slowly began trending down and his urine output was good, suggestive of non-oliguric ATN. 8. RASH: The patient deveoped a hives on his arms, chest, abdomen, and ears 10 minutes after reinfusion on [**5-30**] which was treated with benadryl and hydrocortisone with improvement. On [**6-7**], however, the patient was noted to have a new diffuse erythematous macular rash, thought to be a sign of GVHD. His solumedrol was increased to 70 mg [**Hospital1 **] on [**6-13**]. Pt rash resolved with resolution of his GVHD, and he was rash-free for a couple weeks prior to discharge. 9. NEURO: On [**6-10**], while in the ICU, the patient was noted to have R gaze preference and progressive obtundation. A CT of the head on [**6-10**] was without incracranial pathology, however it was a poor study. The patient subsequently developed seizures. An MRI on [**6-11**] also demonstrated no acute intracranial pathology. He continued to have occasional twitching of his left arm and eyelid suggestive of seizure that was responsive to ativan, and he was noted to be confused and agitated. He was loaded on Dilantin as well. An EEG at this time showed frequent bursts of generalized delta frequency slowing with a low voltage theta frequency background, consistent with a moderate encephalopathy. No epileptiform or lateralizing features were seen. Dilantin was tapered, and then d/c'ed on [**6-16**]. He was on a heavy propofol drip during intubation because when sedation was lifted he became very aggitated, pulling out tubes. He was therefore sedated for much of his ICU stay. His mental status seemed to improve on [**6-16**], however, and he was able to be successfully extubated. He was noted to be talkative and interactive s/p extubation, and his altered mental status was thus attributed to his hepatic and renal impairment which was resolving at the time of his improvement. Pt had generalized tonic clonic seizures x 2 on [**2102-6-20**] in the ICU and was reintubated. Pt had small focus bleed in right frontal sinus at the time, which was not thought to be the cause of his seizures. Defibritide was held d/t risk of subarachnoid hemorrhage, but restarted in a few days. Placed on Keppra, which was eventually weaned off d/t a falling WBC count/marrow suppression. Neurontin added and pt remained seizure-free. Pt was encephalopathic in the ICU, thought to be multifactorial in etiology. His encephalopathy progessively improved. An MRI on [**7-11**] negative for mass lesion. Mr. [**Known lastname **] continued to have a baseline level of confusion after transfer to the BMT floor on [**7-11**], however it worsened over the first week of [**Month (only) 4278**] to the point where his answers to questions were incoherent and he no longer knew in which hospital he was. In addition, he had hallucinations. A repeat CT of the head was performed on [**7-22**] which showed hypodensity of the white matter in both parietal and occipital lobes, right worse than left. Given the recent onset of these findings, and the history of cyclosporine administration, consideration of reversible posterior leukoencephalopathy syndrome was suggested. An MRI of the head was performed on [**7-23**] to further evaluate these findings, however the patient was uncooperative and it was therefore a poor study - it did again demonstrate hypointensity in the occipital and parietal lobes bilaterally. Neurology and psychiatry were both involved, and recommended starting haldol at a low dose, in addition to maintaining the Ativan at 1 mg IV q 6 hours. Mr. [**Known lastname **] did have an isolated elevated ammonia level at 115 on [**7-23**], however it was in the 20s on [**7-24**] and lactulose was not started. Cyclosporine was discontinued on [**7-23**] because of cyclosporin toxicity as suggested by an MRI on [**7-23**] showing questionable edema in the occipital and parietal lobes bilaterally. A repeat MRI on [**7-26**], which was not limited by pt uncooperation like the first study, showed no abnormal signal in the white matter to suggest cyclosporin toxicity. Pt's mental state was back to baseline by [**7-28**] with only mild residual confusion. Cyclosporin was soon restarted and pt was d/c'd on 324mg/day continuous infusion. He continued to exibit some frontal release signs with increased emotionality, which gradually started to improve. As his anxiety improved, ativan was tapered to just prn, and pt was maintained on Haldol 1mg at bedtime. 10. DIET, FLUID, ELECTROLYTES AND NUTRITION: The patient was maintained on a neutropenic diet initially. When counts decreased during chemotherapy, he was maintained on intravenous fluids. Once his hydration reached an equilibrium after chemotherapy, he was switched to KVO during the day and maintenance fluids at night times one liter. He gradually was placed back on a neutropenic diet and was able to take in adequate nutrition to meet caloric requirements. However, on [**6-5**] nutrition recommended that he start supplemental TPN in addition to PO, as his PO had decreased s/p reinfusion secondary to nausea and vomiting, and on transfer to the ICU he was placed exclusively on TPN in early [**Month (only) **]. After transfer back to the BMT unit, Mr. [**Known lastname **] was strictly on TPN until he was cleared to eat by speech and swallow on [**7-17**], and he began taking in PO, very minimally secondary to poor taste. We began switching his medications to PO at this time, which he tolerated well. He gradually developed an appetite, and was tolerating a regular diet by [**7-29**]. His TPN was tapered off, and pt was taking about 1,000 calories by mouth for several days prior to discharge. His magnesium (3 amps) and phosphate (15mmol) were repleted intravenously daily. He was eager to eat a McDonald's Big Mac on day of discharge, but this was discouraged. 12. VERTIGO: The patient experienced a one time episode of vertigo while getting blood and while getting high dose ARA-C. Otoscopic examination was unremarkable. He had an MRI with gadolinium which was negative for any abnormalities except for mastoid and sphenoid fluid. Vertigo resolved. 13. OPHTHALMOLOGY: The patient had a history of a visual field cut defect and optic disc swelling right greater than left. The patient had Ophthalmology consulted in- house. They recommended an orbital MRI to rule out leukemic infiltrate. The patient had a fine cut MRI of the orbits which was negative for a leukemic infiltrate or mass effect. He also was noted to have a subconjunctival hemorrhage of the right eye on [**6-14**] that was seen by ophthalmology and presumed to be secondary to low platelets. Discharge Disposition: Home with Service Discharge Diagnosis: Primary: 1. Acute Myelogenous Leukemia (M7) s/p allo matched unrelated donor bone marrow transplant on [**2102-5-29**] Complicated by: 1. Repiratory Failure requiring intubation 2. Febrile neutropenia 3. Vaso-oclusive Disease with hepatic failure 4. Acute renal failure 5. Graft vs. Host Disease treated with steroids and cyclosporine 6. Small frontal intracranial hemorrhage 7. Seizures 8. Pericardial effusion Discharge Condition: Pt was in stable condition on discharge. He was afebrile for > 2 weeks, without diarrhea or rash, and his mentation continued to clear during the weeks prior to discharge. Pt was walking around nursing station multiple times a day, sometimes without a walker. Discharge Instructions: You will be followed very closely once you go to the apartments. Return to the hospital if you experience any fevers, chills, diarrhea, rash, abdominal pain or cramping, confusion, shortness of breath, palpitations, change in mental status, bright red or black stools, seizures, acute loss of limb strength, pain or burning with urination. Followup Instructions: 1) You will follow-up closely with Dr. [**Last Name (STitle) **]. Her office will call you for an appointment time very soon. 2) Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: KS [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) BEHAVIORAL NEUROLOGY UNIT Phone:[**Telephone/Fax (1) 810**] Date/Time:[**2102-9-4**] 2:30 3) Provider: [**Name10 (NameIs) 8950**] LABORATORY Where: CLINICAL CTR-[**Location (un) 10309**]-NEUROLOGY DEPT Date/Time:[**2102-9-5**] 2:00. Do not wear any body lotion or excessive jewelry. 4) Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Where: [**Hospital6 189**] NEUROLOGY Phone:[**Telephone/Fax (1) 764**] Date/Time:[**2102-9-18**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**] MD [**MD Number(2) 2085**] Completed by:[**2102-8-12**]

[ "V58.1", "570", "038.9", "518.81", "584.9", "484.6", "117.3", "995.92", "205.00" ]

icd9cm

[ [ [] ] ]

[ "33.24", "99.25", "99.05", "96.72", "96.71", "34.91", "99.07", "37.0", "41.03", "34.04", "33.28", "99.04", "96.04", "89.61" ]

icd9pcs

[ [ [] ] ]

39328, 39347

13813, 14789

13632, 13790

39803, 40066

40455, 41501

8820, 8881

39368, 39782

14807, 39305

40090, 40432

9147, 10323

13586, 13594

7084, 8362

8385, 8803

8898, 9124

7,753

114,079

13096

Discharge summary

report

Admission Date: [**2149-12-10**] Discharge Date: [**2149-12-15**] Service: #58 HISTORY OF PRESENT ILLNESS: The patient is a 79 year-old female with a past medical history significant for dementia and chronic obstructive pulmonary disease, status post pneumonectomy for lung cancer, hypertension. The patient was noted to be less active and with decreased po intake over to [**Hospital 1474**] Hospital for evaluation by her husband on [**2149-12-8**]. According to outside records, the patient denied symptoms of chest pain, shortness of breath, nausea, vomiting, neck pain, arm pain, abdominal pain until she arrived at the [**Hospital1 1474**] Emergency Department at which time she did complain of chest pain. The patient was seen by the Cardiology Service there and had evidence of an evolving inferior and right-ventricular myocardial infarction with ST depressions in leads 2, 3, AVF, V1, V3. The patient was hypotensive to a blood pressure of 70/30, which responded to intravenous fluids after which her blood pressure rose to 100/60. The patient required Dopamine intravenous to maintain her blood pressure as well as intravenous fluids. An echocardiogram was done at [**Hospital 1474**] Hospital demonstrating a akinetic and hypokinetic right ventricle. Urgent cardiac catheterization was deferred initially due to comorbid conditions and risks. The patient's peak CPK was 3777 on [**12-8**] at 1:00 p.m., CKMB was greater then 300 at that time. Per the patient's family request, the patient was transferred to [**Hospital1 69**] for further care on [**2149-12-9**]. The patient was no longer on a Dopamine drip, but apparently was complaining of some residual chest pain and was therefore admitted to the Coronary Care Unit. PAST MEDICAL HISTORY: 1. Status post cholecystectomy. 2. History of Lithium toxicity. 3. Dementia. 4. Chronic obstructive pulmonary disease. 5. Lung cancer status post left pneumectomy in [**2138**]. 6. Hypertension. 7. Bipolar disorder. 8. History of gastrointestinal bleed. ALLERGIES: Sulfa drugs. MEDICATIONS ON TRANSFER: Aspirin 325 mg po q.d., Lipitor 40 mg po q.d., Lopressor 25 mg po q.d., Colace 100 mg po b.i.d., Plavix 75 mg po q.d., Risperdal .5 mg po q.h.s., Tylenol prn, Serax 15 to 30 mg po t.i.d. prn, Gatifloxacin for presumed pneumonia, Pepcid. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient denies alcohol or tobacco use. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.9. Pulse 102. Respiratory rate 28. Blood pressure 100/55. Oxygen saturation 96% on 2 liters nasal cannula. General, the patient is an elderly well developed, well nourished female in no acute distress. Head and neck examination, pupils are equal, round and reactive to light. Sclera anicteric. Oropharynx clear. No JVD. Lungs clear to auscultation bilaterally. Abdomen soft, nontender, nondistended. Good bowel sounds in all four quadrants. Extremities no clubbing, cyanosis or edema. Neurological examination alert and oriented times three. No focal deficits. LABORATORY ON ADMISSION: White blood cell count 16, hematocrit 26.9 (decreased from 37 to 31 at outside hospital), platelets 186, sodium 33, potassium 4.1, creatinine 2.2, glucose 83, PTT 28. Cardiac enzymes, on [**2149-12-7**] CPK was 1277 with CKMB of 198 (MB index of 15.5) troponin greater then 50. On [**2149-12-8**] CPK was 2677, CKMB greater then 300. On [**2149-12-8**] CPK 3777 with CKMB greater then 300, troponin of 7.9. On [**12-8**], CPK was 3653 with CKMB of 212, troponin of 5.8. On [**2149-12-9**] CPK was 2736, CKMB 101, troponin of 3.7. Echocardiogram from outside hospital done on [**12-8**] was as follows, ejection fraction was grossly normal (45%), dilated right ventricle, inferior wall hypokinesis, no effusions, normal valves. Electrocardiogram on [**2149-12-8**] showing normal sinus rhythm at 100 beats per minute, [**Street Address(2) 12501**] elevations in 3 and AVF, [**Street Address(2) 1766**] depressions in 1 and AVL. Electrocardiogram on [**2149-12-10**] showing normal sinus rhythm at 100 beats per minute, low voltages, flattened or inverted T waves throughout (accept increase in 1 and AVL), normal intervals, Q waves in 3, V1 to V2, AVR. HOSPITAL COURSE: The impression was that this is a 79 year-old female with baseline dementia status post pneumonectomy presenting from [**Hospital 1474**] Hospital with an inferior myocardial infarction about 48 hours old, and renal insufficiency. 1. Cardiovascular: A: Ischemia, the patient was status post inferior wall myocardial infarction at [**Hospital 1474**] Hospital with CPK now trending down. The patient's CKs continued to be cycled and showed a pattern of downward trend. The patient was continued on aspirin, Plavix, low dose beta blockade, Lipitor. The patient was given intravenous fluids for right ventricular support given her recent RV infarction. As the patient was hemodynamically stable on admission, there was no initial indication for invasive monitoring. It was determined that the patient should go for a cardiac catheterization. A cardiac catheterization was performed showing 90% diffuse stenosis of the right coronary artery. Thrombectomy was performed with stent to right coronary artery with subsequent restoration of flow, 50% left anterior descending coronary artery lesion. Other disease was diffuse, there was still some residual laminated thrombus after the procedure. The patient was transferred back to the Coronary Care Unit after the procedure as intracardiac hemodynamic monitoring showed pulmonary artery oxygen saturation of 43%, pulmonary artery pressure of 33/17, right ventricular pressure of 33/11, with an estimated cardiac index of less then 2. The patient was monitored for 24 hours and was stable requiring less intravenous fluid support. The patient had no further episodes of chest pain after intervention. The patient was noted to be wheezing during her hospital course. As the patient was not previously on a beta blocker prior to this hospitalization the beta blocker was discontinued as it was presumed to be possible cause of her wheezing. The patient's Captopril was titrated up to 25 mg po t.i.d. for optimal blood pressure control. The patient was also placed on Digoxin for optimizing cardiac output. B: Pump, the patient was initially given aggressive intravenous fluid for right ventricular support status post right ventricular infarct, with caution to avoid fluid overload. After cardiac catheterization the patient's blood pressure remained stable off intravenous fluid support and was therefore discontinued. 2. Hematology: The patient was transfused one unit of packed red blood cells for a hematocrit drop from 28.6 to 27 after cardiac catheterization. The patient's hematocrit remained stable after transfusion. Hemolysis laboratories were negative. The patient's stool guaiac was subsequently reported to be positive (no gross blood or melana), the decision was made to follow up with outpatient colonoscopy. 3. Infectious disease: The patient was started on Gatifloxacin at outside hospital without documentation for the reason, besides an elevated white blood cell count at the outside hospital. The patient was continued on renally dosed Levaquin during her hospital stay. The patient spiked a temperature once to 101 during her hospital course. All cultures were negative with chest x-ray showing no infiltrates and urinalysis showing no signs of infection. The Levaquin was subsequently discontinued secondary to a rash on the patient's back, after having finished a seven day course. 4. Renal: The patient was given intravenous fluid as necessary to maintain renal perfusion and at the same time to avoid congestive heart failure. All medications were renally dosed. 5. Fluids, electrolytes: The patient's electrolytes were repleted prn, and the patient was placed on Protonix for gastrointestinal prophylaxis. DISCHARGE STATUS: The patient is stable. The patient is going to short term rehab facility to follow up with primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 17385**] within two weeks post discharge. MEDICATIONS ON DISCHARGE: Aspirin 325 mg po q.d., Atorvastatin 40 mg po q.d., Plavix 75 mg po q.d. for one month, Protonix 40 mg po q.d., heparin 5000 units subQ q 12, Colace 100 mg po b.i.d., Risperdal 0.5 mg po q.h.s., Serax 15 to 30 mg po q.h.s. prn, Tylenol 650 mg po q 6 hours prn, Captopril 25 mg po t.i.d., Digoxin 0.25 mg po q.d., Combivent MDI two puffs inhaled q.i.d., Flovent four puffs inhaled b.i.d. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Name8 (MD) 2692**] MEDQUIST36 D: [**2150-1-4**] 20:25 T: [**2150-1-5**] 11:23 JOB#: [**Job Number 40016**]

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icd9cm

[ [ [] ] ]

[ "88.53", "37.23", "36.01", "37.78", "99.20", "88.56", "36.06" ]

icd9pcs

[ [ [] ] ]

2356, 2374

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28,566

190,098

45863

Discharge summary

report

Admission Date: [**2110-8-6**] Discharge Date: [**2110-8-8**] Date of Birth: [**2059-9-20**] Sex: M Service: MEDICINE Allergies: Epoetin Alfa Attending:[**First Name3 (LF) 905**] Chief Complaint: nausea, vomiting, chest pain Major Surgical or Invasive Procedure: Central line placement, s/p ICU admission History of Present Illness: This is a 50 year old african-american male with a history of coronary artery disease s/p CABG, HCV, ESRD on HD who presented with nausea/vomiting, chest pain, and headache to OSH ([**Hospital 6451**]) last Monday. He reports that he has had symptoms similar to this before due to uncontrolled hypertension. The headache was a throbbing, painful pressure and was associated with feeling "woozy" and lightheaded. He did not lose consciousness at any time. He had stopped eating because of nausea/vomiting. Reports gradual onset substernal chest pain/pressure without radiation associated with nausea that came on at rest. He also noticed swelling in his belly and leg (s/p AKA), some shortness of breath, and malaise. Denied visual disturbances or confusion. . At OSH, patient was found to be fluid overloaded, and underwent 2 days of HD and was disharged home on Wednesday, feeling better, but still not back to baseline. On Thursday morning he awoke with the return of his prior symptoms. He presented to [**Hospital1 18**] ED that afternoon. . The patient has recently been trying to control his fluid intake by cutting out diet soft drinks in favor of chewing ice, and reports that he dropped from 127lbs to 118lbs in the past few weeks although has been eating salty popcorn. He also noticed a change in his urinary habits, urinating twice per day rather than his usual one time. He sometimes has to wake up at night to urinate. His stream starts out strong and then sputters. No increased urinary urgency. He occasionally feels palpitations which he describes as pounding in his chest or skipped beats. He sleeps on 3 pillows at night and cannot lie flat without shortness of breath. He is not sure how compliant he has been with his medication regimen as he has been distracted by other health problems and relies on his pharmacy to remind him to refill his meds. . In the ED at [**Hospital1 18**], initial vital signs were: T 97.5, P 78, BP 192/101, R 16, O2 sat 100%RA. Highest BP recorded was 200/83. Patient was given metroprolol IV for BP control without much improvement, then started on a nitro ggt. Also given ASA 325mg x1. CXR showed mild pulmonary congestion. Troponins were noted to be 0.13 with normal CKs. Prior to transfer to the MICU for hypertensive emergency, vitals were P 57 Bp 156/61 R 23 O2 sat. 99% RA. . Please see MICU documentation for full report. In brief, in the MICU he was weaned from his nitro ggt and put on his home regimen of PO antihypertensives (Clonidine, Hydralazine, metoprolol, minoxidil, norvasc, lisinopril). Per Renal consult, he did not receive dialysis. His blood pressure stabilized and he was transferred to the medicine floor Thursday evening. . On the floor, he was resting comfortably. Said he was feeling much better. Denied any residual chest pain, but does have intermittent headache, nausea, and palpitations. Mild shortness of breath. Past Medical History: - Left total knee replacement. Medial femoral condylar fracture, non-[**Hospital1 **]. First replacement at [**Hospital1 112**] 7/[**2105**]. Revision/washout 8/[**2106**]. Hardware removal [**10/2106**], Enterococcal infection, abx spacer (6 weeks of antibiotic). Revision/washout 12/[**2106**]. Excision/arthroplasty [**3-/2107**] (2nd TKR). Revision/debridement 12/[**2107**]. Revision/debridement [**6-/2108**] (3rd TKR). I&D, synovectomy, [**2109-10-25**]. History of Enterococcus and coag neg Staph from joint. - Left trimalleolar ankle fracture. Closed reduction, external fixator, 6/[**2109**]. Revision, irrigation and debridement, 8/[**2109**]. Debridement, joint fusion, w/ hardware, [**2109-11-8**]. - Coronary artery disease s/p CABG x6v 8/[**2108**]. - Diabetes mellitus type 2, insulin-dependent. Diabetic enteropathy with chronic diarrhea, peripheral neuropathy, autonomic neuropathy, orthostatic hypotension - End stage renal disease. HD T/R/S. Left AV fistula [**7-/2106**]; thrombectomy/angioplasty 4/[**2107**]. H/o MRSA bacteremia, line-associated. - Hepatitis C. Stage I fibrosis; Grade [**1-31**]; genotype 4c/4d; no h/o treatment. - Clostridium difficile (at OSH and [**Hospital1 18**] [**10-28**]) - Peripheral vascular disease and neuropathy. Right lower extremity 5th digit amputation. - Anemia - Penile prosthesis, [**2107**] Social History: Retired salesman. Lives with wife in [**Name (NI) 1474**]. Said he has been having trouble following up on health problems recently due to issues with L leg. Past smoker, 14 pack years quit in 03/[**2109**]. Drinks occasional glass of wine with dinner (1x month). Denies recent drug use, remote IVDU history of heroin + cocaine. Family History: Mother d. 50s of MI Sister with [**Name (NI) 2320**] Father died young of unknown cause Physical Exam: Vitals: T: 98.1 BP: 138/76 P: 64 R: 18 O2: 99%RA . General: Alert, oriented, not in acute distress, normal weight Skin: No rashes or ulcerations, central line site healing well HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, loud S2, III/VI blowing systolic murmur best heard at LUSB w/o radiation, no rubs, gallops Abdomen: soft, non-tender, soft bowel sounds present, warm to touch, no rebound tenderness or guarding, no organomegaly Ext: L AKA amputation, clean site, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII intact, PERRLA, strength 5/5 throughout, no sensation to light touch in R leg below ankle Psych: A&O x3, able to say days of week backwards Pertinent Results: [**2110-8-8**] 06:55AM BLOOD WBC-6.5 RBC-4.27* Hgb-12.5* Hct-35.8* MCV-84 MCH-29.3 MCHC-34.9 RDW-15.1 Plt Ct-254 [**2110-8-7**] 03:45AM BLOOD WBC-8.6 RBC-4.47* Hgb-12.9* Hct-37.4* MCV-84 MCH-28.8 MCHC-34.4 RDW-14.7 Plt Ct-277 [**2110-8-6**] 04:45PM BLOOD WBC-6.1 RBC-5.07 Hgb-14.3 Hct-43.0 MCV-85 MCH-28.2 MCHC-33.3 RDW-14.5 Plt Ct-238# [**2110-8-7**] 03:45AM BLOOD Neuts-78.0* Bands-0 Lymphs-11.2* Monos-5.8 Eos-0.3 Baso-0.3 [**2110-8-6**] 04:45PM BLOOD Neuts-57 Bands-0 Lymphs-25 Monos-15* Eos-1 Baso-2 Atyps-0 Metas-0 Myelos-0 [**2110-8-8**] 06:55AM BLOOD Plt Ct-254 [**2110-8-7**] 03:45AM BLOOD Plt Ct-277 [**2110-8-7**] 03:45AM BLOOD PT-12.8 PTT-27.2 INR(PT)-1.1 [**2110-8-6**] 04:45PM BLOOD Plt Ct-238# [**2110-8-6**] 04:45PM BLOOD PT-13.5* PTT-28.5 INR(PT)-1.2* [**2110-8-8**] 06:55AM BLOOD Glucose-138* UreaN-37* Creat-10.3*# Na-129* K-4.1 Cl-89* HCO3-23 AnGap-21* [**2110-8-7**] 04:33AM BLOOD Glucose-132* UreaN-25* Creat-8.0* Na-133 K-3.9 Cl-93* HCO3-23 AnGap-21* [**2110-8-6**] 04:45PM BLOOD Glucose-158* UreaN-21* Creat-7.0* Na-131* K-3.8 Cl-93* HCO3-22 AnGap-20 [**2110-8-6**] 04:45PM BLOOD estGFR-Using this [**2110-8-7**] 01:22PM BLOOD CK(CPK)-54 [**2110-8-7**] 04:33AM BLOOD CK(CPK)-50 [**2110-8-6**] 04:45PM BLOOD ALT-30 AST-36 CK(CPK)-58 AlkPhos-81 TotBili-0.4 [**2110-8-6**] 04:45PM BLOOD Lipase-32 [**2110-8-7**] 01:22PM BLOOD CK-MB-NotDone cTropnT-0.15* [**2110-8-7**] 04:33AM BLOOD CK-MB-NotDone cTropnT-0.13* [**2110-8-6**] 04:45PM BLOOD cTropnT-0.13* [**2110-8-6**] 04:45PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 23416**]* [**2110-8-8**] 06:55AM BLOOD Calcium-10.0 Phos-4.5 Mg-2.4 [**2110-8-7**] 04:33AM BLOOD Albumin-4.2 Calcium-10.7* Phos-3.9# . ECG ([**2110-8-6**]): Sinus rhythm. Left axis deviation. Left atrial abnormality, Right ventricular conduction delay. Left anterior fascicular block. Diffuse non-diagnostic repolarization abnormalities. Compared to the previous tracing of [**2110-6-27**] no diagnostic change. . CXR ([**2110-8-6**]): FINDINGS: AP upright and lateral views of the chest are obtained. Midline sternotomy wires and mediastinal clips are again noted, as is a left IJ access dialysis catheter with tip in the proximal location of the superior vena cava. Comparison is also made with a prior chest CT from [**2108-9-24**]. There is blunting of the left CP angle, compatible with pleural effusion. In the left mid lung, there is vague airspace consolidation, which may reflect an area of loculated fluid seen on the prior chest CT scan. There is no overt CHF, though mild pulmonary vascular prominence is similar to that seen previously and may represent patient's baseline. Cardiomediastinal silhouette is unremarkable. Bony structures are intact. IMPRESSION: Small left pleural effusion with probable loculated effusion resulting in left mid lung opacity, which appears unchanged from prior CT. No overt CHF. . Echo ([**2110-8-7**]): The left atrium is mildly dilated. The estimated right atrial pressure is 10-20mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The 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. There is moderate thickening of the mitral valve chordae. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2108-9-26**], the left ventricle is more hypertrophied and the other findings are similar. . Brief Hospital Course: Assessment and Plan: This is a 50 year old man with a h/o CAD s/p CABG, HCV, ESRD on HD presenting with hypertensive emergency with elevated blood pressure, chest pain, and elevated trops. . # Hypertensive emergency: Patient's presentation meets criteria given SBP > 180 and symptoms suggestive of end-organ damage (chest pain). Chest pain was concerning for ischemic damage, but given lack of ECG changes and mildly elevated troponins (may be due to ESRD) in the setting of a normal CK, unlikely that patient experienced myocardial infarction. Likely demand ischemia due to severely elevated hypertension (pumping against a high afterload). In MICU, without any response to IV metoprolol, but improvement with nitro gtt which was weaned. As initial systolic blood pressure was over 200, initial BP goal in unit was 150-180 systolic. Upon reaching the floor, blood pressures were stable in the 130 SBP range on home medication regimen. Patient underwent HD prior to discharge. Etiology of hypertensive emergency unclear, but there is suspicion of medication noncompliance given history provided by patient (which was later denied), and the fact that blood pressure has been very well controlled upon the initiation of home medications without any need for alterations. Diet may also be playing a factor. Patient counseled on the importance of a heart healthy, diabetic, renal diet. . # Chest pain: Chest pain had resolved in the MICU, and patient denied any symptoms upon transfer to the floor. Troponins, CKs were cycled. Patient was monitored with telemetry throughout his stay. Elevated troponins thought to be due to cardiac strain produced by increased cardiac work against a high cardiac afterload in combination with setting of ESRD. Stable CK X3, and no acute changes on EKG, were non-suggestive of MI. Elevated BNP unable to be evaluated as we have no prior value to compare it to, but it is likely chronically elevated [**3-3**] ESRD. . # CAD s/p CABG:# CAD s/p CABG: patient with significant coronary disease. Has mild troponin elevation but likely due to ESRD as well demand ischemia given such elevated blood pressures. No concerning ECG changes. Aspirin was continued, as well as statin. . # ESRD: BUN and Creatinine have been highly variable and it is unclear how compliant he has been with HD regimen. Renal service was consulted and recommended HD in the AM prior to discharge. Discharged with home medication regimen. . # Diabetes: Discharged with stable sugars on home SC insulin regimen. Not an issue during this hospitalization. . # FEN: No IVF were given, but electrolytes were repleted as needed. Patient was given heart healthy/diabetic diet. . # Prophylaxis: Subcutaneous heparin was administered for DVT prophylaxis. . # Access: peripheral IVs used. . # Code: FULL code . # Disposition: Discharge home as blood pressure has stabilized and symptoms have improved. Medications on Admission: Home Medications: Polysorbate 100mcg w/dialysis Aspirin 81 mg PO DAILY Clonidine 0.1 mg PO DAILY Insulin SC Sliding Scale & Fixed Dose Hydralazine 25 mg PO Q6H Lisinopril 10 mg PO BID Loperamide 4mg PO TID PRN Metoprolol Tartrate 50 mg PO BID Minoxidil 2.5 mg PO DAILY Amlodipine 5 mg PO DAILY Oxycodone SR (OxyconTIN) 80 mg PO Q12H Oxycodone-Acetaminophen 3 TAB PO PRN Simvastatin 10 mg PO QHS . Medications prior to transfer to floor: Aspirin 81 mg PO DAILY Clonidine 0.1 mg PO DAILY Insulin SC Sliding Scale & Fixed Dose Hydralazine 25 mg PO Q6H Lisinopril 10 mg PO BID Metoprolol Tartrate 50 mg PO BID Minoxidil 2.5 mg PO DAILY Amlodipine 5 mg PO DAILY Oxycodone SR (OxyconTIN) 80 mg PO Q12H Oxycodone-Acetaminophen [**1-31**] TAB PO Q6H:PRN pain Simvastatin 10 mg PO DAILY Heparin 5000 UNIT SC TID Senna 1 TAB PO BID Polyethylene Glycol 17 g PO DAILY:PRN constipation Docusate Sodium 100 mg PO BID Ondansetron 4 mg IV Q8H:PRN nausea Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Insulin Lispro 100 unit/mL Cartridge Sig: as directed as directed Subcutaneous four times a day: per sliding scale. 12. Insulin Regular Human 100 unit/mL Cartridge Sig: Ten (10) U Injection qAM. 13. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twelve (12) U Subcutaneous qAM. Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive emergency . Secondary: end-stage renal disease diabetes coronary artery disease peripheral vascular disease hepatitis C Discharge Condition: Vital signs stable with good blood pressure control and significant improvement in symptoms. Ruled out for heart attack. Discharge Instructions: You were admitted to the hospital with dangerously high blood pressure and heart failure (hypertensive emergency). We gave you IV metoprolol and nitroglycerin to lower your blood pressure and admitted you to the ICU to continue a constant infusion of nitroglycerin and monitor your blood pressure overnight. We also confirmed that you did not have a heart attack. Once your blood pressure stabilized we started you on your home medications. We delayed your regular dialysis appointment by one day, and you had dialysis on Friday. . We are not making any changes to your medications at this time. Please continue to take all your medications as they are prescribed to you. It is very important that you continue your medications as directed. . Please call your PCP or return to the hospital if you experience chest pain, pounding headache, swelling in your legs/belly, nausea/vomiting, fever/chills, or any symptoms for which you would normally seek medical attention. Followup Instructions: You missed an appointment with your endocrinologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Last Name (un) **], this morning. We have scheduled a follow-up appointment with Dr. [**Last Name (STitle) **] to discuss your blood pressure management. Dr.[**Name (NI) 97678**] office will call you if an appointment becomes available sooner: [**Name6 (MD) 1730**] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 2378**] Date/Time: [**2110-9-1**] 11:20am You also have the following appointments scheduled: Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2110-11-24**] 1:20 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name11 (NameIs) **] SOCIAL WORK Date/Time:[**2110-11-24**] 2:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2101-10-31**] Discharge Date: [**2101-11-17**] Service: MEDICINE Allergies: Zocor / Prednisone / Enalapril Attending:[**First Name3 (LF) 1145**] Chief Complaint: severe abdominal pain radiating to back Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] F HTN, Hyperlipidemia, hx AAA repair who p/w acute onset of epigastric/LUQ [**9-5**] abdominal pain for 3 hours radiating to back, beginning at 6PM night of admission. In ED, with BP 212/40. Nausea after attempting meal. No fevers, chills, HA, vision changes. No BRBPR, change in stool color, or hematemesis. . In ED, started on Nipride and Esmolol gtts, received Morphine for pain control. Past Medical History: 1. AAA Repair [**2081**] 2. Bladder CA ([**5-1**]) /Ovarian CA (stage 4 papillary serous mullerian origin tumor, grade 3 papillary urothelial CA, recent transitional cell ca on cysto) 3. CVA 1 year ago (on Plavix) 4. Arthritis 5. s/p Appy 6. s/p Cataract Surgery Social History: Lives alone at home with VNA assistance. Has sister and [**Name2 (NI) 802**] in NY. Family History: NC Physical Exam: VITALS: T 96.2; HR 88; BP 212/140; RR 24; O2 SAT: 91%RA GEN: moderate distress [**12-29**] pain HEENT: MMM. OP Clear. Sclerae anicteric. NCAT. JVP 10 cm. CV: S1 -S2 loud III/VI holosystolic murmur late peaking in all 4 quadrants, best at apex LUNGS: Bibasilar crackles. ABD: diffuse abdominal tenderness. No rebound. +BS, soft. EXT: 1+ edema to ankles. 1+ DPs. Pertinent Results: MRA CHEST W&W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVIC Reason: eval for dissection Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with epigastric pain, hypertension REASON FOR THIS EXAMINATION: eval for dissection INDICATION: Epigastric pain, which radiates to the back. Evaluate for aortic dissection. TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained through the chest and abdomen. Axial 2D time-of-flight images were obtained through the region of the arch vessels. Multiple cine sequences were performed. VIBE images were performed pre- and post-administration of contrast, and subtraction images were obtained. Multiplanar reformations were created and analyzed on a workstation. COMPARISON: CT studies from [**2099-1-21**], [**2101-1-6**], [**2101-3-30**], and two hours earlier. FINDINGS: The ascending aorta and visualized portions of the arch vessels appear normal, and there is no evidence for dissection. On the cine images through the aortic valve, a dephasing jet is seen, which is compatible with aortic stenosis. The left ventricle is also noted to be prominent. The descending aorta is tortuous, and a large aneurysm of the distal thoracic and abdominal aorta is again seen. Overall, the size of the aorta has not significantly changed from prior CT examinations dating back to [**2098**]. However, an intimal flap is identified which originates just above the aortic hiatus and extends to the level of the left renal artery. The celiac artery, superior mesenteric artery, and right renal artery arise from the true lumen. The left renal artery arises from the false lumen, and the dissection terminates at this level. The left kidney appears to be perfused. The right kidney was not imaged on the post-contrast sequences, as the study was targeted to the aorta. Multiple cysts are seen within the left kidney. There is diffuse atherosclerotic disease of the aorta, as seen on the prior CT studies. Multiple areas of ulceration are present. On the pre-contrast images, there are a few focal areas of increased signal intensity within the descending aorta, which may represent areas of hemorrhage within the wall. The multiplanar reformations were critical in delineating the above findings. IMPRESSION: 1. Dissection involving the descending aorta, which extends from just above the aortic hiatus to the level of the left renal artery. The left renal artery arises from the false lumen while the celiac artery, SMA, and right renal artery arise from the true lumen. 2. Diffuse atherosclerotic disease with multiple areas of ulceration within the descending aorta, as seen on prior CT examinations. 3. Findings consistent with aortic stenosis. . CT ABDOMEN W/O CONTRAST [**2101-10-30**] 7:25 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: SEVERE ABD PAIN Field of view: 36 [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with severe ab pain REASON FOR THIS EXAMINATION: eval for aaa rupture CONTRAINDICATIONS for IV CONTRAST: renal failure INDICATION: [**Age over 90 **]-year-old female with severe abdominal pain. Patient has a history of a primary peritoneal neoplasm. COMPARISONS: Comparison is made to [**2101-3-30**]. TECHNIQUE: CT of the abdomen and pelvis without IV or oral contrast. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are atelectatic changes versus scarring in the lung bases. The thoracic and upper abdominal aorta are again noted to be aneurysmal. There are also mural calcifications. In the largest diameter, the suprarenal aorta measures 4.0 cm and is unchanged when compared to the prior study. The patient is status post infrarenal AAA repair. There is a stable left iliac aneurysm which appears to be bypassed. The appearance of the aorta is unchanged when compared to the prior studies. There is a small calcified granuloma in the right lobe of the liver. The liver otherwise has unremarkable CT appearance with the limitations of this non-contrast study. There are gallstones within the gallbladder. The spleen is unremarkable with the limitation of the non-contrast scan and the pancreas is also within normal limits. The appearance of the kidneys and adrenal glands is also unchanged. Both adrenal glands appear to be prominent but stable when compared to the prior study. There is a soft tissue density nodule within the abdominal wall just lateral to the umbilicus (image 2, 38) which appears to be enlarged when compared to the prior study. It now measures 2.0 x 1.4 cm (the soft tissue component previously measured 10 x 8 mm). CT OF THE PELVIS WITHOUT IV CONTRAST: There is again noted a left inguinal lymph node which is enlarged when compared to the prior study. It now measures 2.1 x 1.7 cm (previously 1.6 x 1.5 cm). There are also several external iliac lymph nodes, the largest one measuring 1.4 x 1.4 cm (image 2, 64). There are also cystic-appearing areas in the region of the left ovary, the largest one measuring 3.0 x 2.9 cm in the largest axial diameter. The smaller one located slightly more anteriorly measures 2.1 x 2.0 cm in largest axial diameter. They are both not well characterized in this study. There is no free fluid or free air in the pelvis. BONE WINDOWS: There are again noted severe degenerative changes of the spine. There is a compression fracture of L4 which is mild. There are also severe degenerative changes of L4/L5 with grade [**11-28**] anterolisthesis of L4 over L5. There is likely also a mild compression fracture of L5. These compression fractures are of unknown acuity. IMPRESSION: 1. No definite reason for acute abdominal pain identified in this study. 2. Thoracoabdominal aortic aneurysm as described above is stable when compared to prior study. 3. Interval enlargement of subcutaneous nodule lateral to the umbilicus which could represent a lymph node and also left inguinal and external iliac nodes which appear to be larger, suggesting progression of known tumor. 4. Cystic structures in the region of the left adnexa are abnormal in a postmenopausal woman. 5. Severe degenerative changes of the lumbar spine as described above. . RENAL ULTRASOUND: Limited assessment of renal blood flow was performed. There is arterial flow to the right and left kidneys. Color flow is demonstrated within the kidneys bilaterally, which appears symmetric. . ECHO Conclusions: 1.The left atrium is mildly dilated. The left atrium is elongated. 2. Left ventricular wall thicknesses is mildly increased. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The ascending aorta is moderately dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. A mobile density is seen in the descending aorta consistent with an intimal flap/aortic dissection. 5.The aortic valve leaflets are mildly thickened. There is moderate aortic valve stenosis. Trace aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. 7. There is moderate pulmonary artery systolic hypertension. 8.There is no pericardial effusion. . INDICATION: [**Age over 90 **]-year-old woman with severe abdominal pain and back pain with hematocrit drop. Evaluate for change in dissection. COMPARISON: CT of the abdomen dated [**2101-10-30**] and MRI of the chest dated [**2101-10-30**]. TECHNIQUE: Contiguous axial images through the chest were obtained without contrast. Subsequently, following the administration of IV Optiray, contiguous axial images through the chest, abdomen and pelvis to the level of the aortic bifurcation were obtained. Coronal and sagittal reconstructions were obtained. CTA OF THE CHEST AND ABDOMEN: The ascending aorta measures approximately 3.7 cm in diameter, unchanged. There is severe atherosclerotic disease of the aorta, with numerous penetrating ulcers. The descending thoracic aorta measures 3.8 cm at the level of the pulmonary artery. At the level of the pulmonary artery, there is a thin hypodense flap, likely present on the prior MRA of the chest. The extent of the known thoracic aortic dissection is likely not significantly different from [**10-30**]. There is a false lumen that is filling with contrast at the inferior portion of the chest superior to the aortic hiatus. The aorta at the aortic hiatus measures about 4 cm, also unchanged. The celiac, SMA and right renal artery arise from the true lumen and are patent, opacifying with contrast. The left renal artery does arise from the false lumen, which fills with a lesser amount of contrast. The false lumen appears slightly larger in width on the CTA exam compared to the recent MRA, but this may be due to differences in modality. The dissection ends just distal to the origin of the left renal artery. The patient is post infrarenal AAA repair, and there is an unchanged left common iliac aneurysm that appears to be bypassed. CT OF THE CHEST WITHOUT AND WITH CONTRAST: There are new small bilateral pleural effusions that are simple fluid attenuating. There is bibasilar associated atelectasis. No pulmonary nodules are identified. The central airways are patent to the level of the segmental bronchi bilaterally. No pathologically enlarged mediastinal, hilar, or axillary lymph nodes. CT OF THE ABDOMEN WITH CONTRAST: There is a small low attenuation lesion within the inferior tip of the liver that is too small to characterize. There is a tiny granuloma within the right lobe. There is a small gallstone within the gallbladder, which is otherwise unremarkable. The spleen, pancreas, and adrenal glands are normal. The cortex of the right kidney enhances more than that of the left kidney, which is likely related to the origin of the right renal artery arising from the true lumen and the left from the false. The kidneys are atrophic. The soft tissue nodule of the left anterior abdominal wall adjacent to the umbilicus is unchanged. In addition, there is an oval soft tissue calcified nodule within the subcutaneous tissues of the right back. No free air or free fluid within the abdomen. No pathologically enlarged mesenteric or retroperitoneal lymph nodes. Bowel loops are unremarkable. Imaged bowel loops in the pelvis are unremarkable. The bladder and low pelvis was not imaged. BONE WINDOWS: Again severe degenerative changes are noted. There are no suspicious osteolytic or sclerotic lesions. Mild compression fracture of the mid L2 vertebral body is unchanged, as is mild compression of the L5 vertebral body. Grade I-II anterolisthesis of L4 on L5 is unchanged. Coronal and sagittal reformatted images were essential in delineating the anatomy in this case, and were especially helpful in comparing the known thoracic aortic dissection to the prior exams. IMPRESSION: 1. No significant interval change in the appearance of the known descending thoracic aortic aneurysm extending from the inferior portion of the chest to just distal to the origin of the left renal artery. The celiac, SMA and right renal artery remain patent, arising from the true lumen. The left renal artery again arises from the false lumen and does have some flow within it. 2. Numerous incidental findings are unchanged from [**10-30**]. . [**2101-10-30**] 06:52PM PT-13.8* PTT-26.5 INR(PT)-1.3 [**2101-10-30**] 06:52PM PLT COUNT-135* [**2101-10-30**] 06:52PM PT-13.8* PTT-26.5 INR(PT)-1.3 [**2101-10-31**] 05:50PM URINE HOURS-RANDOM CREAT-108 SODIUM-71 [**2101-10-30**] 06:52PM GLUCOSE-164* UREA N-39* CREAT-2.1* SODIUM-138 POTASSIUM-6.0* CHLORIDE-103 TOTAL CO2-22 ANION GAP-19 [**2101-10-30**] 06:52PM PT-13.8* PTT-26.5 INR(PT)-1.3 Brief Hospital Course: Patient is a [**Age over 90 **] year-old female with a history of AAA repair ([**2081**]), HTN who presented with a Type B aortic dissection in setting of hypertensive emergency. The following issues were addressed during her hospital stay: 1. ABDOMINAL PAIN/AORTIC DISSECTION MRA confirmed evidence of aortic dissection extending from level of diaphragm to below renal arteries. CT Abdomen on admission ruled out other abdominal pathology as cause of patient's complaints. Patient was admitted to the CCU and BPs were initially controlled with Esmolol and Nitroprusside drips. Vascular surgery was consulted; given Type B aortic dissecion and multiple comorbidities, it was felt that medical management was best option for patient. Patient was switched to PO blood pressure control regimen consisting of Metoprolol, Valsartain, HCTZ, and Hydralazine. Patient blood pressure remained difficult to control initially, and PRN IV medications were used to control sudden exacerbations. Patient received Morphine for pain control. Given continued abdominal pain with blood pressure elevations, drop in Hct, and need to better delineate vasculature per Vascular surgery, patient received CTA to rule out progression to mesenteric arteries and to assess if endovascular temporizing measure could be feasible. CTA showed stable size of dissection with slight interval increase in size of false lumen, but no extension to mesenteric vasculature. Patient's oral blood pressure medications continued to be titrated as necessary, and standing morphine was used for pain control. Vascular surgery re-assessed possibility of intervention, and decided that risks of stenting outweighed benefits. 2 days after dye load from CTA, patient went into ATN (see renal discussion); blood pressure medications were subsequently dc'd as renal insult caused decreased clearance of anti-hypertensives. Once ATN resolved, Metoprolol was titrated with good effect. As needed, Metoprolol to be increased for goal SBP 120-140. If second [**Doctor Last Name 360**] needed, outpatient Diovan can be resumed. Patient to follow-up with PCP on [**11-23**]. . # RENAL/ATN Patient with history of chronic renal insufficiency, with baseline Cr 1.9. Following control of blood pressure, patient had picture consistent with ATN. Creatinine improved with better blood pressure titration. Electrolytes were repleted as necessary, and patient received Mucomyst and Bicarbonate for renal protection prior to CTA. 2 days post-CTA, patient had progressive decline in urine output, with worsening Creatinine and GFR. Peak Creatinine was 4.0. Given hypotension and poor UO, pateint was started on low-dose dopamine to maintain renal perfusion and forward flow. Dopamine drip was continued for 6 days, with significant improvement in both urine output and creatinine. Renal service was consulted in the interim for considerations of dialysis; temporary RIJ dialysis catheter was placed, but given patient's improvement in renal function on dopamine, dialysis was not pursued and line was removed. On discharge, patient's Cr had trended down towards baseline to 2.2. Given fluid overload from renal insult, patient was started on low dose Furosemide 10mg PO qd, and will follow-up with PCP for electrolyte monitoring. During acute period of insult, patient was started on Phoslo; with improvement in function, medication was no longer needed. please f/u as outpatient. . # UTI Patient developed Ampicillin-sensitive Enterococcal UTI treated with Ampicillin x 5 days. . # CARDIAC Patient had loud III/VI late peaking holosystolic murmur on exam, and ECHO confirmed presence of aortic stenosis. Patient was preload dependent, and team was cautious in use of nitrates for blood pressure control. Patient was continued on outpatient statin and aspirin. . # NEUROLOGIC Patient with history of CVA [**07**] months ago, was continued on outpatient Plavix. No focal issues were encountered during hospital stay. . # HCT DROP Patient had gradual drop in Hct during hospital stay, and was managed with red cell transfusions. Patient was guiaic positive on exam, but stool was brown (not melanotic). Patient had no known history of endoscopy or colonoscopy. Given stability of Hct post-transfusion, existing comorbidities, 2 known primary malignancies, and other acute medical issues, further work-up was deferred to outpatient management. Mesenteric ischemia from expansion of dissection or other concerning acute pathology was ruled out with repeat imaging. Patient likely with anemia of chronic disease with overlying component of slow GI bleed. No acute blood loss leading to hemodynamic instability was witnessed. . # CODE STATUS Following extensive discussion between attending and patient, patient changed code status to DNR/DNI. . # PAIN Pain from aortic dissection and chronic low back pain were well controlled with Oxycontin 10mg PO BID. Patient did not tolerate lower doses as inpatient. Patient was kept on bowel regimen given opiate use. Medications on Admission: Diovan 160 mg PO qd Lipitor 80 HCTZ 25 Metoprolol 100 [**Hospital1 **] Plavix 75 PO qd Zantac 150 [**Hospital1 **] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 7. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary 1. Type B aortic dissection 2. Resolving ATN 3. Anemia . Secondary 1. HTN 2. DJD Discharge Condition: hemodynamically and clinically stable, without chest pain, BP under good control, Hct stable Discharge Instructions: 1. Please take all medications as prescribed 2. Please make all follow-up appointments 3. If you develop chest pain, shortness of breath, abdominal pain, or any other concerning signs/symptoms, please contact your PCP [**Name Initial (PRE) **]/or report to the Emergency Department immediately. Followup Instructions: Your first follow-up appointment is with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 7158**] [**Name8 (MD) 107141**], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2101-11-23**] 2:30. . Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2101-12-7**] 11:10 . Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5250**], M.D. Phone:[**Telephone/Fax (1) 5251**] Date/Time:[**2102-2-10**] 1:30 . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1843**], RN Phone:[**Telephone/Fax (1) 28471**] Date/Time:[**2102-2-10**] 2:00Provider: [**Name6 (MD) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2101-11-23**] 2:30 Completed by:[**2101-11-17**]

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icd9cm

[ [ [] ] ]

[ "99.04", "00.17", "38.95" ]

icd9pcs

[ [ [] ] ]

19202, 19273

13349, 18341

280, 287

19406, 19501

1531, 1638

19844, 20713

1131, 1135

18506, 19179

4441, 4495

19294, 19385

18367, 18483

19525, 19821

1150, 1512

201, 242

4524, 13326

315, 727

749, 1014

1030, 1115

1,442

173,708

25333

Discharge summary

report

Admission Date: [**2182-11-26**] Discharge Date: [**2182-11-29**] Date of Birth: [**2099-10-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1257**] Chief Complaint: hyponatremia Major Surgical or Invasive Procedure: none History of Present Illness: 83-year-old woman with history of CAD (s/p CABGx2 '[**79**]) and DM2 presented to [**Hospital1 **] with confusion x 1 week and weakness x 4 weeks. The patient has experienced weakness with an 8-lb weight loss since [**2182-7-7**]. Three weeks ago she had a few episodes of nonbloody diarrhea, presented to [**Hospital1 **] a few weeks ago for work-up, which was reportedly unrevealing. She was then diagnosed with an asymptomatic UTI, treated with antibiotics, during that admission. The diarrhea resolved after the discontinuation of stool softeners and she was discharged home. For the past week, according to her son, she was confused intermittently. She reports having poor PO intake for the past few weeks. Patient talked to her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6051**], on the phone the day of admission and reportedly had some confused speech. She presented to [**Hospital1 **] ED and was found to have Na 110 and transferred to [**Hospital1 18**] after getting 250 ml of NS then 3% NaCl IVF at 29 cc/hr. . In ED, T 98.0, BP 156/67, HR 66, RR 20, O2 sat 99%. Renal was consulted and recommended 3% NaCl at 15 ml/hr with q4h Na checks. . ROS: The patient reports 8-lb weight loss. Denies any fevers, chills, nausea, vomiting, abdominal pain, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, vision changes, headache, rash or skin changes. Past Medical History: CAD: s/p CABG (LIMA to LAD, SVG to PDA) in [**2179**] DM2 Hyperlipidemia Diverticulosis Anemia Osteoporosis Renal caluli PUD Kyphosis Social History: quit smoking in [**2173**] after 120 pack years. No EtOH or drug use. Lives by self after husband died 9 years ago. Grown-up children in the area. Family History: Mother, sisters and brothers all with [**Name (NI) 5290**] Physical Exam: Vitals: T: BP: HR: RR: O2Sat: GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2182-11-26**] 07:30PM BLOOD WBC-6.1 RBC-3.92* Hgb-11.9* Hct-33.0* MCV-84 MCH-30.3 MCHC-36.0* RDW-13.4 Plt Ct-238# [**2182-11-26**] 07:30PM BLOOD Neuts-67.9 Lymphs-27.5 Monos-3.8 Eos-0.6 Baso-0.2 [**2182-11-26**] 07:30PM BLOOD PT-13.2 PTT-36.4* INR(PT)-1.1 [**2182-11-26**] 07:30PM BLOOD Glucose-133* UreaN-11 Creat-0.6 Na-115* K-4.3 Cl-86* HCO3-23 AnGap-10 [**2182-11-26**] 11:33PM BLOOD Glucose-111* UreaN-9 Creat-0.6 Na-115* K-4.3 Cl-85* HCO3-24 AnGap-10 [**2182-11-27**] 03:23AM BLOOD Glucose-91 UreaN-9 Creat-0.6 Na-121* K-4.5 Cl-91* HCO3-25 AnGap-10 [**2182-11-27**] 08:02AM BLOOD Na-124* [**2182-11-27**] 03:23AM BLOOD ALT-26 AST-32 AlkPhos-49 TotBili-0.7 [**2182-11-26**] 07:30PM BLOOD Osmolal-242* [**2182-11-26**] 11:33PM BLOOD TSH-2.7 [**2182-11-27**] 08:02AM BLOOD Cortsol-18.4 . CXR: FINDINGS: In comparison with the study of [**2179-9-8**], there is again evidence of intact sternal sutures and the patient has undergone a previous CABG procedure. No evidence of vascular congestion, pleural effusion, or acute pneumonia. Brief Hospital Course: Summary by problem: 83-year-old woman with history of CAD (s/p CABGx2 in [**2179**]) and DM type 2 presented to OSH with confusion, weakness, 8-lb weight loss, nonbloody diarrhea, poor PO intake, and hyponatremia. She was recently trated with Celexa for depression. She was transferred to [**Hospital1 18**] ICU for hyponatremia and sodium level of 110. She was initially treated with 250 ml of NS and then 3% NaCl IVF at 29 cc/hr (hypertonic 3% saline). She received the latter for approx 4 hours and her Na rose from 110 to 115 in 5 hours. Her sodium rose the following morning to 121. She was then maintained on normal saline and free water restriction. She was then transferred out of the ICU to the medical floor. She was placed Off IV fluids on PO fluid restriction only. Sodium has been within normal levels for the last 3 days. However, she was noted to continue to have problems with cognition and gait. Her confusion and disorientation have resolved. She had no illusions, delusions, or hallucination. She had no focal neurological defects. . . # Hyponatremia: Cortisol and TSH levels were normal. A CT Chest was obtained to look for possible pulmonary malignancy (pulmonary causes of SIADH). It showed no evidence of any mass. Hyponatremia resolved on conservative management. We avoided the use of SSRI which could be responsible for her hyponatremia. . . #Cognitive impairment with gait abnormality with DDX of Delirium, frontal dementia, or normal pressure hydrocephalus. She was evaluated by Gerontology. She may need brain MRI if symptoms progress. However, most of her symptoms can be explained by depression and her OSH CT head was unremarkable. The geriatrics service questioned the diagnosis of [**Last Name (un) 309**] body or frontal lobe dementia. They recommended out patient follow up with neuropsychiatry. We avoided the initiation of new antidepressants in the hospital as we need to monitor their effects on her. This can be done in the out patient. . . # Diarrhea: resolved last 48 hours. Weight loss: may be related to underlying depression or see above. . . # CAD: History of 2-vessel CABG in [**2179**]. She was restarted on aspirin. Both carvedilol and Valsartan were restarted later as SBP was initially in 90s. . . # DM2: Oral hypoglycemics were held initially and she was maintained on an insulin sliding scale. Then we restarted Glyburide and placed Metformin on hold secondary to significant GI symptoms. . . # FEN: diabetic, free water restriction. . . # Code: DNR/DNI. . . Diso: to Rehab . . [**First Name4 (NamePattern1) **] [**Name8 (MD) **], M.D. . . . total discharge time 56 minutes Medications on Admission: alendronate ASA 81 mg qday calcium MVI atorvastatin 20 mg daily Fe valsartan 320mg daily omeprazole 20mg daily carvedilol 6.25 - 1.5 tabs [**Hospital1 **] glyburide 5mg po bid ezetimibe 10mg daily metformin 500mg daily Discharge Medications: 1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 15644**] Healthcare Center Discharge Diagnosis: Hyponatremia Depression Discharge Condition: good Discharge Instructions: stop metformin because of low appetite and diarrhea. Fluid restriction of 1200 ML daily. Stop Celexa monitor Sodium level twice weekly for 2 weeks and then, if levels are stable, once weekly for 1 month. Followup Instructions: PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 25493**]. Follow up with geriatrics and/or neuropsychiartry.

[ "285.9", "305.1", "E939.0", "733.00", "781.2", "737.10", "294.9", "253.6", "272.4", "414.00", "562.10", "250.00", "533.90", "V45.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7866, 7932

4065, 6695

330, 336

8000, 8007

3002, 4042

8260, 8400

2185, 2245

6965, 7843

7953, 7979

6721, 6942

8031, 8237

2260, 2983

278, 292

364, 1846

1868, 2004

2020, 2169

21,554

168,486

10909

Discharge summary

report

Admission Date: [**2133-9-20**] Discharge Date: [**2133-10-4**] Service: Neurosurgery Service HISTORY OF PRESENT ILLNESS: The patient is an 83 year old right-handed man brought to my [**Hospital **] [**Hospital 35467**] Hospital by the family status post a fall after his cane slipped on a wet surface and falling on his right knee. The family reported he had increased lethargy and weakness for two weeks prior to presentation and that the patient was not himself at all on presentation to the outside hospital. The patient had also reported that he was having hip pain for one week and that he had hit his head on the fall. The patient takes Coumadin at home for deep vein thrombosis. Computerized tomography scan was taken and showed evidence of subarachnoid and subdural hemorrhage. The patient was given Dilantin, fresh frozen plasma, Vitamin K and was transferred to [**Hospital6 1760**] for further management. The patient denied any chest pain, loss of consciousness, syncope, shortness of breath, fever, chills or nausea and vomiting. On admission to [**Hospital6 256**] the patient was admitted to the Intensive Care Unit for blood pressure control and frequent neurological checks. He was seen by Neurosurgery and found to have no acute indication for neurosurgery at that time. On admission his systolic blood pressure was 220. The patient remained stable in the Intensive Care Unit for 24 hours and became oriented times three and was less lethargic and was therefore transferred out of the Intensive Care Unit to the floor. PAST MEDICAL HISTORY: Noninsulin dependent diabetes mellitus, deep vein thrombosis with Factor [**First Name9 (NamePattern2) 7060**] [**Location (un) 5244**] mutation, cerebrovascular accident on the left side with left-sided weakness, glaucoma, diverticulosis, nephrolithiasis, poor caval shunt for cirrhosis and varices, diverticulitis and malaria. MEDICATIONS: Coumadin, Avandia, Demodex, Glucotrol and glaucoma drops. PHYSICAL EXAMINATION: On physical examination the patient was awake, alert and oriented times three with no external evidence of head trauma, no stiff neck. Neurologically the patient was awake, normal extraocular muscles, visual fields were normal and funduscopic examination showed no blood, no ptosis, face symmetric. Cranial nerves were grossly intact. Head computerized tomography scan from an outside hospital showed subarachnoid blood over the frontal convexity bilaterally and layered blood in the occipital hones of both lateral ventricles. Magnetic resonance imaging scan of the head confirmed computerized tomography scan findings and magnetic resonance angiography was of poor quality. On physical examination this was an alert, awake patient in no acute distress. Cardiovascular, S1 and S2, I/VI systolic murmur. Pulmonary, lungs clear to auscultation except for bibasilar crackles, no wheezing, abdomen was soft, nontender with positive bowel sounds. Extremities, no edema, clubbing or cyanosis. The patient had a mild left pronator drift, strength was 4+/5, normal bulk and tone. Mild left dysmetria. Reflexes were 3+ in the upper extremities and 2+ in the lower extremities and toes were upgoing bilaterally. He had a negative [**Doctor Last Name **] sign. Sensation was intact to light touch. HOSPITAL COURSE: The patient had an episode of wide complex tachycardia to a rate of 133. CPKs were cycled. The patient had no chest pain, palpitations or diaphoresis with this episode. He was started on Lopressor for rate control. Cardiology was consulted. The patient also ruled in for a deep vein thrombosis on the right side. He had an inferior vena cava filter placed. On [**2133-9-23**] the patient was found unresponsive. Stat head computerized tomography scan showed new left temporal bleed with mild mass effect and shift. The patient was transferred back to the Intensive Care Unit. The patient had urgent neurosurgery consult who placed an external ventricular drain in the patient. Computerized tomography scan showed marked intracerebral hemorrhage with subarachnoid hemorrhage into the suprasellar cisterns and intraventricular blood. The patient went on angiogram on [**2133-9-23**] which showed a left middle cerebral artery bifurcation, bilobar aneurysm. The patient was taken emergently to the Operating Room for a clipping of the aneurysm which was done successfully without intraoperative complications. On [**2133-9-24**] the patient had a low sodium and was started on 3% saline at 10 cc/hr. Postoperative he had high CPKs into the 300s with a positive MB but no associated ischemic electrocardiogram changes and a troponin level of 39.5 on [**2133-9-23**]. The patient was continued to be followed by Cardiology. The patient was treated with Esmolol for rate control. Neurologically on the day of surgery the patient was sedated with minimal spontaneous movement of his extremities. His pupils were 3, down to 1.5 mm and briskly reactive. He had no withdrawal to painful stimuli in the upper extremities and slight withdrawal of the lower extremities with triple flexion to painful stimuli in the lower extremities. The patient continued to be followed by the Hematology/Oncology Service for his thrombocytopenia as well as his Factor V deficiency. Hematology/Oncology is likely attributing his thrombocytopenia to underlying liver disease with splenomegaly. The patient had cardiac echocardiogram on [**2133-9-26**] which shows preserved left ventricular function. On [**2133-9-28**], the pupils are 5 mm and slightly reactive, otherwise the patient remained unresponsive. His chest x-ray showed bilateral pleural effusions. He continued on Kefzol 1 gm intravenously q. 8 hours. The patient had repeat head computerized tomography scan on [**2133-9-28**] which was unchanged from previous scans. On [**2133-10-1**], after being weaned off of sedation for 24 hours the patient continued to be unresponsive to painful stimuli in his upper extremities and had slight triple flexion to painful stimuli in his lower extremities. The patient also had intact corneal reflexes but no gag reflex and continued to breathe spontaneously over a ventilator. At a family meeting on [**2133-10-4**] it was determined that the patient would not want to be kept alive by artificial means. The patient was extubated and placed on a Morphine drip. He expired on [**2133-10-4**] at 1645. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2134-1-6**] 12:19 T: [**2134-1-6**] 18:35 JOB#: [**Job Number 23320**] RP12/24/[**2133**]

[ "287.5", "250.00", "518.5", "430", "997.3", "486", "410.71", "286.3", "453.8" ]

icd9cm

[ [ [] ] ]

[ "38.7", "96.72", "39.51", "88.41", "96.6" ]

icd9pcs

[ [ [] ] ]

3329, 6709

2011, 3311

135, 1562

1585, 1988

23,650

102,161

1005

Discharge summary

report

Admission Date: [**2115-3-29**] Discharge Date: [**2115-3-29**] Service: MEDICINE Allergies: Demerol Attending:[**First Name3 (LF) 425**] Chief Complaint: Transfer from OSH Major Surgical or Invasive Procedure: None History of Present Illness: This is a 87 y/o F with h/o CAD s/p CABG [**01**] who is transfered from OSH after having PEA arrest s/p Right knee replacement. . Patient underwent Right knee replacement [**2115-3-28**] without aparent complications. This morning at around noon patient went into afib with RVR, diltiazem drip was started but after a bolus she started droping her HR and BP, code blue was called, patient received epinephrine, atropine x1 and was intubated. There were no strips sent during the code. EKG were received and it seems that patient had an inferior MI and also escape junctional rhytm after the events. Echocardiogram was done that showed dilated RV and given high suspicion for PE patient was started heparin. Patient remained hypotensive levophed and dopamine were started. . Patient transfered to [**Hospital1 18**] for further management. Past Medical History: 1. CAD - s/p CABG two vessels [**2101-11-21**] LIMA--LAD, SVG -- OM1 2. HTN 3. Paget's disease 4. Hyperthyroidism 5. History of seizures 6. Paroxysmal SVT 7. Osteoarthritis 8. s/p Total abdominal histerectomy 9. s/p Right Knee replacement [**2115-3-28**] Social History: Lives at home. Daughter lives upstairs. Per prior records no tobacco use. No alcohol abuse. Family History: No family history of CAD. Physical Exam: VS: SBP 60's. HR 80 externally paced, Sats 93% AC 450/18/100/10 General: Patient intubated, sedated, pale HEENT: pupiles dilated non reactive to light. Fixed. doll's eyes. No JVD appreciated, no lymphadenopathy. Oropharinx: ETT tube in placed. echymosis upper lip. Lungs: clear to ausculation bilaterally. Cardiovascular: distant heart sounds, regular rate rhytm, no murmurs appreciated. Abdomen: BS decreased, mildly distended. obese. No hepatomegaly. Extremities: cold, clamy, cyanotic. Pertinent Results: [**2115-3-29**] 09:19PM LACTATE-12.3* [**2115-3-29**] 09:19PM TYPE-ART O2-100 PO2-61* PCO2-30* PH-7.19* TOTAL CO2-12* BASE XS--15 AADO2-641 REQ O2-100 -ASSIST/CON INTUBATED-INTUBATED [**2115-3-29**] 09:23PM PT-22.7* PTT-150* INR(PT)-2.2* [**2115-3-29**] 09:23PM PLT COUNT-108* [**2115-3-29**] 09:23PM WBC-21.4* RBC-4.26 HGB-12.6 HCT-38.2 MCV-90 MCH-29.6 MCHC-33.0 RDW-14.5 [**2115-3-29**] 09:23PM CALCIUM-7.0* PHOSPHATE-5.9* MAGNESIUM-2.7* [**2115-3-29**] 09:23PM ALT(SGPT)-11 AST(SGOT)-81* LD(LDH)-699* CK(CPK)-402* ALK PHOS-75 TOT BILI-0.8 [**2115-3-29**] 09:23PM estGFR-Using this [**2115-3-29**] 09:23PM GLUCOSE-425* UREA N-10 CREAT-1.1 SODIUM-134 POTASSIUM-5.6* CHLORIDE-100 TOTAL CO2-16* ANION GAP-24* . EKG: Hr 53, junctional scape rhytm. St elevation III. 2D-ECHOCARDIOGRAM bed side echo: largely dilated RV. EF ~ 10-15% Brief Hospital Course: This is a 87 y/o with h/o HTN, CAD s/p CABG, s/p recent R knee replacement c/b PEA arrest likely secondary to PE transfered for further management. # Hypoxemic Respiratory Failure: Patient with an elevatede A-a gradient, FIo2 100% and PaO2 60, x ray with no clear evidence of infiltrates, this is more likely secondary to pulmonary embolism - continue vent support - heparin drip - midazolam - fentanyl drip - recheck x ray after transfer for ETT tube . # Hypotension: Patient with severe hypotension on dopamin and levophed drip on arrival. Likely secondary to poor cardiac output secondary acute PE. - continue IV fluids - continue dopamin, levophed, and add vasopresin - Bedside Echo - holding all BP meds - Stat labs - lactate . # Cardiac: CAD: EKG from OSH showed st elevations in the inferior leads. Last troponin 3.36 More likely demand ischemia in the setting of acute hypotension. . Rhytm: after external pacer was discontinued, patient with a junctional escape rhytm. - continue to monitor . Pump: cardiogenic shock - Bed side echo - continue dopamin, levophed . # Neuro: patient with fix dilated pupiles and dull eyes which represent severe brain injury. Very poor likelyhood of recovery. . # Communication: daughter [**Name (NI) **] HCP - [**Telephone/Fax (1) 6621**] cell [**Telephone/Fax (1) 6622**] (H), [**Telephone/Fax (1) 6623**] (w) Addendum: After patient evaluation, patient clinical status was discussed with daughter [**Name (NI) **] at length. Given the poor prognosis of recovery, worsening acidosis, poor neurological status patient's code status is changed to DNR. No further scalation of care. The patient died within 4 hours of admission to the hospital. Medications on Admission: Medications on transfer: Heparin drip Fentanyl Midazolam Dopamin drip Norepinephrine Home Meds: Fosamax 10 mg daily aspirin 81 mg p.o/ day phenobarbital 6.2 mg t.i.d. quinapril 20 mg p.o/ day metoprolol 37.5 mg p.o. b.i.d. methimazole 5 mg q.a.m. alternating with 2.5 mg Dilantin 100 mg p.o. t.i.d. Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A

[ "V45.81", "348.1", "458.29", "785.51", "427.5", "401.9", "410.41", "V43.65", "415.19", "518.5", "997.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5007, 5016

2938, 4628

232, 238

5063, 5068

2065, 2915

5120, 5126

1513, 1540

4979, 4984

5037, 5042

4654, 4654

5092, 5097

1555, 2046

175, 194

266, 1108

4679, 4956

1130, 1387

1403, 1497

22,213

148,154

27423

Discharge summary

report

Admission Date: [**2190-6-26**] Discharge Date: [**2190-6-29**] Date of Birth: [**2126-9-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 7539**] Chief Complaint: Transfer for acute CHF exacerbation Major Surgical or Invasive Procedure: Intubation History of Present Illness: 63 y/o man with PMH of DMII, COPD, CKD/ESRD on HD, 3VD s/p RCA stent ([**5-13**]). Admitted to OSH with resp distress, intubated and noted to have elev tropI and CKs. Pt developed acute dyspnea and nausea while watching TV with his family late PM on [**6-25**]. Denied CP per notes. Intubated in OSH ED. Peak myoglobin > 1000, Troponin I 0.74. . Recently admitted to OSH ([**6-16**]) with CHF exac from dietary indiscretion which family says has been continuing issue. . Upon admission, decision was made not to take for immediate intervention given his questionable NSTEMI and known anatomy. Cards to consider intervention on Monday. Past Medical History: 1. CAD- known 3VD with 90% RCA s/p DES, 70% ulcerated LMCA lesion, pt and CT [**Doctor First Name **] declined CABG ([**5-13**]) [**3-11**] co-morbidities (ICA disease, ESRD) Cath [**2190-6-3**] = Right dominant circulation. LMCA was short and heavily calcified with a distal taper. LAD proximal eccentric 80% lesion and the distal vessel had a tubular 70% lesion. Numerous diagonal arteries were without critical lesions. LCx = non-dominant vessel with heavy calcifications. Only a ramus was seen and it was occluded proximally. RCA = dominant vessel with a proximal 99% lesion. The abdominal aorta was found to have moderate diffuse disease with iliac aneurysmal dilation and poor distal flow to the CFA. The RCA was stented with a 3.0 x 18 Cypher. The final residual was 0% with normal flow. 2. DMII 3. ESRD on HD- Tuesday, Thursday, and Saturday. 4. COPD 5. Hypertension 6. s/p CVA, b/l ICA occlusion 7. s/p ccy Social History: Pt is separated from his wife. [**Name (NI) **] has not worked for the past three years but used to be employed as a salesman. He has an 80 pack year tobacco history and smokes 2.5 packs per day. ? EtOH use. Denies IV drug use. Family History: He is unsure of what diseases run in his family. He reports that his parents had "all the big diseases." His brother had an aneurysm. He reports that his sister has inner ear troubles. Physical Exam: 100.6 120/80 109 20 AC 600x FiO2 0.4 PEEP 5 Gen- Intubated and sedated Neck- L >R carotid bruit Cardiac- II/VI systolic murmur, crescendo/descrescendo Pulm- exp wheeze, mild basilar rales Abdomen- soft, + BS Extremities- cool, 1+ palpable DPs Neuro- responds to voice, follows simple commands Pertinent Results: [**2190-6-26**] 11:49PM TYPE-ART PO2-118* PCO2-41 PH-7.55* TOTAL CO2-37* BASE XS-12 [**2190-6-26**] 11:49PM LACTATE-1.4 [**2190-6-26**] 07:58PM GLUCOSE-104 UREA N-16 CREAT-3.5*# SODIUM-142 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-30 ANION GAP-18 [**2190-6-26**] 07:58PM ALT(SGPT)-10 AST(SGOT)-24 LD(LDH)-202 CK(CPK)-249* ALK PHOS-84 TOT BILI-0.2 [**2190-6-26**] 07:58PM CK-MB-3 cTropnT-0.41* proBNP-[**Numeric Identifier 67127**]* [**2190-6-26**] 07:58PM ALBUMIN-4.0 CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-1.9 [**2190-6-26**] 07:58PM WBC-9.0 RBC-3.42* HGB-10.0* HCT-29.9* MCV-87 MCH-29.3 MCHC-33.6 RDW-15.9* [**2190-6-26**] 07:58PM NEUTS-82.2* LYMPHS-13.4* MONOS-3.9 EOS-0.3 BASOS-0.2 [**2190-6-26**] 07:58PM PLT COUNT-245 [**2190-6-26**] 07:58PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.014 [**2190-6-26**] 07:58PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-MOD [**2190-6-26**] 07:58PM URINE RBC-[**7-17**]* WBC-[**7-17**]* BACTERIA-OCC YEAST-NONE EPI-0-2 . ECG: sinus tachy at 100, nl axis, 1-[**Street Address(2) 1766**] depr V3-V6, I, L (old, v3-v6 improved) . Imaging: CXR = no signif pulm edema/infiltrates, lines and tubes ok . ECHO: EF 45-50% The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with nmore prominent hypertrophy of the basal septum, but no resting LVOT gradient. Normal cavity size with hypokinesis of the basal half of the inferior wall. The remaining segments contract well. Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure. 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. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . Brief Hospital Course: A/P:63 yo male with 3VD s/p RCA DES ([**5-13**]) p/w acute pulm edema at OSH and ?NSTEMI. . #) CAD: known 3VD, not CABG candidate; recent RCA DES, 80% LAD lesion, diffuse LCx disease, now with ?NSTEMI -- rx with ASA, plavix, high dose statin, beta blocker, hep gtt, -- NO GIIbIIIa (given ESRD) -- cycle CKs, follow EKGs -- to more urgent cath if hemodynamics worsen, STE develop... . #) Pump: -- recent TTE with EF 40-45%, mild sLVH, mild global HK, mildly dilated LA; repeat TTE in 48hrs -- volume o/l noted at OSH and here BNP > 54,000 -- will consider PA cath if hemodynamics change . #) Rhythm: -- NSR, follow EKGs . #) Resp failure: -- likely related to acute pulm edema from ?ischemic event, volume o/l from inadequate HD -- will try to wean vent as tolerated -- pt with known COPD, tolerate elev pCO2 (approx 55) -- c/w ATC combivent MDI . #) ESRD on HD: - Getting HD TTHSat; had HD on [**6-26**] at OSH. - c/w EPO, hold phoslo for now - Renal following . #) Fever: Could be COPD exacerbation/bronchitis vs. UTI vs. inflammation (s/p MI, pulm edema, etc.) - Sputum, blood and urine cx - CXR clear - Will trend fever curve and CXR and exam and assess WBCs in am. Consider Azithromycin for acute exacerbation of COPD . #) s/p CVA: b/l 100% ICA stenosis -- monitor neuro status, c/w ASA, plavix, statin for [**3-11**] prevention . #) COPD: -- ATC MDI as above -- bl pCO2 near 55 based on HCO3 . #) DM 2: -- RISS, hold oral hypoglycemics . #) FEN: -- NPO for now, start TF if intervention not planned for > 24hrs . #) Dispo: Full Code. . #) Communication - sister, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 67128**] . Medications on Admission: 1. Paxil 2. Lopressor 50 mg [**Hospital1 **] 3. Plavix 300 mg x1 4. Protonix 5. Dilantin 400 daily 6. Nephrocaps 1 tab daily 7. Lipitor 40 mg daily 8. Gemfibrozil 600 mg [**Hospital1 **] 9. Phoslo 10. Combivent 11. Advair 12. ASA 13 Humulin 10mg [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Insulin Regular Human 100 unit/mL Solution Sig: Ten (10) units Injection twice a day: same outpatient dose. 8. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): during dialysis. 9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 10. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 12. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. Dilantin 100 mg Capsule Sig: Four (4) Capsule PO once a day. 14. Paxil 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Primary: CHF CAD Resp failure Secondary: ESRD COPD DM2 Discharge Condition: Stable Discharge Instructions: Please take all medications as prescribed. Seek medical attention immediately if you experience symptoms including shortness of breath, chest pain, numbness, fatigue, weakness, seizure, arm or jaw pain or any other new concerning symptoms. You need to avoid salty foods including pizza and chinese food. These foods are clearly causing you to have excess fluid in your lungs. Follow up as per below. Followup Instructions: 1) [**Last Name (LF) 39008**], [**Name6 (MD) **] G MD [**Doctor Last Name 67129**] #201 Doctors phone [**Name5 (PTitle) 67130**]: [**Telephone/Fax (1) 57082**]. Friday [**6-29**] @ 11am 2) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2190-9-20**] 11:30 Completed by:[**2190-6-29**]

[ "518.81", "410.71", "250.00", "428.0", "403.91", "496", "414.01", "V45.82", "585.6" ]

icd9cm

[ [ [] ] ]

[ "96.71", "39.95", "96.04" ]

icd9pcs

[ [ [] ] ]

8134, 8190

4851, 6489

358, 371

8290, 8299

2755, 4828

8750, 9117

2237, 2426

6803, 8111

8211, 8269

6515, 6780

8323, 8727

2441, 2736

283, 320

399, 1036

1058, 1976

1992, 2221

23,833

195,898

52282

Discharge summary

report

Admission Date: [**2137-5-25**] Discharge Date: [**2137-6-5**] Service: General Surgery ADMISSION DIAGNOSIS: Small bowel obstruction. HISTORY OF PRESENT ILLNESS: The patient is an 85 year-old Hispanic speaking male status post laparoscopic cholecystectomy [**4-10**] for gallstone pancreatitis. The patient was doing well at home postoperatively until he developed epigastric pain over the past 24 hours. Over the past 8 hours prior to admission the pain became sharp and more severe in nature. The patient describes radiation to his back. There is also associated nausea and emesis times two. Emesis was nonbilious. The patient also notes that he had not had bowel movements during the two days prior to admission. He denies fevers or chills. PAST MEDICAL HISTORY: Atrial fibrillation on Coumadin, which was discontinued. Gout, arthritis, status post laparoscopic cholecystectomy [**2137-4-10**]. MEDICATIONS: Colace, Percocet, Coumadin, the three of which were discontinued. Lopressor 50 b.i.d., Allopurinol 300 q.d., Protonix 40 q.d., aspirin q.d. PHYSICAL EXAMINATION: Vital signs temperature 98. Pulse 100. Blood pressure 168/78. Respiratory rate 16. Sats 94% on room air. General, well developed, well nourished, alert and oriented times three, nontoxic appearing. Cardiac regular rate and rhythm. Lungs clear to auscultation bilaterally. Abdomen distended, nontender. Rectal examination normal tone, guaiac negative. LABORATORY STUDIES: White blood cell count 18, hematocrit 43, platelets 378, panel 7 within normal limits. Amylase 44, lipase 42, CPK 69, troponin less then 0.3. Abdominal ultrasound 6 mm common bile duct, no stones. KUB multiple air fluid levels. No distal air. HOSPITAL COURSE: The patient presented to the Emergency Department on [**2137-5-25**]. Given his obstructive symptoms he was placed with a nasogastric tube, Foley and placed on intravenous fluids. Serial examinations throughout the course of the day noted that his belly was soft, minimally tender and nondistended. There is no flatus or nausea. Repeat white blood cell count was 12.8. Preoperative studies included a urinalysis, which was notable for a large amount of blood and moderate bacteria. Electrocardiogram showed no ST or T wave changes. On [**5-26**] hospital day number two on AP and lateral view of the abdomen was notable for multiple gas distended loops of small bowel, fluid levels and small amount of gas in the colon. The small bowel distention slightly increased since the prior film the day before literally. The examination was consistent with small bowel obstruction. On [**2137-5-26**] the patient was taken to the Operating Room for exploratory laparotomy and lysis of adhesions. Surgical findings included a small bowel mesenteric abscess. There was evidence of sigmoid ticks with chronic inflammation with bonds to the mesentery. Notably urology was consulted in the setting of the Operating Room and assisted with placement of a 16 French Foley catheter. Postoperatively, the patient's abdomen was minimally distended with diffuse tenderness. The patient's white count was 11.1, hematocrit 32.5. Panel 7 was within normal limits. Postoperative day number one the patient's abdomen was soft and appropriately tender. The patient was NPO and was receiving intravenous fluids. Nasogastric output was 50 cc following surgeries and 400 cc on postoperative day number one. On postoperative day number two the patient's abdomen was soft, nontender, nondistended and his dressing was clean dry and intact. He remained afebrile. On postoperative day number three the patient's nasogastric tube was discontinued. His abdomen remained benign. Later in the day the patient complained of knee pain, which was consistent with the history of gout. The patient was started on Allopurinol. On postoperative day number four the patient was passing flatus and had a bowel movement. Diet was advanced to clears. The patient was heplocked and changed to po medications. Later in the day on [**5-30**], the patient's cardiac rhythm changed to rapid atrial fibrillation with a ventricular rate in the 140s. Cardiology was consulted. The patient remained hemodynamically stable and was asymptomatic. Notably the patient had preserved left ventricular ejection fraction from an echocardiogram of [**2136-3-9**]. There is no evidence of PR prolongation or bundle branch block. The patient was subsequently rate controlled with intravenous and po Lopressor. The patient was kept on telemetry and electrolytes were repleted. Overnight the patient received 20 mg of intravenous Lopressor on [**5-30**]. However, the patient's heart rate remained in the 140s the morning of [**5-31**]. The patient was subsequently transferred to the Intensive Care Unit for Diltiazem drip. On postoperative day number six the patient's heart rate was controlled with a pulse of 69. Blood pressure was 128/55. CPV was 15. The patient was kept in the CICU. On postoperative day number seven the patient received intravenous Lasix for wheezing. He was continued on Ampicillin, Levo and Flagyl. The patient's A line was discontinued. On postoperative day number eight the patient was transferred to the floor. Again he received a dose of intravenous Lasix for bibasilar crackles and mild wheezing. The patient was continued on heparin and Coumadin dosing was started. His Metoprolol dose was decreased to 75 mg po b.i.d. On [**2137-6-5**] the patient was accepted by [**Location (un) 86**] Center in [**Location (un) 2312**]. He was subsequently discharged. FOLLOW UP INSTRUCTIONS: The patient will be transferred to rehab for dressing changes and monitoring of his cardiac rhythm. He will require wet to dry dressing changes twice a day. The patient will follow up with Dr. [**Last Name (STitle) 5182**] in two weeks. DISCHARGE MEDICATIONS: 1. Lopressor 75 mg po b.i.d. hold for systolic blood pressure less then 100 or heart rate less then 60. 2. Amiodarone 200 mg po q.d. 3. Allopurinol 300 mg po q.d. 4. Percocet one to two tabs po q 4 to 6 hours prn. 5. Protonix 40 mg po q.d. 6. Indomethacin 50 mg po b.i.d. 7. Albuterol nebulizers q 6 hours prn. 8. Atrovent nebulizers q 6 hours prn. 9. Coumadin 2 mg titrate for goal INR 2 to 2.5. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 49859**] Dictated By:[**Last Name (NamePattern1) 108101**] MEDQUIST36 D: [**2137-6-5**] 08:24 T: [**2137-6-5**] 08:35 JOB#: [**Job Number 108102**]

[ "789.5", "562.10", "274.9", "560.81", "427.31", "567.2" ]

icd9cm

[ [ [] ] ]

[ "54.59", "45.02" ]

icd9pcs

[ [ [] ] ]

5904, 6571

1749, 5881

1101, 1731

120, 146

175, 765

788, 1078

6,756

166,095

9378

Discharge summary

report

Admission Date: [**2142-8-3**] Discharge Date: [**2142-8-19**] Date of Birth: [**2070-1-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9180**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Tunneled hemodialysis line placement Upper endoscopy Persantine sestamibi cardiac imaging History of Present Illness: Mr. [**Known lastname 32034**] is a72 year old man with history of type I diabetes with triopathy, Cr4, and CHF(last ETT in [**2139**] reportedly normal). The patient was in his usual state of health until until yesterday when he woke up with non-productive cough. The patient and his son thought this might be a cold, but decided to go to [**Hospital 32036**] Hospital today where they noted that he had an O2 sat in 80's on room air. He was given a dose of lasix and was transferred to [**Hospital1 18**] for further workup. The ED noted him to be in CHF, JVP to jaw and lat ST depressions (which are old). Pt reported to be 92% on 4L. Pt also given levaquin 500mg x1. Past Medical History: Type I diabetes mellitus, dx in [**2105**] complicated by: - peripheral neuropathy - retinopathy - nephropathy Hypertension Aortic Stenosis Chronic renal insufficiency Spinal spondylosis Idiopathic dilated cardiomyopathy BPH Compression fracture C4-5 Bone cancer in childhood Social History: Mr. [**Known lastname 32034**] lives with his son and his son??????s wife and daughter in [**Name (NI) **]. His son has been very involved in his care since last [**Month (only) 956**] ([**2139**]). He has another son, two biological daughters and an adopted daughter. His wife passed away 10yrs ago. He is a retired police officer. He has a 60 pack-year smoking hx, but quit many years ago. He used to drink ~8 drinks/day, but also quit some time ago and neither smokes or drinks anymore. Family History: Noncontributory Physical Exam: VS: T 98.6 HR 92 reg BP 158/63 RR 22 Sat 85% RA --> 91% 5L Gen: Pleasant man in bed in moderate respiratory distress HEENT: Neck: JVP to angle of jaw. CV: normal s1/s2, tachy, regular Pul: Rales > [**12-29**] way up with associated wheezes Abd: Soft, NT, ND +BS Ext: 1+ LE edema. DP 2+ b/l, no femoral bruits. Fistula with sutures in forearm, good bruit. Neuro: Awake, alert, oriented to person, place. Pertinent Results: EKG [**2142-8-3**]: NSR, nl axis, ST dep V5-6 (old) CXR [**2142-8-3**]: Lateral aspect of the right lower chest is excluded from the examination. Pulmonary vascular congestion is more pronounced. Heart size is top normal. Small left pleural effusion may be present. Greater opacification of the retrocardiac lung is probably due to atelectasis at both lung bases, though pneumonia cannot be excluded. No pneumothorax. [**2142-8-14**] 1. No evidence to suggest ischemia or infarction. 2. Severely enlarged left ventricular cavity size, increased from prior study. 3. LVEF 34%, decreased from prior study. [**2142-8-4**] ECHO The left atrium is elongated. 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. Overall left ventricular systolic function is severely depressed with global hypokinesis. No masses or thrombi are seen in the left ventricle. There is mild global right ventricular free wall hypokinesis. The aortic root is mildly dilated. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2142-1-2**], severe LV systolic dysfunction, pulmonary hypertension and afib are new . COAGS [**2142-8-18**] 12:45PM BLOOD PT-22.1* PTT-32.8 INR(PT)-2.2* CHEMISTRIES [**2142-8-3**] 12:15PM BLOOD Glucose-216* UreaN-74* Creat-4.2* Na-135 K-4.9 Cl-100 HCO3-22 AnGap-18 [**2142-8-18**] 08:30AM BLOOD Glucose-181* UreaN-27* Creat-2.9* Na-135 K-3.7 Cl-96 HCO3-29 AnGap-14 [**2142-8-3**] 12:15PM BLOOD CK-MB-6 cTropnT-0.13* proBNP-[**Numeric Identifier 32037**]* [**2142-8-7**] 05:48AM BLOOD PTH-105* [**2142-8-4**] 06:30AM BLOOD TSH-2.3 [**2142-8-7**] 05:48AM BLOOD calTIBC-231* Ferritn-344 TRF-178* HEPATITIS SEROLOGIES [**2142-8-7**] 05:48AM BLOOD HCV Ab-NEGATIVE [**2142-8-7**] 05:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE Brief Hospital Course: Mr. [**Known lastname 32034**] is a 72 year old man with history of type I diabetes, chronic renal insufficiency (cr4) pre-dialysis, here with congestive heart failure exacerbation of unknown etiology. 1) Cardiac: His CHF was initially treated aggressively with diuretics and diuresed well with lasix + metolazone ant nitroglycerin drip. Mr. [**Known lastname 32038**] [**Known lastname 461**] was last done in [**2141-12-27**] and was noted to have an EF of 50%. Repeat echo done on [**8-4**] (albeit done shortly after going into AF) notes a much lower EF of 25% with diffuse wall motion abnormalities. On his second hospital day, he developed atrial fibrillation with rapid ventricular response (he had no symptoms even with a HR to 160's). The differential diagnosis for his diffuse cardiomyopathy was ischemia versus a tachycardia-induced cardiomyopathy. Heart rate control was attempted with lopressor as well as low-doses of diltiazem. On his third hospital day, he developed hypotension and required transfer to the CCU. Heparin drip was started for the atrial fibrillation and after transfer to the CCU, the patient developed an upper GI bleed. Cardioversion was performed. He received one shock and went into sinus rhythm for less than 1 minute. Amiodarone IV and then a PO load was started. His synthroid dose was also lowered. His hypotension on the floor was later attributed to his upper GI bleeding. Within 1-2 days, the patient's AF reverted to a predominantly sinus rhythm, but he continued to have 2-6hr runs of AF to the low 100's noted on telemetry. He will continue 400mg daily for a total of one month. Prior to discharge, his beta blocker was converted from metoprolol to carvedilol 25mg twice daily. 2) GI For his upper GI bleed, this came on in the setting of initial anticoagulation for his atrial fibrillation. He had a positive NG lavage x1liter. An urgent EGD was performed and ulcerations were noted in his esophagus and stomach. He was started on carafate for about a week as well as protonix twice daily. 3) Renal For his renal failure, he had a fistula placed to his right arm in late [**Month (only) 216**] prior to this admission. Nephrology was consulted and they recommended starting the patient on hemodialysis for help with his fluid management. 4) ID The patient had a productive cough, and an abnormal chest exam. He was initially treated with levaquin, dosed renally. Given its QT prolonging effects, and a rising white blood cell count, this was changed to cefepime. He received a total of 2wks of antibiotics and his WBC slowly fell to 8. 5) Nutrition Renal diet. 1500cc fluid restriction. Nutrition was consulted. 6) Prophylaxis The patient was initially on heparin sc, then a heparin drip, and then coumadin for DVT prophylaxis. Following his GI bleed, he was treated with protonix twice daily. 7) Communication: was with the patient, his daughter [**Name (NI) **] and son [**Name (NI) **]. [**Known firstname **] [**Last Name (NamePattern1) **]. is his HCP, power of attorney and family spokesperson. Home# [**Telephone/Fax (1) 32039**] / cell [**Telephone/Fax (1) 32040**] Medications on Admission: Lantus 20u at bedtime HISS Toprol 100mg daily Citalopram 40mg at bedtime Lasix 20mg daily Procardia XL 60mg daily Aspirin 81mg daily Calcium-Vit D 600-200 daily Terazosin 2mg at bedtime Levothyroixne 25mcg daily Iron 325mg daily Colace 100mg twice daily Discharge Disposition: Home With Service Facility: vna carenetwork Discharge Diagnosis: Congestive heart failure EF 25% Tachycardic cardiomyopathy Upper GI bleed Pneumonia Atrial fibrillation with rapid ventricular response Renal failure requiring hemodialysis Type I Diabetes Mellitus Hypotension Discharge Condition: Stable, afebrile, satting well on room air Discharge Instructions: Please seek medical attention for fevers > 101, for chest pain, for shortness of breath, or for anything else concerning to you. Please take all of your medications as directed. Followup Instructions: Please have your INR checked (see prescription) on Wednesday [**8-21**] and have the results sent to Dr. [**Last Name (STitle) 713**]. Please report to dialysis as had been arranged. Please schedule an appointment with Dr. [**Last Name (STitle) **] within [**11-27**] weeks following discharge. Please schedule an appointment with Dr. [**Last Name (STitle) 713**] in [**11-27**] weeks. 1) Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT CENTER - NON BILLING Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-9-25**] 7:45 2) Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2142-9-25**] 8:30 3) Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2143-1-10**] 9:00

[ "250.41", "585.6", "486", "424.1", "427.31", "428.0", "532.40", "531.40", "425.4" ]

icd9cm

[ [ [] ] ]

[ "44.43", "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

8323, 8369

4865, 8018

334, 426

8623, 8668

2413, 4842

8896, 9685

1955, 1972

8390, 8602

8044, 8300

8692, 8873

1987, 2394

275, 296

454, 1132

1154, 1431

1447, 1939

30,924

110,932

10055

Discharge summary

report

Admission Date: [**2173-3-12**] Discharge Date: [**2173-3-21**] Date of Birth: [**2097-5-3**] Sex: F Service: CT SURGERY ADMISSION DIAGNOSIS: Coronary artery disease. DISCHARGE DIAGNOSIS: Coronary artery disease, status post coronary artery bypass graft times five. HISTORY OF PRESENT ILLNESS: The patient is a 75 year old woman with a history of coronary artery disease, status post percutaneous transluminal coronary angioplasty and stent placement in [**2167**], for angina. She has been well for the past five and one half years until one week prior to admission where she developed crescendo angina with episodes occurring at rest. Workup at [**Hospital3 **] ruled out a myocardial infarction. However, Persantine Thallium showed a reversible defect in the posterolateral wall with an ejection fraction of 60%. She was referred for catheterization at [**Hospital1 69**]. Her catheterization showed 70 to 80% left main and left anterior descending stent D1 disease. No significant circumflex disease. Left to right collaterals to the right posterior descending artery. Right coronary artery with a tight midlesion and proximal ostial posterior descending artery lesion. The ejection fraction was preserved at 60%. PAST MEDICAL HISTORY: Significant for: 1. Coronary artery disease, status post stent in [**2167**], as above. 2. Hyperlipidemia. 3. Noninsulin dependent diabetes mellitus. 4. History of deep vein thrombosis times two in the right lower extremity, status post venous ligation with veins left in situ by report. 5. Status post cholecystectomy. 6. Arthritis in both knees, status post steroid injections. MEDICATIONS ON ADMISSION: 1. Glucophage 1000 milligrams p.o. q.d. 2. Glucotrol 10 milligrams q.d. 3. Actos 45 milligrams q.d. 4. Lipitor 20 milligrams q.d. 5. Lopressor 25 milligrams q.d. 6. Vasotec 10 milligrams q.d. 7. Aspirin 81 milligrams q.d. 8. Coumadin which was held for catheterization. ALLERGIES: Morphine, Codeine which cause nausea and vomiting. PHYSICAL EXAMINATION: On admission, significant for regular rate and rhythm. The lungs are clear. Palpable distal pulses. LABORATORY DATA: On admission, significant for a white count of 10.0, hematocrit 30.0. Normal chemistries. Normal coagulation studies. Electrocardiogram shows sinus rhythm at 78 with left axis deviation and left ventricular hypertrophy. Chest x-ray showed no acute cardiopulmonary process. Venous duplex of the lower extremity veins was done which revealed patent greater and lesser saphenous veins. HOSPITAL COURSE: The patient was admitted to the Cardiology Service where she remained pain free until she was taken for coronary artery bypass graft on [**2173-3-15**]. She had coronary artery bypass graft times five with left internal mammary artery to the left anterior descending, saphenous vein graft to the posterior descending artery and sequential to the PL, saphenous vein graft to the OM and to the diagonal. The patient tolerated the procedure well and was taken to the Cardiothoracic Intensive Care Unit postoperatively where on postoperative day number one she was extubated and transferred to the floor. She was evaluated by physical therapy. On the morning of postoperative day number three, she was found to be in atrial fibrillation. She was rate controlled with Lopressor and converted with Procainamide. She continued to work with physical therapy. She remained in sinus rhythm throughout the remainder of her hospital stay and on postoperative day number six was found to be suitable for discharge to home. She is to follow-up with [**First Name8 (NamePattern2) **] [**Doctor Last Name 1537**] in three weeks time and with [**First Name8 (NamePattern2) **] [**Last Name (un) 18323**] tomorrow who will also follow her INR. Given her history of deep vein thrombosis, the patient's Coumadin was resumed on postoperative day number two. DISCHARGE MEDICATIONS: 1. Coumadin dose per [**First Name8 (NamePattern2) **] [**Last Name (Titles) 18323**]. 2. Lopressor 100 milligrams p.o. b.i.d. 3. Lipitor 20 milligrams p.o. q.h.s. 4. Procainamide SR 500 milligrams p.o. q6hours. 5. Glucophage 1000 milligrams p.o. q.a.m.. 6. Glucotrol 10 milligrams p.o. q.d. 7. Actos 45 milligrams p.o. q.a.m. 8. Lasix 20 milligrams p.o. q.d. times five days. 9. KayCiel 20 meq p.o. q.d. times five days. 10. Colace 100 milligrams p.o. b.i.d. 11. Vasotec 20 milligrams p.o. b.i.d. 12. Percocet one to two tablets p.o. q4hours p.r.n. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 22884**] MEDQUIST36 D: [**2173-3-21**] 13:33 T: [**2173-3-21**] 15:50 JOB#: [**Job Number 33605**]

[ "280.9", "411.1", "250.00", "414.01", "V45.82", "997.1", "427.31", "V12.51", "716.96" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3961, 4803

208, 287

1698, 2041

2591, 3938

2064, 2573

160, 186

316, 1250

1273, 1672

43,925

179,764

36641

Discharge summary

report

Admission Date: [**2102-11-15**] Discharge Date: [**2102-11-29**] Date of Birth: [**2026-1-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: Resp distress Major Surgical or Invasive Procedure: Intubation Arterial line History of Present Illness: 76 year-old male with diabetes mellitus type II, CAD s/p MI and PCI ([**4-29**]), and hypertension admitted [**2102-11-15**] to ortho spine for recurrent lumbar spine epidural abscess and L3-L4 discitis and ostemyelitis. He is now post-op day 4 for partial vertebrectomy, fusion, debridement, and vertebral spacer placement at L3-L4. Previously followed by medical service, transferred to unit for respitatory distress. . Patient initially presented [**6-29**] with coag-negative Staph lumbar epidural abscess at L3-S1 and bacteremia attributed to prior epidural infection for chronic LBP. He subsequently underwent debridement and lumbar laminectomies and was maintained on a prolonged antibiotic course. TTE at that time was without evidence of endocarditis. Patient returned for follow-up to ortho spine clinic [**10-30**] and was found to have recurrent back pain and difficulty walking. MRI L-spine showed L3-L4 discitis and osteomyelitis with recurrent paraspinal fluid collection. He underwent partial vertebrectomy, fusion, debridement, and vertebral spacer placement at L3-L4 on [**2102-11-17**]. . Post-op, patient was noted to be hypoxic. In PACU, 100% 3L NC. On floor, per surgical team, O2 saturation >88% on 6L shovel, 2L nasal canula. Today improved to 100% on same setting. [**Name8 (MD) **] RN, patient with hypoxia to 83% on 35% facemask when need suctioning. Suctioning with scan white sputum, and improves O2 saturation to 96% on facemask FiO2 35%. . This AM patient was improved early but spiked to 102 mid-morning, followed by respiratory distress with O2 sats down to 70's, RR up to 30's, tachycardia. O2 sat to 95 with NRB, EKG negative. New lower left chest consolidation on exam; CXR obtained and difficult to interpret given ileus. Transferred to ICU for presumed PNA and further respiratory support. . Post-op course also complicated by altered mental status. By report, patient with waxing and [**Doctor Last Name 688**] mental status. Per discussion with RN, much improved today, particularly with decreasing fentanyl patch from 50mcg to 25mcg. Past Medical History: Coronary artery disease. MI ([**4-29**]) with subsequent DES to unknown vessel Hypertension Diabetes mellitus type 2, complicated by neuropathy Hyperlipidemia Low back pain, chronic Social History: Social History: lives with his wife. Was 1st a shoe shop salesmen before he went into the service (on aircraft carrier). He worked as an electrical and mechanical engineer at [**Company 2676**] after this and has been an electrician the rest o fhis life. He never smoked tobacco and denies illicit drug use. He reports prior history of EtOH use while in the service, but denies EtOH currently. Has a son in jail. Family History: Family History: son with "prostate problems" Physical Exam: VS: 98.4, 129/78, 87, 20, 100% 2LNC General: NAD, using accessory muscles. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: [**Last Name (un) **] anterolaterally. Unable to move patient to listen to bases. CV: RRR w/o M Abdomen: S, NT/ND +BS GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission WBC count 5.3 --> discharge: Hct 33.9 MCV 83 --> discharge: Plts 266 PT 14.0 PTT 34.3 INR 1.2 ESR 87 Retic 1.4 140 101 26 4.6 32 1.1 Ca 9.6 Mg 2.3 Phos 4.2 Alb 2.5 Iron 9 ALT 71 AST 147 LDH 259 AlkP 339 Tbili 1.4 CRP 28.5 [**11-15**] BCx negative x2 [**2102-11-17**] 2:58 pm TISSUE L3-4 DISC. GRAM STAIN (Final [**2102-11-17**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2102-11-20**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 82905**] [**2101-11-19**] @ 11:35 AM. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. ACID FAST CULTURE (Preliminary): ACID FAST SMEAR (Final [**2102-11-18**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. ANAEROBIC CULTURE (Final [**2102-11-21**]): NO ANAEROBES ISOLATED. [**11-20**] UCx negative [**11-21**] BCx negative x3 [**11-21**] Ucx negative [**2102-11-21**] 8:09 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2102-11-24**]** GRAM STAIN (Final [**2102-11-21**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2102-11-24**]): SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. SPARSE GROWTH. Please contact the Microbiology Laboratory ([**6-/2399**]) immediately if sensitivity to clindamycin is required on this patient's isolate. 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 + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S [**11-15**] CXR The heart size is normal. Mediastinal position, contour and width are unremarkable. Lungs are essentially clear except for bibasal linear small opacities consistent with small areas of atelectasis. There is slight deviation of the upper trachea towards the left that might be consistent with thyroid enlargement, unchanged since the prior study. No pleural effusion or pneumothorax is demonstrated. 11/27 L spin Three views. Comparison with the previous study done [**2102-10-18**]. Changes consistent with laminectomy from L3 to S1. Disc space narrowing and degenerative arthritic change are again noted. A cage device has been inserted in the L3-4 disc space which is widened. L3-4 endplates are less distinct and this may be due to post-surgical change. Metal rod is present to the left of the spine with screws extending into the L3 and L4 vertebral bodies. Vertebral body alignment appears to be good. IMPRESSION: L3-4 fusion as described. [**11-19**] Abd plain film FINDINGS: The entire colon is distended with gas and stool unlikely to represent obstruction. There is spinal fixation hardware in the lumbar spine. NG tube is seen coiled within the stomach under the diaphragm. The visualized lung bases are unremarkable, and the heart size is normal. The pelvis is not included in the current study. IMPRESSION: NG tube below the diaphragm in the stomach. [**11-20**] EKG Sinus tachycardia. Baseline artifact. Diffuse non-specific ST-T wave change. Compared to the previous tracing of [**2102-7-8**] the rate has increased. The previously recorded ST-T wave abnormalities persist. The tracing is marred by baseline artifact. Repeat recording suggested. [**2102-11-23**] CXR There are persistent low lung volumes. ET tube is in the standard position. Right central catheter is in the lower SVC. NG tube is in unchanged position coiled in the stomach. Small to moderate bilateral pleural effusions are unchanged allowing the difference in positioning of the patient and are associated with bibasilar atelectasis. Opacity previously seen in the right perihilar region is obscured by the pleural effusion and right lower lobe atelectasis. Brief Hospital Course: 76yoM originally admitted to ortho spine service s/p I&D, laminectomy L3-S1 for coag negative Staph epidural abscess, who was readmitted for recurrent lumbar epidural abscess, L3-L4 discitis and osteomyelitis, went to the OR for repeat partial vertebrectomy, fusion, debridement, and vertebral spacer placement at L3-L4, who then went to the MICU and intubated for respiratory distress, and now extubated, found to have a HAP during his MICU [**Last Name (un) 10128**], Tx'd with IV ABx. 1. Epidural abscess/osteomyelitis: Pt had original debridement on coag negative staph epidural abscess in [**6-/2102**], presented for f/u to ortho spine [**10-30**] with recurrent back pain and difficulty walking, admitted for second round of debridement and ortho instrumentation [**2102-11-17**]. The patient is s/p repeat partial vertebrectomy, fusion, debridement, and vertebral spacer placement at L3-L4. ID was consulted and he will need a total of 6-8wks of Vancomycin (day 1 = [**2102-11-17**]) for osteomyelitis. The plan is for the patient to follow up with ID as an outpatient to determine final treatment course. PT followed the pt through admission and pt will need to continue PT for significant deconditioning, likely at long term rehab. - Vancomycin 750mg q12 - Please check weekly LFTs, Chem 7, CBC - Vancomycin trough 27 on [**2102-11-29**]. Dose will be held on [**2102-11-29**] and will resume on [**2102-11-30**]. Please follow Vancomycin tough, goal 15-20 2. Respiratory distress/HAP: The pt had post operative respiratory distress requiring transfer to MICU where he was intubated for three days, likely secondary to aspiration vs HAP. Sputum cultures found to have GPC's in clusters/pairs. The patient was intubated in the MICU and treated with Vancomycin and Zosyn, and had improvement to room air after three days. The patient finished an 8 day course of Vanc/Zosyn during his hospitalization and was using incentive spirometry on discharge. 3. CAD s/p BMS to OM1 in [**4-29**], BMS to LAD in [**2094**]: Prior to the procedure, patient's ASA+Plavix was held because of the bleeding risks with the procedure. The patient had BMS placed in [**4-29**] and was on ASA 81mg/Plavix 75mg until prior to the procedure. POD #10, patient's ASA and Plavis were restarted. 4. DM: Patient was started on sliding scale insulin and glargine - Monitor fingersticks Medications on Admission: No list in chart and patient currently unable to provide. Discharge Medications: 1. Clopidogrel 75 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. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 6. Vancomycin 750 mg IV Q 12H 7. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs PO Q4H (every 4 hours) as needed for pain. 8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4 PRN () as needed for wheezing. 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for dyspnea. 10. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 11. Insulin Glargine 100 unit/mL Solution Sig: One (1) 12 Subcutaneous at bedtime: Please take 12u sc at bedtime. 12. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: Please sliding scale. 13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Willow Manor - [**Hospital1 189**] Discharge Diagnosis: Primary Diagnosis - L3-L4 discitis/osteomyelitis with extensive paravertebral phlegmon - Hospital Acquired Pneumonia Secondary - Coronary Artery disease Discharge Condition: Activity Status:Ambulatory - requires assistance or aid (walker or cane) Level of Consciousness:Alert and interactive Mental Status:Clear and coherent Discharge Instructions: You were hospitalized because you had back pain. You were found to have another epidural abcess and underwent a procedure to remove part of your vertebrae. You also had a short ICU stay for respiratory distress and pneumonia and were treated with antibiotics. You will be on long term vancomycin to fully treat your osteomyelitis. You will be going to a long term rehab to make progress to regain your steadiness on your feet. Followup Instructions: Appointment #1 MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] Specialty: Orthopedics Date/ Time: Wednesday, [**12-6**], 2pm Location: [**Hospital Ward Name 23**] building, [**Location (un) **] Phone number: [**Telephone/Fax (1) 3573**] Appointment #2 MD: [**Doctor First Name **] [**Doctor Last Name 1420**] Specialty: Infectious Disease Date/ Time: Thursday, [**12-7**], 9am Location: [**Last Name (NamePattern1) **], [**Location (un) 86**] - [**Hospital Unit Name **], Basement Phone number: [**Telephone/Fax (1) 457**] Completed by:[**2102-12-13**]

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icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "84.52", "80.50", "38.93", "81.06", "80.99", "81.62", "38.91", "84.51" ]

icd9pcs

[ [ [] ] ]

12130, 12191

8439, 10820

331, 357

12389, 12507

3571, 4251

13021, 13602

3131, 3162

10928, 12107

12212, 12368

10846, 10905

12566, 12998

3177, 3552

4288, 4438

4474, 8416

278, 293

385, 2462

12521, 12542

2484, 2668

2700, 3099

29,797

111,828

49522

Discharge summary

report

Admission Date: [**2160-6-13**] Discharge Date: [**2160-7-4**] Date of Birth: [**2080-8-19**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1666**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Percutaneous Nephrostomy Tube Percutaneous Coronary Catheterization History of Present Illness: 79yoF with hx of CABG ([**2153**]), EF 65%, prior MI, PAF of Coumadin, DM, sinus node dysfunction with hospitalization in [**2158**], that on [**2160-6-12**] experienced [**9-26**] mid sternal chest pain, radiating to her back. Pt reports that the pain felt steady. No SOB, palpitations or diaphoresis. No nausea or vomitting. The patient was subsequently brought to [**Hospital6 17032**] were she ruled in for a NSTEMI with a peak troponin of 2.14 from 0.05. She is on Coumadin for PAF, her last dose was [**6-11**] in the PM. Upon arrival to [**Location (un) **] the patient received Morphine and Nitro which releived her pain. She was kept there overnight and subsequently transfered to [**Hospital1 18**] for cardiac catheterization. Cardiac cath was delayed due an increased INR. . Pt also admitted to abdominal pain without dysuria at OSH, +UA and started on Levaquin for UTI. Abdominal U/S revealed L Hydrophrosis. Increased WBC without fevers or CVAT. Past Medical History: #Sinus node dysfunction, #Paroxysmal atrial fibrillation, history of #coronary artery disease, S/P CABG in [**2153**], #peripheral vascular disease, #status post left AKA in [**2153**], #status post right TMA, history of #hypertension #diet controlled diabetes #Renal US - Left hydronephrosis #known history of gallstone #CRI #UTI Social History: Pt lives in an [**Hospital3 **] facility. She is a widow. She has one son who lives in [**Name (NI) **] and one daughter who lives in [**Name (NI) 4310**]. She denies having a drink in the past 15 years, before that she was a social drinker. She is a former smoker, quit 15 years ago. Physical Exam: VS 98.2F 119/61 18 65 95%RA Gen: Middle aged female lying 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 8 cm. CV: PMI could not be appreciated, RR normal S1, S2. Grade II/VI systolic ejection murmur at the left sternal border. No rubs or gallops. No thrills, lifts. No S3 or S4. Chest: Well healed thoroctomy scar with keloid, no scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Resp: Mild inspiratory crackles [**12-20**] bilaterally otherwise CTAB, no wheezes or rhonchi. Abd: Soft, morbidly obese, NT/ND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits apprecaited. Ext: No c/c/e. Hyperdactyly of left hand. No femoral bruits appreciated. AKA of left, TMA on right. Tenderness to palpation on dorsal aspect of right foot. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Back: No CVA. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 1+ Left: Carotid 2+ Pertinent Results: Pertinent Labs from OSH: Troponin 2.14->1.62 WBC 16.0 -> 12.1 Cr 2.2. -> 2.1 INR 1.9 Amylase 109, Lipase 26 UA +Leuk Est, +Nitrites BCx ([**6-12**]) - [**1-19**] E.coli, pansensitive . CT abd/pelvis [**6-14**] - 1. Moderate left-sided hydronephrosis with an obstructive stone at the left ureteropelvic junction measuring 13 x 8 mm. Smaller stone in the left lower renal pelvis measuring 7 mm. 2. Nonobstructive stone on the right measuring 4 mm. . Renal U/S: [**6-15**] FINDINGS: The right kidney is normal measuring 8.9 cm. There is no right hydronephrosis. The left kidney measures 8.5 cm with mild hydronephrosis with the renal pelvis measuring approximately 1.7 cm. The bladder is collapsed with a Foley catheter. There are no obstructive stones noted on US. IMPRESSION: Both kidneys are relatively small in size, with mild left hydronephrosis. . [**2160-6-18**] Pmibi stress test - - No anginal symptoms or ischemic ST segment changes. Transient drop in heart rate noted post-infusion (? related to medication or SA Node dysfunction or ?combination of both). Nuclear report sent separately. - Moderate fixed perfusion defects involving the inferior wall and inferolateral base. No reversible ischemia. EF preserved, 51%. . Ct abd/pelvis: [**6-21**] There is bibasilar atelectasis, more extensive on the right than left, with a small right pleural effusion. Marked coronary artery calcifications are present. Within the limitations of a non-contrast study, the liver is unremarkable. The pancreas is atrophic. The adrenal glands and spleen are within normal limits. The left kidney is again larger than the right and again shows a persistent nephrogram. Medial to the left kidney are foci of air and hemorrhage, similar in extent. However, although there is fat stranding about the left kidney and proximal course of the ureter, there is no fluid collection or ascites. Although retention of contrast is noted in the cortex of the right kidney, a much denser persistent nephrogram on the left is present, as before. There is a stone in the left renal collecting system of 7 mm in diameter and another of 7 mm at the left ureteropelvic junction. A nephrostomy tube is in an unchanged position, terminating immediately above the ureteropelvic junction. The stomach, small and large bowel are within normal limits. There is no lymphadenopathy. CT OF THE PELVIS WITH IV CONTRAST: A Foley catheter is within a collapsed bladder. There a few uterine calcifications attributable to fibroids. The rectum and sigmoid are unremarkable. There is no lymphadenopathy. Stranding is again present along the course of the left ureter up to the pelvic brim. BONE WINDOWS: There are no suspicious lytic or blastic lesions. Degenerative changes are noted in the lumbar spine with large osteophytes. IMPRESSION: 1. Pigtail catheter terminating shortly above the ureteropelvic junction, above the site of a known UPJ stone. 2. Persistent asymmetric nephrogram, with a greater degree of cortical contrast retention on the left than right, as before. . CXR [**6-23**]: In comparison with study of [**6-20**], there is progressive clearing of the lower lung zone with some residual atelectatic change. The possibility of some pleural fluid at the right base cannot be excluded. No focal pneumonia. . Microbiology: multiple negative blood cultures UA: positive with large leuk, nitrite positive, moderate bacteria, WBC 34, RBC 6 Ucx: - neg on [**6-13**] - proteus 10,000- 100,000 URINE CULTURE (Final [**2160-6-25**]): PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R . COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2160-6-26**] 08:49AM 15.5* 3.37* 9.2* 28.7* 85 27.4 32.1 14.8 333 Source: Line-central [**2160-6-25**] 05:45AM 27.5* 3.59* 9.9* 31.3* 87 27.6 31.7 15.0 378 Source: Line-Left IJ [**2160-6-24**] 05:28AM 22.7* 3.95* 10.8* 33.5* 85 27.4 32.3 15.1 396 Source: Line-LIJ [**2160-6-23**] 07:44AM 22.1* 4.10* 11.7* 35.1* 86 28.5 33.3 15.4 394 Source: Line-unh30JLC [**2160-6-22**] 06:30AM 20.6* 3.90* 10.9* 32.9* 84 27.9 33.1 15.7* 444* [**2160-6-21**] 05:39AM 25.0* 4.00* 11.1* 33.4* 84 27.8 33.2 15.5 474* Source: Line-left tcl [**2160-6-20**] 03:00AM 21.2* 3.78* 10.6* 32.0* 85 28.1 33.2 15.5 365 Source: Line-central [**2160-6-19**] 09:03PM 23.1*# 3.79* 10.6* 31.7* 84 27.9 33.3 15.5 372 Source: Line-central [**2160-6-19**] 08:15AM 14.9* 3.66* 10.4* 31.4*# 86 28.4 33.1 15.1 306 Source: Line-left IJ [**2160-6-18**] 10:25PM 22.0* Source: Line-left IJ [**2160-6-18**] 09:40PM 21.8* Source: Line-left IJ [**2160-6-18**] 07:37AM 21.1* 3.23* 8.6* 27.2* 84 26.8* 31.8 15.4 417 Source: Line-LIJ [**2160-6-17**] 07:00AM 19.6* 3.65* 9.8* 31.0* 85 26.7* 31.4 14.2 432 [**2160-6-16**] 07:35PM 31.2* Source: Line-left CVL [**2160-6-16**] 02:32PM 13.9* 3.45* 9.6* 28.9* 84 27.8 33.1 14.7 392 Source: Line-central [**2160-6-16**] 03:41AM 15.0* 3.55* 9.6* 29.6* 83 27.2 32.6 14.1 357 Source: Line-central [**2160-6-15**] 05:56AM 13.2* 3.71* 10.1* 30.8* 83 27.1 32.7 14.7 370 Source: Line-left TCL [**2160-6-14**] 07:37AM 12.5* 3.74* 10.2* 31.7* 85 27.3 32.3 14.2 341 . Glucose UreaN Creat Na K Cl HCO3 AnGap [**2160-6-26**] 01:00PM 108* 34* 2.0* 139 3.4 105 24 13 Source: Line-IJ [**2160-6-26**] 08:49AM 191* 37* 2.1* 137 3.4 105 23 12 Source: Line-central [**2160-6-25**] 05:45AM 96 45* 2.5* 146* 4.2 112* 23 15 Source: Line-Left IJ [**2160-6-24**] 02:08PM 106* 43* 1.8* 145 4.0 111* 25 13 Source: Line-Central [**2160-6-24**] 05:28AM 98 42* 1.8* 145 3.6 111* 24 14 Source: Line-LIJ [**2160-6-23**] 01:56PM 156* 50* 2.1* 147* 3.8 111* 25 15 Source: Line-Central [**2160-6-23**] 07:44AM 108* 50* 2.2* 147* 4.4 111* 24 16 Source: Line-unh30JLC [**2160-6-22**] 05:39PM 365* 65* 3.2* 143 3.0* 106 24 16 Source: Line-LIJ triple lumen [**2160-6-22**] 02:49PM 413* 66* 3.2* 144 3.0* 107 25 15 Source: Line-IJ [**2160-6-22**] 11:16AM 284* 69* 3.4* 149* 3.1* 113* 26 13 Source: Line-IJ [**2160-6-22**] 06:30AM 130* 73* 4.1*#1 154*2 3.3 115* 26 16 [**2160-6-21**] 05:39AM 126* 76* 5.5* 147* 3.5 108 23 20 Source: Line-left tcl [**2160-6-20**] 03:54PM 278* 76* 5.8* 145 3.7 110* 19* 20 Source: Line-central [**2160-6-20**] 03:00AM 134* 72* 5.4* 147* 4.2 110* 21* 20 Source: Line-central [**2160-6-19**] 09:03PM 150* 69* 5.4* 145 4.5 110* 18* 22* Source: Line-central [**2160-6-19**] 08:15AM 108* 63* 4.8* 143 5.3* 111* 18* 19 Source: Line-left IJ [**2160-6-18**] 07:37AM 86 59* 4.2*# 142 4.8 109* 21* 17 Source: Line-LIJ [**2160-6-17**] 07:00AM 100 52* 3.1* 143 5.1 109* 22 17 [**2160-6-16**] 02:32PM 45* 2.2* Source: Line-central [**2160-6-16**] 03:41AM 96 46* 2.3* 140 4.4 107 24 13 Source: Line-central [**2160-6-15**] 05:56AM 92 38* 2.1* 142 4.5 108 24 15 Source: Line-left TCL [**2160-6-14**] 07:37AM 80 40* 2.1* 143 4.4 108 25 14 . [**2160-6-22**] 06:30AM ALT 15 AST18 LD220 AlkP 138* Tbili 0.5 Lipase 26 Trop 0.14 Brief Hospital Course: 79yo female with hx of CABG ([**2153**]), EF 65%, PAF on Coumadin, and DM who was transferred from an OSH with a NSTEMI, found to have bacteremia and Lt hydronephrosis secondary to an impacted stone complicated by acute on chronic renal failure now s/p ureteral stent placement. . #. CAD - Patient with known CAD, S/P CABG [**2151**]. + Troponins at OSH. Patient has not had chest pain since admitted. The initial plan was for her to go to cath, however as she was bacteremic we decided to treat her medically with heparin, ASA, Beta blocker, statin, and ACEi. On [**6-18**] she underwent a P-Mibi stress test which showed no reversible ischemia. As she developed acute on chronic renal failure, we held her acei which was restarted prior to discharge. . #. Pump - PMIBI in [**1-25**] EF 65%. Initially she was euvolemic on exam with no signs of increased JVD, trace crackles [**12-20**], and no edema. Pt was normotensive. On Wednesday night ([**6-18**]) she received 2 units FFP, 2 units PRBC in conjuction with decreased UOP and acute renal failure and started looking volume overloaded with crackles b/l on exam and new O2 requirement, and requried 5 L to maintain sats in the low 90's. In the setting of increased O2 requirement, decreased BP, and her retroperitoneal bleed, the patient's amlodipine, isosorbide mononitrate, and metoprolol were held on the morning on [**2160-6-19**]. She was transferred to the MICU as it was thought she would need dialysis and renal wanted to use CVVHD, however once at the MICU her urine output picked up and she was able to maintain her oxygen sats on oxygen. Once back on the floor, she was weaned off the oxygen and sating in the high 90's on room air. . #. Rhythm - Pt with hx of PAF and sinus node dysfunction, admitted in NSR. We initially continued the patient on her beta blocker and calcium channel blocker. As she developed acute on chronic renal failure the disopyramide was at first renally dosed, and then dc'ed on [**6-17**] (but she got some at her PMibi on [**6-18**]). On the morning of [**6-19**] she was found to have a junctional rhythm with HRs in the high 40's maintaining her BP. We held her B-blocker and CCB at this time. She was restarted on the B-blocker on [**6-21**]. Since this time she has remained in NSR with HR 60's, except for occasional regular irregularity which was likely caused by runs of premature atrial contractions. She was restarted on her norpace ([**7-2**]) when her ARF had resolved. Coumadin was held for procedures and she was intermittently on a heparin drip. Heparin drip was also held after retroperitoneal bleed but then restarted when her HCT stabalized. After ureteral stent placement, she was restarted on heparin for bridge to coumadin. On [**7-4**] her INR reached 2.0 and her heparin drip was stopped. She will need her INR checked frequently until it stablely ranges between 2.0-3.0. . # Bacteremia/ Pyelonephritis - The patient was found to grow pansensitive E. coli [**1-19**] from [**6-12**] BCx(OSH). Pt had + UTI with WBC of 16 which decreased to 12. New L hydronephrosis confirmed on U/S and 1.3 x 0.8 stone seen obstructing the Lt ureter. We think her bacteremia was secondary to her hydronephrosis in the setting of obstructive nephrolithiasis. She was treated with levaquin q48h and switched to ciprofloxacin and then back to levaquin. BCx from [**6-14**], [**6-16**], [**6-18**], [**6-19**], and [**6-23**] are no growth/ NGTD. The patient has remained afebrile. Her WBC remained elevated in the low to mid 20's throughout most of her stay. She had the inital perc nephrostomy attempt on [**6-16**] which may have drained some of the pus. A second attempt took place on [**6-18**] which resulted in a small retroperitoneal bleed with HCT drop. She was transfused 2 units, heparin drip was held and her HCT were followed closely. HCT remained stable. On [**6-19**] IR placed a nephrostomy tube using CT-guidance. However the tube did not drain well and was removed on [**6-24**]. On [**6-25**] the patient went for stone removal and stent placement by urology. Urology was unable to remove the stone via laser and placed a stent. Repeat Ucx revealed proteus resistant to floroquinolones; she was switched to ceftriaxone. She had a PICC placed to receive 14 days of ceftriaxone. After antibiotics and resolution of acute pyelonephritis/bacteremia, she should be seen in urology for repeat attempt at stone removal vs lithotripsy. An appointment has been made for her with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] follow up. Her WBC dropped from 27 to 15 after stent placement and continued to trend down to 12. . # Acute on chronic renal failure: The patient has a baseline Cr of appromiately 2. Once the stone was visialized, urology was consulted, however they did not feel comfortable with surgical stone removal due to the risk of sepsis as she was already bacteremic, they recommended IR doing a percutaneous nephrostomy. After the first perc nephrostomy attempt on [**6-16**](during which she had an episode of hypotension) her Cr began rising and she developed acute renal failure likely due to ATN versus obstructive uropathy. On Wednesday we reultrasounded her left kidney and saw reaccumulation of the fluid, so a second perc nephrostomy was attempted, however they were unable to place a tube. We followed her electrolytes and volume status and on [**6-19**] consulted nephrology as we anticipated that she might need dialysis. As her Cr rose to from 3.1 to 3.4 to 4.8 and her urine output droped from 800 to 400 to very little. The patient was given in succession 60mg lasix iv, 100mg lasix iv, then 200mg lasix iv with no significant urine output following the blood cell transfusions on [**6-19**]. She was transferred to the MICU as it was thought she would need dialysis and renal wanted to use CVVHD, however once at the MICU her urine output picked up and her Cr peaked around 5. From [**6-20**] to [**6-24**] her Cr continued to decrease to 1.8, but then rose to 2.5 on [**6-25**]. Urology place a ureteral stent. Her cr trended down to her baseline of 1.4-1.6. . # Anemia - The patient has chronic anemia, likely secondary to CKD with a baseline Hct of approximately 31. After the second percutaneous nephrostomy attempt, the patient developed a retroperitoneal bleed on [**2160-6-18**] with a HCT drop from 31 to 21.9. The patient was also noted to be hypotensive with SBPs 90s and HR 40s-50s. A noncontrast CT showed a bleed along her iliopsoas. Patient was given 3 units of packed red blood cells [**6-19**], and vitamin K 10mg [**5-19**], and 5mg [**5-20**]. The patient's hematocrit responded well and her HCT was 31.4. Over [**6-26**] to [**6-28**] her Hct slowly declined from to 26.1 and in the setting of chest pain overnight on [**6-27**] she was transfused 2 units PRBC on [**6-28**] and a noncon CT of her abd/pelvis was completed to look for intrabdominal bleeding. Her heparin gtt and coumadin were also stopped. Once her Hct stabilized again her heparin gtt and coumadin were restarted until her INR was therapeutic at 2.0 and then only coumadin was continued. . # Hypernatremia: Peak sodium 154 w/o mental status changes. Given poor PO intake and mild post-ATN diuresis, this was thought to be due to free water deficit. Her sodium improved with repletion of free water deficit. Free water intake needs to be encouraged. . # Leukocytosis: [**1-19**] to pyelonephritis. CXR showed no PNA. Blood Cultures after the initial E.coli from the OSH were all negative. C.diff x1 negative but no diarrhea. LFT's normal. Peaked at 27 and then trended down after ureteral stent placement. . # Right upper extremity DVT - patient developed swelling in her RUE on [**6-29**] and was found on US to have a nonocclusive thrombus at her PICC site. The PICC was pulled and she was restarted on her heparin drip. . # DM: The patient's glucose has been well-controlled on SSI. . # Access: It was extremely difficult to establish access. She had a left internal jugular central line placed and in anticipation of dialysis a right non-tunneled HD catheter. Dialysis line and IJ were pulled prior to discharge. PICC line was placed for IV antibiotics for on the right side, now on the left as she developed a right DVT. Medications on Admission: OUTPATIENT MEDICATIONS: Norpace CR 100-mg [**Hospital1 **], Imdur 90-mg/day, Norvasc 5-mg [**Hospital1 **], Lisinopril at an unknown dose, Simvastatin at an unknown MEDICATIONS ON TRANSFER: EC ASA 325mg PO Daily RISS LEVAQUIN 250mg IV Q24 (Day 1) PRILOSEC 20mg PO BID CARAFATE 1gm PO QID NORVASC 5mg PO BID NORPACE CR 100mg PO BID ISOSORBIDE 90mg PO QAM LISINOPRIL 10mg PO QAM SIMVASTIN 80mg PO QPM COUMADIN (Held since 6/25pm) NITROPASTE 1 inch q6 HR Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 10. Phenergan 25 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea. 11. Insulin give insulin as per attached sliding scale 12. Outpatient Lab Work Monitor INR every other day and adjust coumadin as needed to keep INR 2.0-3.0 13. PICC line care PICC line care as per protocol. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: adjust dose to maintain INR 2.0-3.0. 15. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 5 days: day 1 is [**2160-6-25**], will need a total 14 day course to end on [**2160-7-8**]. 16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*0 Tablet(s)* Refills:*0* 18. Disopyramide 100 mg Capsule Sig: One (1) Capsule PO Q 12H (Every 12 Hours). 19. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 20. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 21. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) Units Injection QMOWEFR (Monday -Wednesday-Friday). Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Primary- NSTEMI Urinary Obstruction/ Hydronephrosis Pyelonephritis Bacteremia Acute renal failure Junctional Bradycardia due to Norpace toxicity (in the setting of renal failure) Retroperitoneal Bleed Right upper extremity deep venous thrombosis Secondary - Diabetes Mellitis, type II Hypertension Discharge Condition: improved Discharge Instructions: You were admitted for a heart attack for which you received medications. You were also found to have a kidney stone that was blocking your kidneys leading to acute renal failure and kidney infection. A stent was placed in your urinary tract system to drain the kidney. You were also given antibiotics. . Because of your impaired renal function, your medications lisinopril and norpace were held. You will need to restart these medications in the future. . If you have fever, chills, rising WBC count or chest pain, you should return to the emergency room. Followup Instructions: You will need to have your renal function, white blood cell count and INR monitored. . Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1911**] (cardiology) [**Telephone/Fax (1) 62**] [**2160-9-4**] 2:40 pm Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (urology) [**Telephone/Fax (1) 921**] [**2160-7-9**] 3:30am Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12982**] (primary care) [**Telephone/Fax (1) 62842**] [**2160-7-17**] 11:15am. Fax number: [**Telephone/Fax (1) 15181**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**] Completed by:[**2160-7-4**]

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icd9cm

[ [ [] ] ]

[ "57.32", "59.8", "87.74", "55.03", "57.0", "38.93" ]

icd9pcs

[ [ [] ] ]

21746, 21832

10857, 19155

325, 394

22175, 22186

3155, 10834

22790, 23487

19660, 21723

21853, 22154

19181, 19181

22210, 22767

2055, 3136

19206, 19348

275, 287

422, 1383

19374, 19637

1405, 1737

1753, 2040

4,641

168,331

18161

Discharge summary

report

Admission Date: [**2187-8-3**] Discharge Date: [**2187-9-29**] Date of Birth: [**2137-4-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: increased shortness of breath and worsening dysphagia Major Surgical or Invasive Procedure: tracheostomy, PEG placement, IVC filter placement, peptic ulcer cauterization History of Present Illness: 50 yo M Spanish speaking quadraplegic male with h/o ALS related muscle weakness and worsening respiratory failure s/p multiple hospital admissions for worsening weakness and FTT who presents from home w/ continued chronic complaints of weakness, difficulty eating, and intermittent shortness of breath. He denies any new complaints in the last 5 months. He has had intermittent SOB and intermittent O2 requirement at home. He has had continued problems with eating. Food gets stuck in his throat when eating. He also complains of intermittent nausea. He is wheelchair bound at home. He was last admitted [**Date range (3) 50217**] for FTT, nausea and decreased po intake. At that time, neurology recommended hospice care because of frequent admissions for failure to thrive. It was also recommended that he have acute rehab placement rather than a discharge home as it seemed he needed more help at home. However patient refused and was discharged home with VNS. . In ED, was febrile to 101. CXR and U/A were unremarkable. Blood cultures were drawn. Given total of 3L NS in ED. He states he has not received any of his medications today. On the floor, he is comfortable and smiling. He denies and chest pain, abdominal pain, vomiting, dysuria, changes in his stools, fever, chills. Past Medical History: *ALS. Dx [**4-13**]. Home O2 requirement. *Quadraplegic. *Respiratory failure (FVC 40% predicted). *Hx L common femoral vein DVT [**5-15**]. *Hypertension. *Migraines. *Arthritis. *Actinic keratosis. Social History: No tobacco, etoh, drugs. Lives with family. Has 2 kids ages 5 and 10. Former custodian. Spanish is preferred language. Family History: *Mother: DM. *Father: MI at 70. Physical Exam: PE: T: 99.1 BP: 130/90 HR: 106 RR: 18 O2: 98% RA Gen: Pleasant, well appearing male in NAD. HEENT: B conjunctivitis R>L. B eye discharge. No icterus. Dry mucous membranes. OP clear. NECK: No LAD and no JVD. CV: Regular. Tachycardic. No murmurs. LUNGS: Poor air movement throughout. No rhonchi, rales, wheezes. ABD: Soft, NT, ND. Normal BS. No HSM EXT: WWP. 2+ pedal edema bilaterally. Mild ankle tenderness on R. No erythema, effusion, warmth. SKIN: Rash on chest. Unchanged in 2 weeks per patient report. Small 0.5cm ulcer on R buttock. NEURO: A&Ox3. Appropriate affect. CN 2-12 grossly intact. Preserved sensation throughout. Increased tone in all extremities. Cannot move extremities. Pertinent Results: CXR([**8-3**]): Stable chest radiograph with no convincing radiographic evidence of acute cardiopulmonary disease. . EKG([**8-3**]): Sinus tachycardia. Nonspecific ST-T changes . Cardiology Report ECHO Study Date of [**2187-8-22**]: The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. The mitral valve leaflets are structurally normal. There is a small pericardial effusion. No definite valvular regurgitation seen in suboptimal views. . OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION Date: [**2187-8-29**] Signed by [**Doctor First Name **] [**Doctor Last Name **], CCC,SLP on [**2187-8-29**] Affiliation: [**Hospital1 18**] EVALUATION: An oral and pharyngeal swallowing videofluoroscopy was performed today in collaboration with Radiology. Thin liquid, Nectar-thick liquid, and pureed consistency barium were administered. He refused to try a ground consistency. The exam was performed with him seated fully upright at 90 w/the Passy-Muir Valve in place over the trach. Results follow: SUMMARY: Significant worsening of his oral and pharyngeal swallowing ability s/p trach placement compared with his videoswallow on [**2187-8-9**]. He is now having penetration with straw sips of thin and nectar thick liquid and aspiration with straw sips of thin liquid. Aspiration is "silent" or without coughing. He can not clear the aspirated material with a cued cough. He has residue in his valleculae even when he alternates between bites of puree and sips of nectar. He refused to try a ground consistency. RECOMMENDATIONS: 1. It is not possible to eliminate the aspiration risk if he takes PO's. However, we can reduce the risk. Head position is critical to adequate airway protection. He must be propped up with his head at 90 to fully protect his airway, and the Passy-Muir speaking valve must be in place over the trach. He reported difficulty breathing by with the PMV on by the end of our study despite 02 sats of 98%. His respiratory rate was 31 by the end of the exam and it dropped back to 24 after removal of the PMV. 2. The safest way to feed him with the least aspiration risk: A. Sit fully upright w/head propped forward at 90 B. Cup sips of nectar thick liquid C. Alternated with bites of pureed foods D. Only when wearing the PMV e. Only after thorough suctioning prior to any PO's 3. If he is made CMO and he wants water, we would suggest Thorough suctioning & complete oral care w/mouthwash first then cup sips of ice water only when fullu upright w/PMV on 4. If he is unable to wear the PMV, we should repeat the videoswallow without it to see if he is still safe to take PO's without the PMV. These recommendations were shared with the patient, the nurse and the medical team. . OPERATIVE REPORT [**Last Name (LF) 2194**],[**First Name3 (LF) 900**] J. **NOT REVIEWED BY ATTENDING** Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 50218**] Service: Date: [**2187-8-23**] Date of Birth: [**2137-4-17**] Sex: M Surgeon: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 33887**] PREOPERATIVE DIAGNOSES: Amyotrophic lateral sclerosis with 1) respiratory failure, 2) nutritional failure. POSTOPERATIVE DIAGNOSES: Amyotrophic lateral sclerosis with 1) respiratory failure, 2) nutritional failure. PROCEDURE: 1. Tracheostomy. 2. Gastrostomy. DESCRIPTION OF PROCEDURE: The patient was brought to the operating theater and his neck, chest and abdomen were prepared with Betadine and draped sterilely. The head was positioned extended with shoulder roll placed. The tracheostomy incision was performed first with the remainder of the field isolated with an over drape. A vertical midline incision was formed in the neck between the cricoid and the sternal notch. This was infiltrated with 1% lidocaine with epinephrine for improved hemostasis. The wound was taken down in the midline using cautery taking care to remain in the raphae. The anterior surface of the trachea was crossed at the first interspace by the thyroid isthmus. The isthmus was therefore isolated and suture ligated bilaterally with #2-0 silk. It was then divided and the second and third tracheal rings exposed widely by dissection of the thyroid off of the trachea. At this time, stay sutures were placed into the trachea in the midline at the first and third rings with 3-0 Prolene. A trap door was scored with cautery and then the trachea was entered sharply with the endotracheal balloon deflated. The transverse incision at the second ring was used to visualize the endotracheal tube, which was then passed distally and further work was done with airway control above the balloon until we were ready for the exchange. At this time the remainder of the flap was cut using [**Hospital1 **] scissors and hemostasis was obtained using cautery on the tracheal mucosa. At this time, a prelubricated #8 Shiley tracheostomy was brought onto the field. The endotracheal tube was withdrawn under direct vision to above the tracheotomy site and the tracheostomy placed into the trachea uneventfully. CO2 return was assured as was ventilation. The tracheostomy was sutured in place with 0 silk and then secured with umbilical tapes. The inferior portion of the tracheostomy wound was closed slightly with a single #3-0 nylon. The superior stay suture was removed. The inferior stay in the flap was left in place and secured with a Tegaderm for access should there be an inadvertant removal. Procedure was terminated. Estimated blood loss was less than 5 cc. At this time, the neck wound was covered. The over drape was removed and attention was turned to the abdomen. A 6 to 8 cm incision was fashioned in the midline. The skin was incised sharply. Subcutaneous tissues were divided with the [**Last Name (un) 4161**] and traction. The linea [**Female First Name (un) **] was incised with cautery and the calciform ligament was visualized. This was swept to the right and the peritoneum was entered along the left margin of the falciform. The abdominal contents were visualized. The colon was identified clearly and swept inferiorly. The stomach was grasped with long Babcocks in left upper quadrant and delivered into the wound. At this time, 2 Babcocks were placed to hold the stomach up in the wound. Concentric 2-0 silk pursestring sutures were placed into the anterior wall of the stomach at the junction approximately of the antrum and the body. At this time [**Last Name (un) **] cautery was used to enter the stomach through the pursestrings. This wound was dilated slightly with a clamp and a #24 Malecot catheter was passed into the stomach. At this time, the pursestrings were tied and the catheter was withdrawn through the abdominal wall approximately 6 cm to the left of the midline and 2 fingerbreadths below the costal margin. This was done by incising the skin generously and passing a Sarot clamp, antegrade into the abdomen and withdrawing the end of the Malecot catheter. At this time, the Malecot was withdrawn to bring the stomach snuggly up against the anterior abdominal wall. Just prior to withdrawing the catheter the final 2 cm, a 3-0 silk suture was placed into the posterior rectus sheath and the stomach to tack the stomach up to the abdominal wall. This was tied as the Malecot was withdrawn to have the stomach flushed with the posterior sheath. At this time, the Malecot catheter was secured in place on the skin with a #2-0 nylon. The midline at this time was irrigated with copious normal saline and closed with a running #0 PDS suture. Subcutaneous tissues were once more irrigated and hemostasis was assured. The skin was closed with staples. Dry sterile dressings were applied. The gastrostomy tube was placed to gravity drainage and will be maintained that way for 24 hours at which point the patient can be fed. Estimated blood loss was less than 5 cc. Patient tolerated both procedures without incident. COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2187-8-31**] 07:53AM 21.3* [**2187-8-31**] 03:05AM 7.9 2.33* 6.8* 21.0* 90 29.3 32.4 13.7 314 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2187-8-31**] 03:05AM 314 [**2187-8-31**] 03:05AM 24.2* 31.5 2.4* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2187-8-31**] 03:05AM 137* 30* 1.6* 141 4.0 106 28 11 BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS Intubat [**2187-8-30**] 01:17PM 145*1 45 7.45 32* 7 1 ARTERIAL [**2187-8-30**] 08:00AM ART 50 162* 50* 7.42 34* 7 NOT INTUBA1 . IVC FILTER PLACEMENT PROCEDURE AND FINDINGS: After informed consent was obtained from the [**Hospital 228**] healthcare proxy, the patient was placed supine on the angiographic table. Right groin was prepped and draped in standard sterile fashion. Using sterile technique, local anesthesia and ultrasound guidance, the right common femoral vein was accessed and a vascular sheath for the delivery system of IVC filter was advanced into the inferior vena cava. The venogram was then performed demonstrating patent inferior vena cava, and the level of renal veins was identified to be at L1 vertebral body. Based on radiologic findings, it was decided that the patient would benefit from placement of an IVC filter. The tip of the sheath was positioned in the infrarenal IVC at the level of L1 under fluoroscopic guidance. The filter was then advanced into the sheath and placed into the infrarenal portion of the IVC under fluoroscopic guidance. The sheath was then removed and hemostasis was achieved after 10 minutes of manual compression. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: 1. No evidence of intraluminal thrombus in the right common femoral vein, right iliac and IVC veins. 2. IVC filter placed into infrarenal location. . COMPLETE BLOOD COUNT Hct [**2187-9-28**] 04:28AM 28.9* [**2187-9-27**] 02:45AM 28.1* [**2187-9-26**] 04:56AM 27.0* [**2187-9-25**] 03:47AM 28.1* [**2187-9-24**] 04:38AM 28.2* [**2187-9-23**] 06:12AM 28.1* . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2187-9-27**] 02:45AM 100 19 0.5 141 4.0 104 28 13 . Brief Hospital Course: A/P: Mr. [**Known lastname **] is a 50yo man w/ rapidly progressing ALS who is status post tracheostomy, PEG, IVC filter placement with course complicated by peptic ulcer cauterization, and antibiotic treatment for S. aureus and B. fragilis bacteremia. . #Respiratory failure: The pt initially presented from home [**2187-8-3**] w/ chronic complaints of weakness, difficulty eating, and intermittent shortness of breath. At the time on the medical floor he had worsening secretions in his oropharynx requiring nasotracheal and oropharyngeal secretions with distress resulting in hypertension and tachycardia. A Scopolamine patch was placed and pt was admitted to the MICU on [**2187-8-8**] for more intensive monitoring and nursing care. He subsequently recovered, was extubated, and was called out to the floor on [**2187-8-10**]. . The patient's respiratory status remained stable until late night on [**8-21**]. The pt had a sudden onset of SOB with diaphoresis, followed by hypotension. The MICU team was called. The pt's vitals at midnight were T 96.1, BP 154/80, HR 100, RR 26, O2 83% on 2L NC. At this point the pt was placed on NRB. During this period the pt's family was contact[**Name (NI) **] regarding his code status. He had been DNI only until the day prior when the pt and his family decided to allow for intubation for scheduled PEG placement [**8-22**]. Given this reversal of code status, clarification was warranted. Initially the pt's wife/hcp could not be reached. At 12:15 am the pt's vitals were BP 86/66, HR 70, RR 16. ABG was done and showed 7.04/121/138. The pt was placed on peripheral dopamine and given an amp of HCO3. A CXR was performed and did not show any acute pulmonary process. An EKG was without acute changes. The pt's wife was reached and affirmed that the pt was to be full code. The pt was intubated at around 12:30 am for hypercarbic respiratory failure. His dopamine was discontinued as his pressure stabilized. He was further supported hemodynamically with IVF boluses (1.5 L) prior to arriving to the ICU. In ICU a R IJ TLC was placed and pt was bolused to maintain pressures. . In the ICU, pt was stable and multiple attempts to wean him for extubation, but he was unable to maintain ventilatory status on his own. After much discussion with the family in conjunction with the palliative care team, the decision was made to place tracheostomy and gastric tube. After trach placement, attempts were made to place him on trach collar which he was only able to tolerate for short periods. He was fitted for a Passy-Muir Valve to allow him to speak with the trach. He has some endotracheal secretions for which he is treated with glycopyrrolate. He is currently vented with Vt 600 cc Respiratory rate: 14 PEEP: 5 cm/h2o FIO2: 40 % which he tolerates well. . #GI bleed: He was initially guaiac negative during his hospitalization. Pt's hematocrit dropped to 17 on [**2187-9-9**]. A abdominal CT was performed that showed no RP bleed but high-density material in the stomach, concerning for gastric hemorrhage. We attempted to draw a residual through his PEG, but it was obstructed, unable to infuse or withdraw. Hemolysis labs were not revealing. His stools then became guaiac positive during this time period. GI was consulted and performed an EGD which showed an ulceration at the PEG tube site that was cauterized. Surgery was consulted to reassess the PEG tube, and it was cleared with sodium bicarbonate tablet solution. He was maintained on [**Hospital1 **] PPI. Anticoagulation was stopped and a retrievable IVC filter was placed on [**2187-9-11**]. His Hct was subsequently stable. He received a total of 5U PRBC for this bleed. Throughout hospitalization PEG worked without difficulty. . #Tachycardia: Pt was tachycardic throughout stay. TSH wnl. Pain and anxiety were adressed with psych consult and starting mirtazapine in addition to his home sertraline. He denied any pain that might be contributing. He had an echocardiogram which showed hyperdynamic LV function. In discussion with cardiology, we believe that his tachycardia may result from autonomic instability resulting from his ALS. During the remainder of his hospitalization, his heart rate was controlled with low-dose metoprolol. . #Bacteremia: Pt has been afebrile. WBC stable. Follow-up cultures are negative to date. Completed 14-day course of vancomycin for coag-negative S. aureus, levofloxacin and metronidazole for B. fragilis. . #h/o DVT: Pt had wafarin and heparin doses adjusted depending on his antibiotic regimen and OR status. He was maintained on low dose wafarin while on levofloxacin and metronidazole. All anticoagulation was stopped on [**2187-9-9**] with his GI bleed. A retrievable IVC filter was placed on [**2187-9-11**]. . #Elevated troponin: Mr. [**Known lastname **] had a troponin leak at the time of intubation peaking at 1.4. He had no EKG changes without a bump in his CK, so he likely had a reversible ischemic event in the context of sepsis, tachycardia, and intubation. He denied any CP at the time. His troponins trended down thereafter. . #ARF: During this hospitalization, Mr. [**Known lastname **] had an acute increase in his creatinine despite good UO. Renal U/S ([**2187-8-27**]) was negative for hydronephrosis. His UA showed urine eosinophils. His creatinine increase corresponded to his starting Zosyn, so Zosyn was stopped with slow resolution of his creatinine to baseline. . #Disposition: Mr. [**Known lastname 50219**] health is stable and transferred to Radius [**Hospital 7755**] Hospital. Medications on Admission: Atenolol 100 mg DAILY Docusate Sodium 100 mg [**Hospital1 **] Baclofen 10 mg TID Megestrol 40 mg/mL [**Hospital1 **] Riluzole 50 mg Tablet PO DAILY Vitamin E 400 unit One Capsule PO DAILY Metoclopramide 10 mg PO TID Coumadin 4 mg Tablet DAILY Fentanyl 75 mcg/hr Patch Q72H Senna Two Tablet PO BID as needed for for constipation Lactulose 30 ML PO TID Milk of Magnesia 30 CC PO q6 hours as needed for constipation Amitriptyline 25 mg PO QHS Sertraline 100 mg PO DAILY Discharge Medications: 1. Mirtazapine 15 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO HS (at bedtime). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 3. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H PRN () as needed for secretions. 10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 11. Glycopyrrolate 0.2 mg/mL Solution Sig: 0.2 mg Injection Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: ALS Respiratory failure requiring ventilatory support Acute renal failure History of DVT on anticoagulation Anxiety Discharge Condition: stable Discharge Instructions: Please take all of your medications as prescribed. Please make all follow up appointments. . If you experience shortness of breath, chest pain, fever >101, or other concerning symptoms, please call your doctor or go to the ER. Followup Instructions: Please call your PCP and neurologist upon discharge and make them aware of your transfer to Radius [**Hospital 7755**] Hospital. You will be followed by several physicians at Radius [**Hospital 7755**] Hospital.

[ "286.7", "414.8", "933.1", "453.8", "790.7", "344.00", "584.5", "285.29", "335.20", "482.41", "E930.0", "531.00", "536.49", "599.7", "280.0", "401.9", "518.84", "E912" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.7", "96.6", "43.11", "99.07", "45.13", "44.43", "31.1", "99.04", "38.93", "96.72" ]

icd9pcs

[ [ [] ] ]

20693, 20748

13607, 19167

366, 445

20908, 20917

2889, 13584

21193, 21409

2132, 2166

19684, 20670

20769, 20887

19193, 19661

20941, 21170

2181, 2870

273, 328

473, 1757

1779, 1980

1996, 2116

14,098

124,288

2766

Discharge summary

report

Admission Date: [**2193-10-26**] Discharge Date: [**2193-11-7**] Date of Birth: [**2132-1-9**] Sex: F Service: MEDICINE Allergies: Demerol / Morphine Sulfate / Heparin Agents Attending:[**First Name3 (LF) 10293**] Chief Complaint: anemia, liver failure Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 13646**] is a 61 year old female with cirrhosis [**1-5**] UC/PBC recently admitted with ulcerative colitis flare and LGIB, now transferred from [**Hospital3 **] after presenting with collapse and decompensation of ESLD (MELD of 28, up from 13). Of note she does endorse persistent bloody stools sicne recent discharge, up to 4-5 times daily(decreased from 20x/day on recent admission). At [**Hospital3 **] she was found to have worsening anemia, HCT 25.7 (31.5 on [**10-16**]) as well as decompensated liver failure with Tbili up to 16.4 (2.6 on [**10-15**]). Her course was complicated by hypotension, she was treated with IVF and 2 units prbc and she had a L subclavian line placed for access. She was treated with Ceftriaxone [**1-5**] concern for possible cholangitis given leukocytosis. She initially had ARF with creatinine 1.4 at OSH which resolved with IVF/PRBC. . Past Medical History: 1. Ulcerative Colitis - Followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**] - Last sigmoidoscopy [**10/2193**] without dysplasia - Recent flares refractory to steroids, currently on Remicade (was on steroids last admission and then transferred to Remicade) 2. Primary biliary cirrhosis - Diagnosed 10 yrs ago - Complicated by ascites, occasional hepatic encephalopathy, variceal bleed - Last EGD [**4-/2193**] without varices 3. Hypokalemia 4. Blood loss anemia secondary to lower GI bleed 5. Portal vein thrombosis 6. Portal-hypertension related ascites 7. HIT positive Social History: The patient is married, lives in [**Location 3320**] with her husband. [**Name (NI) **] [**Name2 (NI) 1139**], EtOH, or illicit drug use. Family History: Father: UC, alive age [**Age over 90 **] Mother: [**Name (NI) **] IBD, + ovarian Cancer Physical Exam: VS T96.5 BP 91/56 - 100/54 RR 16-18 HR 95-102 97% on 4l NC Gen: cachetic frail jaundiced, appears comfortable in no acute distress HEENT: PERRL, EOMI, sclerae icteric, MM slightly dry Neck: JVD with significant respiratory variation CV: RRR no m/r/g. left sided subclavain CVL with intact dressing Resp: Left sideded chest tube in place with clean dressing, breath sounds bilaterally, absent at left base Abd: soft, non-distended, + bowel sounds, diffuse pressure with palpation but denies pain, no rebound or guarding Extrem: 2+ pitting edema b/l to knees Skin: occasional ecchymoses, spider angiomas Neuro: A&O x3, speech clear, mild asterixis present Pertinent Results: Admission Labs: WBC-9.2 RBC-3.46* Hgb-11.2* Hct-32.8* MCV-95 MCH-32.4* MCHC-34.2 RDW-18.5* Plt Ct-32*# Neuts-93.4* Lymphs-3.0* Monos-3.4 Eos-0.2 Baso-0 PT-24.7* PTT-56.1* INR(PT)-2.4* Glucose-169* UreaN-32* Creat-1.0 Na-128* K-4.3 Cl-94* HCO3-28 ALT-98* AST-83* LD(LDH)-377* AlkPhos-314* TotBili-21.3* Albumin-2.0* Calcium-9.5 Phos-2.9 Mg-2.1 [**2193-10-27**] EKG - Sinus tachycardia, rate of 101. Non-specific T wave changes. No other diagnostic abnormality. [**2193-10-27**] RUQ ultrasound - IMPRESSION: 1. New complete thrombosis of the main portal vein. 2. Unchanged cirrhosis and ascites. [**2193-10-27**] CXR PA & LAT - IMPRESSION: Large left pneumothorax. [**2193-10-27**] CXR - FINDINGS: There has been little change in the appearance of the thorax since [**2193-10-27**]. A left-sided chest tube remains in unchanged position with no evidence of pneumothorax. There may have been minimal clearing of the left lower lobe atelectasis. The contour of the azygos vein is prominent, particularly given the upright positioning suggestive of volume overload without frank pulmonary edema. The gaseous distention of the stomach has resolved since the previous study, but now mildly prominent loops of bowel are noted in the upper abdomen. [**2193-10-28**] Chest CT with contrast - IMPRESSION: 1. Compared to a [**Hospital1 18**] study of [**2193-8-30**], and the [**Hospital3 3583**] study of [**2193-10-3**], there has been progression of this patient's splanchnic thrombus, now occluding the left and right portal veins. There is also focal thrombus within the dilated SMV at the SMV-portal vein confluence. The SMV, however, remains patent. Additionally, there has been an increase in ascites. 2. Signs of portal hypertension including intra-abdominal, paraesophageal varices and splenomegaly. 3. Chronic findings including some small bowel thickening (likely related to ascites and venous congestion from splanchnic thrombus) and uncomplicated cholelithiasis. [**2193-10-29**] ECHO - The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. Tricuspid regurgitation is present but cannot be quantified. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. No vegetation seen (cannot exclude). Brief Hospital Course: Mrs. [**Known lastname 13646**] is a 61 yo F w/cirrhosis [**1-5**] UC/PSC, severe LGIB [**1-5**] UC, h/o HIT transferred from OSH with acute decompensated hepatic failure and anemia, found to have large left pneumothorax with concern for progression to tension PTX prompting emergent ICU transfer and CT placement. On arrival to the medical floor she was noted to be hypoxic 88%RA, which was new per discharge summary from the OSH. She had a CXR to further evaluate her hypoxia which showed large left hydropneumothorax in the setting of recent line placement concerning hemopneumothorax, complete collapse of the left lung, and new right effusion. In addition she had abdominal ultrasound on admission given her new hepatic decompensation, which showed new portal vein thrombosis. CT surgery was consulted for chest tube placement. She was also started on vancomycin for report of [**12-4**] blood culture bottle drawn from subclavian line with GPC, peripheral blood culture still with no growth. Prior to chest tube placement she was given vitamin K 10mg po x1, 5 units FFP, 2 units PRBC, 2 bags platelets to reverse her coagulopathy. While on the floor she acutely decompensated with HR up to 150's and hypotension. She was given 1L IVF bolus and transferred to ICU for stat chest tube placement [**1-5**] concern for possible tension pneumothorax. She did well post chest tube placement with post xray showing re-expansion of her left lung. She did have an episode of hypotension following chest tube placement likely [**1-5**] acute reexpansion of her left lung. MICU course: #Acute Hepatic Decompensation/PBC - Most likely secondary to portal vein thrombosis seen on RUQ ultrasound on admission. Unfortunately given her severe LGIB secondary to ulcerative colitis the patient was not a candidate for anticoagulation. SBP was also considered in the differential, but paracentesis could not be performed because of low platelets so she was intially treated empirically with ceftriaxone then switched to cefipime (day #1 = [**10-26**]) for broader coverage. She is not a transplant candidate currently due to UC and sepsis. Per hepatology even if the patient recovers from bactermia and DIC, she is unlikely to be a transplant candidate in the future. She had waxing and [**Doctor Last Name 688**] mental status while in the MICU. At times A&O x3, but usually oriented just to person and place (not date). She continued to receive lactulose, but some doses were held due to extensive stooling with lots of blood. She was continued on rifaxamin and ursodiol # Thrombocytopenia/Coagulopathy: Likely secondary to liver disease and consistent with DIC/sepsis. The patient was given a single dose of Neupogen. Hematology was consulted. Peripheral smear with schisocytes and several other types of dysmorphic RBCs. Her platelets dropped to 13 in setting of an acute bleed. She was transfused 1 unit of platelets. The following day she received 1 unit of platelets and 2U of PRBC. Her platelets subsequently dropped again to 16 and she was given FFP x2 units and 1 unit of cryoprecipitate given positive DIC labs. At one point she was bleeding from both her foley and chest tube in addition to her rectum, but the former resolved and her DIC labs improved. Currently she continues to have melena/BRBPR intermittantly, but no other bleeding. She received her last unit of platelets on [**10-30**] before family decided the patient would receive no further blood products. Serial hematocrits and other labs were also stopped per family wishes. # MRSA bacteremia - One blood culture bottle from OSH drawn from CVL is positive. Culture here positive for MRSA in [**3-8**] bottles. Her line was changed. Chest CT showed no abcesses, although pleural fluid had many WBCs and coag+ Staph. aureus as well. Skin exam shows no focus for bacteremia, although the patient has a history of MRSA skin infections. The primary source of her bacteremia is unclear. ECHO did not show any vegetations on her heart valves. She was started on vancomycin on [**10-26**] for a 14 day course. #Pneumothorax - most likely developed slowly following placement of a left subclavian line at the OSH and likely progressed to cause hemodynamic compromise resulting in tachycardia and hypotension on the floor. She had a chest tube placed with post procedure x-ray showing reexpansion of her left lung. Chest CT showed residual pneumothorax, but chest tube was sealed while at CT. Again, post CT xray showed no pneumothorax. #Atrial Fibrillation/Flutter - Early on in admission she had been going in and out PAF with rate up to 150's, BP stable since CT placed. PAF resolved with IVF. Initially rate controlling agents were held given episodic hypotension and GI bleeding. When she became hemodynamically more stable low dose metoprolol was added. #. Ulcerative colitis: She has severe/refractory disease despite steroid treatment. She recently finished a course of cipro/flagyl as inpt/oupt. She was recently treated with remicaid on [**10-10**] followed by prednisone. She is now on stress dose hydrocortisone. Mesalamine was stopped per hepatology recommendations and remicade and 6MP were also held. # FEN: NGT was placed for tube feeds to improve nutrition status and she was initially given a regular diet as well. Eventually the patient stopped taking POs and tube feeds were held due to high residuals. Tube feeds were subsequently restarted at 10cc per hour and kept at that rate for approximately 24 hours before they were held again because of frequent BRBPR. #Code status: On [**10-29**] the patient stated that she no longer wished to live and began refusing medical intervention. The patient's husband/HCP was [**Name (NI) 653**]. After a family meeting, the patient was made DNR/DNI early in the morning of [**10-30**]. After further discussion, the patient was made CMO on the afternoon of [**10-30**] with the exception that antibiotics are still to be given. However, she is to receive no blood products, lab draws, or radiology studies. Course of care on the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service: On [**10-31**], the patient was transferred to the medical floor given the change in the goals of her care. All phlebotomy and radiographs were stopped. Antibiotics were continued. Stress-dose steroids were tapered. All other medications were stopped. She initially continued to receive tube-feeds, but this was subsequently withdrawn at the family's request. Subsequent;y, after discussion with patient's family, antibiotics and steroids were discontinued and the patient expired on [**2193-11-7**] at 1130am. Medications on Admission: Mesalamine 1g PO QID (4 times a day). Ursodiol 300 mg PO BID Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). Spironolactone 100 mg PO DAILY Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY Protonix 40 mg Tablet PO once a day. Rifaximin 400 mg PO TID Lactulose Thirty (30) ML PO TID titrate to 3 bowel movements daily Lasix 40 mg PO daily: please take if increasing ascites or lower ext edema. Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis End Stage Liver Disease MRSA Bacteremia Pneumothorax Discharge Condition: Expired Followup Instructions: None

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icd9cm

[ [ [] ] ]

[ "34.04", "96.6" ]

icd9pcs

[ [ [] ] ]

12510, 12519

5347, 12027

327, 333

12634, 12644

2844, 2844

12667, 12675

2064, 2153

12540, 12613

12053, 12487

2168, 2825

266, 289

361, 1263

2860, 5324

1285, 1892

1908, 2048

4,277

169,668

22443

Discharge summary

report

Admission Date: [**2152-9-19**] Discharge Date: [**2152-9-22**] Date of Birth: [**2100-5-8**] Sex: F Service: MED Allergies: Augmentin Attending:[**First Name3 (LF) 3326**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: Bronchoscopy x2 History of Present Illness: This is a 52 y.o. female with PMH sig for C2 quadriplegia suffered after an epidural abcess on [**2148**] causing pt to be vent dependent, pacer dependent and s/p diaphram pacer who presents to [**Hospital1 18**] from OSH for persisent fevers. The pt was transfered to have an LP with neurosurg backup. Pt was in USOH when she a migraine requiring narcotics and went to ED with altered MS [**First Name (Titles) **] [**Last Name (Titles) 17267**]s. Found to have R ureteral stone/obstruction. Pt had stent placed and was treated for E. coli sepsis with Levo and cefepime x 2 weeks. 4 days after abx ended she agian had a fever and grew C. albicans from urine and have a ? LLL infintrate on CXR with sputm + for MRSA. PICC line grew coag neg staph. Pt initially treated with Imipenem, Levofloxa and eventually vanco and fluconazole. % days after she finished this treatment she again returned to the ED with fevers and MS changes. Blood cx neg. TEE neg. Vanco d/c'd as thought to be possible cause of MS changes. Pt transfered to [**Hospital1 18**] for difficult LP. Past Medical History: C2 quadriplegia Migraines DM2 Nephrolithiasis- s/p stent s/p colostomy for severe decub chronic indwelling foley Social History: Lives at home with husband and 24 hour nursing. No tob No Etoh Family History: None Physical Exam: Vitals: T-101.1, BP: 106/45, P 90, RR: 12, O2: 100% on home vent Gen: morbidly obese quadriplegic female, NAD, A&O x1 (person) HEENT: MMM, PERRL, OP clear CV: RRR, nl S1S2, no mrg Resp: CTA anteriorly Abd: morbidly obese, NT, + BS, soft Ext: 2+ peripheral edema Neuro: quadriplegic, CNII-XII intact, confused, follows commands, 0/5 strength all ext, + clonus. Pertinent Results: [**2152-9-19**] 11:43PM GLUCOSE-110* UREA N-13 CREAT-0.5 SODIUM-134 POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-22 ANION GAP-14 [**2152-9-19**] 11:43PM ALT(SGPT)-32 AST(SGOT)-20 LD(LDH)-315* ALK PHOS-231* AMYLASE-17 TOT BILI-0.6 [**2152-9-19**] 11:43PM LIPASE-22 [**2152-9-19**] 11:43PM ALBUMIN-3.6 CALCIUM-9.0 PHOSPHATE-1.8* MAGNESIUM-1.0* [**2152-9-19**] 11:43PM TSH-3.8 [**2152-9-19**] 11:43PM WBC-4.1 RBC-2.73* HGB-7.3* HCT-21.3* MCV-78* MCH-26.7* MCHC-34.1 RDW-17.2* [**2152-9-19**] 11:43PM NEUTS-71* BANDS-1 LYMPHS-18 MONOS-4 EOS-0 BASOS-0 ATYPS-6* METAS-0 MYELOS-0 NUC RBCS-1* [**2152-9-19**] 11:43PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL OVALOCYT-1+ STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2152-9-19**] 11:43PM PLT COUNT-166 [**2152-9-19**] 11:43PM PT-14.1* PTT-23.2 INR(PT)-1.3 [**2152-9-19**] 11:43PM SED RATE-83* [**2152-9-19**] 11:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2152-9-19**] 11:43PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [**2152-9-19**] 11:43PM URINE RBC-0-2 WBC-[**7-20**]* BACTERIA-FEW YEAST-OCC EPI-[**4-14**] CT ABD: IMPRESSION: 1. Left lung base consolidation consistent with pneumonia. 2. Vague low-attenuation lesion in the left hepatic lobe may represent a focus of fatty infiltration. Confirmation by MR is recommended. 3. 1.5 cm right suprarenal nodule likely represents a right adrenal adenoma. Confirmation by MR is recommended. [**2152-9-21**] 3:30 pm BRONCHOALVEOLAR LAVAG GRAM STAIN (Final [**2152-9-21**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2152-9-23**]): OROPHARYNGEAL FLORA ABSENT. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. GRAM NEGATIVE ROD(S). SPARSE GROWTH. OF THREE COLONIAL MORPHOLOGIES. STAPH AUREUS COAG +. SPARSE GROWTH. Brief Hospital Course: BY PROBLEM: 1) Fever: Mult potential sources identified. Pt was re-pancultured on admission and started on broad coverage due to mental status changes with ceftriaxone, vanco and PO flagyl for possible c.diff infection. Ct head showed no evidence of a mass lesion. CT chest showed evidence of consolidation in LLL suggestive of infiltrate. Bronchoscopy was performed and there was no evidence of post-obstructive pna. It was felt that pt may be due to constant aspiration. Pt was not inflating cuff for eating as she did not like inability to speak. Pt was then seen by our speech and swallow service for evaluation for Passy-Muir valve. Recommended pt wear valve for parts of day to allow for better cough and clearance of secreations. Pt can also use with eating. After hospital day #1 and all cx's neg, pt taken off all abx and any meds that can potentially cause fevers. Pt was afebrile for remainder of admission. Fevers thought to be [**3-13**] drug reactions. After fevers resolved pts mental status returned to [**Month/Day (2) 5348**]. - No vent changes were made other than valve change - Bronch revealed aspiration. - No fevers after d/c'd unnecessary meds, abx and valve changed. 2) MS changes: as mentioned above, thought to be [**3-13**] fevers. When fevers resolved, MS returned to [**Month/Day (2) 5348**]. 3) Sacral decub: stage 2-3. Applied wet to dry dressing [**Hospital1 **] and rotated frequently to avoid complression. 4) DM2: while in hosptial d/c'd metformin as possible drug reaction. Covered with insulin slidine scale. 5) FEN: diabetic diet. Repleted lytes as needed. 6) Dispo: Pt returned home after afebrile for over 72 hours and MS [**First Name (Titles) **] [**Last Name (Titles) 5348**]. 7) Code: FULL Medications on Admission: Heparin SC MVI Colace 100 PO QD Lasix 80 QD Flovent 220 Neurontin 300 TID Metformin 1g Baclofen 20 QID Elavil 75 QD Spironolactone 25 QD Prevacid Guanifesin 1200 [**Hospital1 **] Kcl 20 Ferrous sulfate 325 QD Flonase Cefepime Zinc Ativan Zofran Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Venlafaxine HCl 75 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. Venlafaxine HCl 75 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 6. Neutra-Phos Oral 7. Potassimin Oral 8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QD (once a day). 9. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 10. Metformin HCl 1,000 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1) Tab,Sust Rel Osmotic Push 24HR PO once a day. 11. Colace Oral Discharge Disposition: Home Discharge Diagnosis: Fever. Discharge Condition: Stable Discharge Instructions: Please follow-up with your regular physician regarding [**Name9 (PRE) 58319**] of permanent intravenous access. Call your physican for fevers or new symptoms Followup Instructions: Follow-up with your regular physician [**Last Name (NamePattern4) **] [**2-11**] weeks. Contact your physician if you develop any fevers or other new complaints.

[ "486", "780.6", "V46.1", "344.01", "996.1", "518.83", "707.0", "V09.0", "V02.59" ]

icd9cm

[ [ [] ] ]

[ "33.24", "99.04", "97.49", "96.72" ]

icd9pcs

[ [ [] ] ]

7175, 7181

4281, 6026

271, 289

7232, 7240

2020, 4258

7446, 7612

1618, 1624

6322, 7152

7202, 7211

6052, 6299

7264, 7423

1639, 2001

225, 233

317, 1384

1406, 1521

1537, 1602

25,742

101,211

21856

Discharge summary

report

Admission Date: [**2130-1-16**] Discharge Date: [**2130-1-23**] Service: MEDICINE Allergies: Chicken Protein Attending:[**First Name3 (LF) 2901**] Chief Complaint: Presenting for revascularzation of left leg. Major Surgical or Invasive Procedure: Lower Extremity Vascular Cath x 2 History of Present Illness: 86 y/o female with PMH significant for PVD and chronic renal failure admitted for planned percutaneous revascularization of the left leg. Pt initially presented to [**Hospital 1474**] Hospital on 0/29 with three to four weeks of claudication that had progressed to rest pain. Work up at [**Hospital1 1474**] included bilateral carotid US that showed 80 to 99% stenosis and ABIs that were consistent with claudictaion. Pt was transferred to [**Hospital1 18**] at that time and received a stent to the [**Country **]. At that time, her hospital course was complicated by renal failure secondary to the dye load from her cath. Pt then returned to [**Hospital1 18**] from [**1-9**] to [**1-13**] for the SFA stent and this went well with no renal failure. At this point of time the patients only complaint is pain in her L leg. The pain is greatest in her foot but also involves her L posterior thigh. Otherwise the patient feels well and denies: CP, SOB, N/V, Abd pain, problems with urination or bowel function, fevers, chills, palpitations, PND, or orthopnea. Past Medical History: 1. PVD s/p left fem-[**Doctor Last Name **] bypass, stent to the [**Country **], and stent to the right SFA. 2. HTN 3. Hyperlipidemia 4. CAD 5. CHF 6. Bilateral heel ulcers 7. Chronic renal failure 8. Former smoker- quit 40 years ago 9. Former ETOH abuse- quit 40 years ago 10. Glaucoma Social History: Former smoker, quit 40 years ago. She has a 60-75 pack-year history. She also quit drinking alcohol 40 years ago, and had a problem with EtOH abuse. Family History: Her father had PVD and CHF. Physical Exam: 98.0 140/40 96 20 97% on RA Gen - Alert and oriented x 3, somewhat confused HEENT - surgical lenses in both eyes, no JVD, no LAD, no carotid bruits Cor - RRR II/VI sys murmur Chest - CTA B Abd - S/NT/ND +BS Ext - R and L fem bruits, no edema hands warm, well perfused, good cap refill R foot - pink, scaly skin, not painful, heel ulcer L foot purple starting at metatarsal, 3 cm black necrotic ulcer on bottom of L foot. Pertinent Results: [**2130-1-16**] 05:42PM WBC-14.9* RBC-4.55 HGB-13.8 HCT-40.4 MCV-89 MCH-30.3 MCHC-34.1 RDW-13.7 [**2130-1-16**] 05:42PM PLT COUNT-277 [**2130-1-16**] 05:42PM PT-13.4 PTT-25.6 INR(PT)-1.1 [**2130-1-16**] 05:42PM GLUCOSE-127* UREA N-39* CREAT-1.3* SODIUM-136 POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-23 ANION GAP-21* [**2130-1-16**] 05:42PM CALCIUM-9.2 PHOSPHATE-4.8* MAGNESIUM-2.1 EKG - NSR 97, LAD, nl intervals, T wave flatening in V4-6 which is new, q in III and aVF which is new. [**1-17**] Cath lower ext 1. Arterial access retrograde from RFA. 2. Initial hemodynamics demonstrated an entry pressure of 197/53 mm hg. 3. Initial angiography demonstrated moderate proximal [**Month/Year (2) 32365**] disease. The [**Female First Name (un) 7195**] and LIIA bifurcation had severe diffuse disease with occlusion of the [**Female First Name (un) 7195**]. The LCFA was not visualized and the profunda reconstituted via the IIA collaterals the the PFA. 4. Successful angiojet thrombectomy and stenting of the LCFA, [**Female First Name (un) 7195**] and [**Female First Name (un) 32365**] using overlapping 6.0 x 28, 8.0 x 60 mm, 9.0 x 40 mm and 9.0 x 20 mm Smart control stents, psot dilated with 8.0 x 40 mm agiltrac balloon at 10 atms with no residual stenosis, no dissection. Distal embolization into the AT/DP was treated with overnight thrombolysis via Unafuse. [**1-18**] Cath lower ext 1. Arterial access retrograde via the RFA. 2. Limtied hemodynamics demonstrated 167/44 mm hg in the RFA. 3. Limited angiography demonstrated patent [**Last Name (LF) 32365**], [**First Name3 (LF) 7195**] and LCFA stents. The Graft was patent into the popliteal artery. The AT was patent with a focal 99% stenosis in the DP. 4. Successful PTCA of the DP with a 1.5 x 9 mm maverick balloon at 10 atms. Brief Hospital Course: 86 y/o female with PMH significant for PVD and chronic renal failure admitted for planned percutaneous revascularization of the left leg. Patient with severe PVD resulting in necrosis of the feet. She has already had procedures to her R leg with reestablishment of blood flow. The patient was first taken to cath and found to have a great deal of thrombus in the L leg. She was cathed with atents to the [**Last Name (LF) 32365**], [**First Name3 (LF) 7195**] and LCFA. A catheter was left in overnight for a slow infusion of TPA. She was kept in the CCU during this infusion. Then she was brought back to the cath lab where the DP was opened using PTCA. After this the patient's L foot became less mottled and had dopplerable fellow. After the second procedure the patient was found to have a decreased mental status and difficult to control blood pressure. She was also found to have a fever and a white count. By Issue: **Hypertension - She was having SBP's in the 180's to 200's following the second procedure. Blood pressure goal in the unit was 160 in order to properly perfuse the leg. Lopressor was not successful in controling her blood pressure. Diltiazem was much more effective. She was brought down to the 160's using diltiazem and hydralazine. By the next morning the patient was awake enough to take po meds. Her oral meds were titrated up to keep her blood pressure in the 130 to 140 range. The blood pressure goal ia a compromise between having high enough pressure to perfuse her foot but not too high to rupture the cath site. The patients BP meds have been steadily titrated up with good effect although her BP at discharge was still slightly high in the 150's. **Infection - Patient was admitted with a UTI being treated with levofloxacin. Patient spiked a fever on [**1-18**] and was started on zosyn. Her prior urine culture [**1-17**] grew Klebsiella, resistant to levo and sensitive to zosyn. Also she was found to have a pneumonia LLL on CXR. Furthermore, the patient was found to have a MRSA infection on bedside wound swab. She was also started on vancomycin. Unfortunately the patient can not have an MRI due to her stents so osteo is difficult to rule out. The patient will need to continue zosyn for a total of 2 weeks and vancomycin for a total of 6 weeks. **Mental Status - Upon returning from the cath lab for the second time the patient has a severe waxing and [**Doctor Last Name 688**] of mental status consistent with delerium on top of her baseline mild dementia. She ranged from aggitated (screaming at nurses) to somnolent (barely arousable). A non-contrast head CT was performed given the high blood pressures and recent TPA infusion which was negative for mass or bleed. Neuro was also consulted and felt the patient had a toxic metabolic delerium rather than a stroke. The patient defervesed on zosyn and her mental status improved. By the morning of [**1-22**], she was back to her slight baseline dementia. 2) CAD - Pt has a history of CAD. Enzymes were cycled for T wave flattening and were negative. Patient continued on [**Date Range **], lipitor, plavix. Also her BP meds were continued includine a bblocker, ACE, and, imdur. 3) Glaucoma - Continued on brimonidine drops. FEN - Cardiac, low sodium diet patient allergic to chicken DNR/DNI - documented in chart Medications on Admission: 1. MVT 1 tab daily 2. Ranitidine 75 mg [**Hospital1 **] 3. Ferrous sulfacte 325 mg daily 4. Zinc sulfate 220 mg daily 5. Folic acid 1 mg daily 6. Atorvastatin 40 mg daily 7. Docusate 100 mg [**Hospital1 **] 8. Plavix 75 mg daily 9. Nortriptyline 30 mg daily 10. Senna 1 tab [**Hospital1 **] 11. Aspirin 325 mg daily 12. Hydrochlorothiazide 25 mg daily 13. Lactulose 30 mg Q8H PRN 14. Brimonidine tartrate 0.2% drops OU Q8H 15. Diltiazem 120 mg daily 16. Metoprolol 50 mg [**Hospital1 **] 17. Lisinopril 20 mg daily 18. Isosorbide mononitrate 45 mg daily 19. Tylenol 1000 mg QID PRN 20. Oxycodone 5 mg [**1-28**] tab PO Q6H PRN Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nortriptyline HCl 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 9. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane Q4H (every 4 hours) as needed for throat pain. 10. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO four times a day. 11. Nitroglycerin 2 % Ointment Sig: One (1) inch Transdermal QD (): please place on dorsum of left foot once a day. 12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 14. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 17. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Diltiazem HCl 360 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 19. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 21. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 22. Piperacillin-Tazobactam 4-0.5 g Recon Soln Sig: 4.5 grams Intravenous Q8H (every 8 hours) for 8 days. 23. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous Q24H (every 24 hours) for 40 days. Discharge Disposition: Extended Care Facility: Baypointe - [**Hospital1 1474**] Discharge Diagnosis: Primary: Severe Peripheral Vascular Disease Secondary: HTN Hyperlipidemia CAD CHF CRI Glaucoma Discharge Condition: Stable Discharge Instructions: 1. Please keep all follow up appointments. 2. Please take all medications as prescribed. 3. Seek medical attention for fevers, chills, chest pain, shortness of breath, abdominal pain, pain in your legs, or other concerning symptoms. Followup Instructions: Dr. [**Last Name (STitle) 911**] ([**Telephone/Fax (1) 920**]) (cardiology) will call the patient's proxy ([**Name (NI) 2411**] [**Name (NI) 57341**]) to set up an appointment for next week [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

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icd9cm

[ [ [] ] ]

[ "38.93", "88.48", "99.10", "39.50", "39.90" ]

icd9pcs

[ [ [] ] ]

10337, 10396

4227, 7579

268, 304

10536, 10544

2404, 4204

10827, 11148

1890, 1919

8256, 10314

10417, 10515

7605, 8233

10568, 10804

1934, 2385

184, 230

332, 1395

1417, 1706

1722, 1874

42,892

115,267

16027

Discharge summary

report

Admission Date: [**2118-3-17**] Discharge Date: [**2118-3-25**] Date of Birth: [**2073-4-21**] Sex: M Service: MEDICINE Allergies: Aloe / Levaquin / Tape [**12-6**]"X10YD / Penicillins / Betaseron / vancomycin Attending:[**First Name3 (LF) 2145**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 44 year old male with history of multiple sclerosis, baseline cognitive defects, chronic indwelling suprapubic catheter and recurrent resistant urinary tract infections presenting with UTI. He was recently hospitalized [**Date range (3) 45860**] for UTI complicated by encephalopathy (somnolent, difficult to arouse). Urine culture grew staph aureus; sensitivities were not back by time of discharge. He improved on bactrim and discharged on 14 day course. However, sensitivities after discharge returned with MRSA. . He was seen by his outpatient urologist (Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**]).... . In the ED, initial VS: 95.1 75 151/100 16 97%. He received 1g IV vancomycin. Previously, he had had an erythematous skin reaction on the arm that vancomycin had been infusing. No history of resp distress on vancomycin. Per ED, he had no ostensible reaction while receiving the vancomycin. Per wife, he appeared more red than usual in face and upper chest. Urology was called (but did not officially consult) and agreed with admission to medicine with urology following. . Within minutes of arrival to the floor, patient began to have active seizures. Per wife, he does not have history of seizures and was conversing and at baseline mental status while in ED. He began to groan, head moving side to side, upper extremities twitching and outstretched. During the first episode, he had oxygen desaturation briefly to the mid 70s on room air for a few seconds. Blood pressure was in systolic 180s; HR in 110s. He then fell into stupor and within a few minutes again became tremulous in upper extremities. Pupils were not reactive to light. He received a total of 10mg iv ativan. Neurology was consulted who recommended 1g loading dose of iv fosphenytoin. Wife confirmed that pt is [**Name (NI) 835**]/DNR. . REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Multiple sclerosis diagnosed in '[**03**]. Wheel chair bound. - Neurogenic bladder s/p suprapubic catheter '[**10**] - Multiple urinary tract infections (Providencia, Pseudomonas, MRSA) - Multiple episodes Bacteremia and urosepsis - Nephrolithiasis s/p R ureteral stent placement [**11-11**], multiple lithotripsy procedure, s/p L ureteral stent exchange [**2114-12-7**]. s/p removal of L stent on [**1-6**]. Social History: - Lives with wife who is primary caretaker. - Former electrician/web designer. - Wheelchair bound. - No tobacco - No Alcohol - No illicits Family History: no history of seizures Physical Exam: Admission exam GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, no JVD, no carotid bruits HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-9**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Discharge exam 98.3 111/77 84 20 97%2L GENERAL - ill-appearing caucasian male,A+O x 2 (not to time), looks improved HEENT - PERRLA, sclerae anicteric, MMd, OP clear. Face is erythematous. NECK - Supple, no JVD HEART - RRR, no MRG LUNGS - bibasilar crackles ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - face is red, w/ well-demarcated areas, though this is improving NEURO - awake, A+ O x 2, PERRL. CNs II-XII grossly intact muscle strength decreased globally, increased muscle tone/spasticity are somewhat better since baclofen restarted Pertinent Results: Admission labs [**2118-3-17**] 09:33PM BLOOD WBC-7.6 RBC-5.12 Hgb-14.4 Hct-45.3 MCV-89 MCH-28.2 MCHC-31.9 RDW-15.4 Plt Ct-152 [**2118-3-17**] 09:33PM BLOOD Neuts-74.2* Lymphs-17.4* Monos-6.5 Eos-1.0 Baso-0.9 [**2118-3-17**] 09:33PM BLOOD Glucose-114* UreaN-12 Creat-0.9 Na-135 K-4.5 Cl-96 HCO3-32 AnGap-12 [**2118-3-18**] 05:57AM BLOOD Albumin-3.5 Calcium-9.1 Phos-4.6*# Mg-1.9 Other labs [**2118-3-19**] 03:06AM BLOOD ALT-55* AST-49* AlkPhos-87 TotBili-0.1 [**2118-3-22**] 06:00AM BLOOD ALT-37 AST-42* AlkPhos-87 TotBili-0.4 [**2118-3-19**] 03:06AM BLOOD TSH-2.9 [**2118-3-22**] 09:26PM BLOOD HEPARIN DEPENDENT ANTIBODIES- negative Discharge labs [**2118-3-25**] 06:16AM BLOOD WBC-6.1 RBC-3.93* Hgb-11.5* Hct-36.1* MCV-92 MCH-29.2 MCHC-31.8 RDW-15.9* Plt Ct-181 [**2118-3-25**] 06:16AM BLOOD Glucose-72 UreaN-15 Creat-0.8 Na-141 K-3.7 Cl-102 HCO3-28 AnGap-15 [**2118-3-25**] 06:16AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.9 Studies EEG [**3-18**]: CONTINUOUS EEG RECORDING: Began at 12:05 on [**3-18**] and continued until 7:O0 the next morning. At the beginning, it showed a low voltage faster pattern in all areas with bursts of focal slowing especially in the left temporal region. There were also some runs of rhythmic 6 Hz slowing in the left temporal area and other runs of periodic slowing with sharp features, none lasting for more than 8-10 seconds or so. On video, they did not appear to have any clinical correlate. By the evening, the background was more suppressed and, while left temporal slowing was still evident, the sharp features were not. SPIKE DETECTION PROGRAMS: Showed a few of the left temporal sharp features, especially early in the record. SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures. PUSHBUTTON ACTIVATIONS: There were none. SLEEP: No normal waking or sleep patterns were evident. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: This telemetry captured no pushbutton activations. There was continued focal slowing in the left temporal region. Early in the record, this also included some runs of irregular sharp activity and some 6 Hz rhythmic slowing in the same area, but these episodes did not appear to show any clinical evidence of seizure on video. They were brief. No more prolonged and clear electrographic seizures were recorded. CXR [**2118-3-18**]: Portable AP chest radiograph demonstrates low lung volumes and worsening basilar atelectasis. The left PICC has been removed. There is no focal consolidation, large pleural effusion, or pneumothorax. The cardiomediastinal silhouette is partially obscured. MR head [**2118-3-19**]: FINDINGS: The study is compared with most recent enhanced MR examination of [**2-/2118**], as well as the remote study of [**2109-9-11**]. Again demonstrated is the extensive confluent T2-/FLAIR-hyperintensity throughout bihemispheric subcortical and periventricular white matter, with similar abnormality involving the posterior fossa, including the brainstem, cerebellar peduncles and cerebellar hemispheres. Allowing for the motion artifact, above, the overall appearance is unchanged. By and in-large, the extensive lesions demonstrate intrinsic T1-hypointensity, representing "black holes" of irreversible demyelination. However, there is a prominent curvilinear or "targetoid" 16 mm focus of enhancement in the right corona radiata with a possible second enhancing focus in the corresponding location on the left. The right-sided focus appears new since the [**4-/2117**] examination, though previously, there was a smaller, more nodular focus in the immediately adjacent centrum semiovale. Allowing for the marked limitation in the post-contrast imaging, no other definite enhancing focus is seen, with apparent interval resolution of the left-sided subcortical white matter, temporal lobar and cerebellar hemispheric foci. Currently, there is no pathologic leptomeningeal or dural focus of enhancement. There is no definite focus of slow diffusion to suggest an acute ischemic event, and the principal intracranial vascular flow-voids, including those of the dural venous sinuses are preserved and these structures enhance normally. In comparison to the more remote study there is no definite progression of the marked global atrophy (particularly given the patient's age) or the severe diffuse atrophy of the corpus callosum. Limited imaging of the upper cervical spinal cord, through the mid-C4 level, demonstrates no definite abnormality. IMPRESSION: The study, particularly the post-contrast MP-RAGE acquisition, is quite limited by motion artifact, with: 1. No significant change in the overall extensive demyelinating "disease burden." 2. Curvilinear rim-enhancing focus in the right corona radiata appears new since the [**2117-4-6**] study and likely represents a site of active inflammation; allowing for the limitation above, there is no definite additional enhancing focus, with apparent interval resolution of many of the foci demonstrated on that study. 3. Marked global and corpus callosal atrophy, not significantly changed since the [**9-/2109**] study. CXR [**2118-3-25**]: : A right-sided PICC terminates within the distal SVC. The aeration of the lungs has improved compared to the prior study. Cardiac silhouette is stable. No large pleural effusions are seen. There is no pneumothorax. Bones are intact. IMPRESSION: Right-sided PICC terminating within the distal SVC. Brief Hospital Course: Mr. [**Known lastname 45855**] is a 44yoM with h/o multiple sclerosis, baseline cognitive defects, chronic indwelling suprapubic catheter and recurrent resistant urinary tract infections presenting with a UTI and new onset seizures. . After initially being admitted to the floor, he developed seizures requiring 10mg IV ativan and started on fosphenytoin with a load and transferred to the MICU. He was noted to be increasingly somnelent with periods of central apenea. ABG showed acidemia with CO2 on the 70s. He was started on Bipap with improvement in his CO2. It was presumed that his central apnea was secondary to his large ativan dose which slowly improved with clearance of the ativan. He was started emperically on vanc/ctx/amp/acyclivir to cover both his UTI and for empiric coverage for meningitis given his AMS. A head MRI was done, which showed unchanged appearance of extensive demyelinated, w/ new curvilinear rim focus in corona radiatia, likely site of active inflammation, no evidence of ischemic event, unchanged marked global atrophy. Given that meningitis was less likely he was narrowed to vanc/[**Known lastname **]. He began to wake up over the day on [**3-19**] and was weaned off BiPap to a shovel mask and transferred to the floor. . On the floor, he remained stable throughout the day on [**3-20**]. However, that morning was noted to be more tachycardic and febrile to 103 in the setting of hypoxia to the 80s. He was put on a NRB and sats remained in the 80s for a while before improving to the mid- 90s. ABG on NRB was 7.48/40/72. His eyes were open but wasn't following commands and appeared obtunded on the floor. CXR on the floor showed no new infiltrate. Patient was transitioned to the MICU and briefly broadened to vanco/[**Month/Year (2) **]/flagyl for aspiration pneumonia, but quickly narrowed given rapid improvement of respiratory status. By morning patient was alert and oriented X3, communicating and breathing comfortably on 2L nasal cannula with saturation in mid to high 90s. Abx were again narrowed to [**Month/Year (2) 21347**]/Vanco for coverage of UTI. Patient was then called out to floor. . #) Seizures (new): several possible etiologies in this patient; he has severe multiple sclerosis, and though he has never had a seizure before, there is a new area of inflammation on his MRI. Infectious causes in setting of severe MS [**First Name (Titles) **] [**Last Name (Titles) 45861**] seizures, most notably his UTI. He was started on fosphenytoin IV initially, then transitioned to phenytoin PO once mental status improved. There was no sign of further seizure activity. He will f/u w/ [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] in ~2 weeks . # Altered mental status: per wife, was at baseline until the seizures. 24h EEG did not show status epilepticus. Mental status then to near baseline by discharge suggesting largely resultant from infections/medications/post-ictal state. . #) Apnea/Hypercarbia: fully resolved as his mental status improved once coming out of the MICU the 2nd time. . #) UTI: growing MRSA and pseudomonas. He will is on vancomycin/ceftazidime, and will complete a 14 day course. A PICC line was insserted and home infusion company will assist w/ antibiotics. There was a question of home aids flushing his foley, thus potentially introducing pathogens. There should be no flushing of the foley and this was addressed w/ wife and in page 1 instructions. . #) Rash w/ vancomycin: pt did develop red rash on arms and face w/ vancomycin infusion. Component of redman syndrome was suspected. Benedaryl was given w/ vancomycin and this improved his symptoms. There was no other evidence of allergic disease, and no facial swelling or airway obstruction. . #) Thrombocytopenia- Bseline ~150's, went downt to 89 this admission. No signs of active bleeding. No rashes on exam. He had been exposed to heparin in the last 30 days, so PF4 antibody was checked and was negative. His platelets responded to baseline by discharge, and likely this was all secondary to acute infection. . #) Multiple sclerosis: initially held home home baclofen given AMS, but restarted by discharge once mental status improved. . #) HTN: continued home amlodipine . # CODE: DNI/DNR (confirmed with wife) . ======================================= TRANSITIONAL ISSUES # further seizure care per Dr [**Last Name (STitle) **] in Neurology # PICC line is to be d/c'ed by home infusion company # Foley catheter should NOT be flushed, except at the direct recommendations of [**Name8 (MD) **] MD Medications on Admission: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. baclofen 10 mg Tablet Sig: Two (2) Tablet PO 5X/DAY (5 Times a Day). 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). Discharge Medications: 1. ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours) for 6 days. Disp:*19 Recon Soln(s)* Refills:*0* 2. vancomycin 1,000 mg Recon Soln Sig: 1250mg Intravenous twice a day for 6 days: Start on [**3-26**] AM. Give IV benadryl prior to infusion. Infuse over 2 hours. Disp:*12 doses* Refills:*0* 3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. baclofen 10 mg Tablet Sig: Two (2) Tablet PO 5X/DAY (5 Times a Day). 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 9. phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO 3 tabs in the morning, 3 tablets at noon, and 4 tablets in the evening. Disp:*300 Tablet, Chewable(s)* Refills:*1* 10. Benadryl 25 mg Capsule Sig: One (1) Capsule PO twice a day: give 20 minutes before vancomycin infusion. Disp:*20 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] [**Hospital1 269**] Discharge Diagnosis: Primary: MRSA urinary tract infection, seizure Secondary: multiple sclerosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr [**Known lastname 45855**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for a urinary tract infection. You then developed seizures. You had a head MRI, which showed a new area of multiple sclerosis, and this plus the infection is probably why you had a seizure. You were started on antibiotics and anti-seizure medications, and got much better. The following changes have been made to your medications: ** START phenytoin (dilantin) [anti-seizure medication]. Take 150mg in the morning and at noon, and 200mg at night (3 total doses per day) ** START vancomycin [antibiotic] ** START ceftazidine [antibiotic] ** START benadryl, take 20 minutes before vancomycin infusion Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] D. Address: [**Location (un) 45857**], [**Location (un) **],[**Numeric Identifier 45858**] Phone: [**Telephone/Fax (1) 45859**] Appointment: Friday [**2118-4-1**] 10:15am Department: NEUROLOGY When: MONDAY [**2118-4-4**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD [**Telephone/Fax (1) 5434**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: SURGICAL SPECIALTIES When: MONDAY [**2118-4-11**] at 1:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD [**Telephone/Fax (1) 164**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: FRIDAY [**2118-5-20**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD [**Telephone/Fax (1) 5434**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

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300, 309

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13,873

146,070

1729

Discharge summary

report

Admission Date: [**2126-11-4**] Discharge Date: [**2126-11-15**] Service: ACOVE CHIEF COMPLAINT: Nausea, vomiting and dizziness. HISTORY OF PRESENT ILLNESS: The patient is an 82 year-old female with a remote history of breast cancer, hypothyroidism, type 2 diabetes mellitus who presents with a three week history of vertigo and episode of weakness this a.m. of admission. For three weeks the patient with daily episodes of feeling like the room was spinning around her only occurring with standing, relieved with sitting and lying supine associated with gait instability and need to support herself with walls. No headache, visual changes, chest pain, shortness of breath, palpitations, diaphoresis, upper or lower extremity weakness. The patient was prescribed Meclozine by her primary care physician for unclear duration with no benefit. The patient recently had a CT, which was read as negative a few days prior to admission. An episode of not being able to stand up from cough without assist. On the a.m. of admission the patient could not get up from her couch for six hours secondary to inability to lift head off the pillow. Denies associated weakness of arms, legs, visual symptoms. When the son arrived he helped her up and she ambulated with the walker. The patient also reports significant nausea and vomiting over the past several days. On arrival to the Emergency Department the patient had a temperature of 97.3, blood pressure 183/76. Pulse 99. She received her Verapamil. She had no acute complaints in the Emergency Department. No vertigo, lightheadedness, nausea, vomiting or diarrhea. No recurrence of difficulty lifting her head. Son expressed concern about the patient's slurred speech, which at the time of initial examination had resolved. PAST MEDICAL HISTORY: 1. History of right breast cancer status post local excision and axillary node dissection in [**2118-6-29**], status post radiation therapy on Tamoxifen. She has had normal mammograms since. 2. Hyperlipidemia. 3. Hypothyroidism. History of thyroidectomy. 4. Hypertension. 5. Type 2 diabetes mellitus. 6. Status post appendectomy. ALLERGIES: Aspirin causes wheezing. MEDICATIONS ON ADMISSION: Meclozine 12.5 mg po t.i.d., iron _______________ 100 mg po q day, Tamoxifen 20 mg po q day, Desoximetasone topicals 0.05% gel, lipiduria 20 mg po q day, Syntropy 88 imcarbofos po q day, Glucotrol XL 5 mg po q day, Lovenox one tab po q day, Metformin 500 mg po b.i.d., Tylenol #3 prn, Meprobamate 800 mg po q day, dextrostat 5 mg po t.i.d., Piroxicam 20 mg po q day, verapamil 240 mg po q day. SOCIAL HISTORY: The patient lives in [**Location 9867**]. Her husband is deceased. The patient is highly functional with activities of daily living at baseline. Son lives nearby. No tobacco, alcohol or intravenous drug use. REVIEW OF SYSTEMS: Positive for constipation, positive for hearing loss, which is chronic, positive for taking good po, positive for bilateral knee pain, which is also chronic and positive for a 12 pound weight loss over the past year, which was not intentional. No history of prior viral episode recently. PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature 97.3. Pulse 99. Blood pressure 183/76. Respiratory rate 16. O2 sat 94% on room air. In general, the patient is awake, alert and oriented times three, hard of hearing and in no acute distress. HEENT examination no nystagmus. Mucous membranes are moist. Oropharynx is clear. Tongue midline and symmetric elevation of palette. Neck no lymphadenopathy. Midline incision status post thyroidectomy. Cardiovascular examination regular rate and rhythm. Normal S1 and S2. No murmurs. Lungs clear to auscultation with occasional wheezes and crackles. Abdomen soft, nontender, nondistended, normoactive bowel sounds. No hepatosplenomegaly. Extremities no edema. Neurological examination cranial nerves II through XII intact. Decreased prominence of left nasal labial fold. Strength 5 out of 5 bilaterally upper and lower extremities. Sensation and light touch intact bilaterally. Reflexes 2+ patella, bicipital bilaterally. Cerebellar function intact, though slightly delayed. LABORATORIES ON ADMISSION: White blood cell count 5.6, hematocrit 33.9, sodium 139, potassium 3.6, chloride 106, bicarbonate 24, BUN 12, creatinine 0.7, glucose 119, LDH 865, which was hemolyzed. PTT 55.9, INR 1.7. ALT 30, AST 129, which changed to 47 with a nonhemolyzed specimen. Albumin 4.2 amylase 107, lipase 45. Urinalysis was essentially negative. Chest x-ray flattening of hemidiaphragm, positive atelectasis, positive opacity in left lower lobe nodule. No consolidations or effusions. Electrocardiogram normal sinus rhythm at 96 beats per minute, first degree AV block, left axis deviation, which is new, right bundle branch block, which is old, no acute ST or T wave changes. Head CT on [**10-31**] showed positive calcified density in right ethmoid sinus with unclear etiology. IMPRESSION: The patient is an 82 year-old year-old female with a history of breast cancer, hypertension, hyperlipidemia with three weeks of vertigo, ataxia and episode of weakness on the morning of admission. Neurological examination unremarkable. HOSPITAL COURSE: 1. Cardiovascular: The patient has a history of diabetes mellitus and was admitted and placed on telemetry and monitored with serial CKs and troponin. The patient actually did rule in for inferior myocardial infarction and was started on Plavix as the patient is unable to take aspirin and given her coagulopathy was not started on heparin, also with the possibility of there being some kind of mass lesion in her brain the patient was not given any heparin. The patient's troponins trended down over the next several days. She underwent an echocardiogram the following day, which showed inferior hypokinesis consistent with an inferior myocardial infarction. The Plavix was discontinued secondary to hematemesis with coffee ground emesis and the patient was not placed on any anticoagulation after this point or antiplatelet agents as she was at significant risk for further gastrointestinal bleeding. Throughout these episodes the patient did not report any chest pain, shortness of breath and only continued to feel nauseous. She was started on a beta blocker as well as an ace inhibitor and nitrates, which she will continue as an outpatient. 2. Neurological: The patient's symptoms were suggestive of either a stroke versus a mass. Imaging was done with MRI as well as MRI with contrast, which showed a mass consistent with hemorrhagic focus in her cerebellum on the right side. Unclear initially if this was a tumor or a stroke. Further imaging was done with MR [**Last Name (Titles) 9868**], which further delineated the mass and showed that it was more consistent with a tumor. The patient declined biopsy or any invasive workup of this mass and it is still unclear whether it is a tumor or a hemorrhagic stroke, however, it is significantly more likely that it is a tumor. The patient's symptoms of nausea and vomiting improved after which she was started on Decadron, which was changed from intravenous to po and continues to do well on the po dosing of Decadron. It appears that the mass was causing compression of her fourth ventricle causing a mass shift and after starting Decadron her symptoms improved likely indicating that the Decadron had caused shrinking of the tumor and decrease of the edema. Hematology/Oncology as well as Neurosurgery as well as Radiation/Oncology was consulted. After much discussion it was decided that if no further surgical workup was to be planned and no further chemotherapy would be planned the patient was to continue on Tamoxifen and would be offered radiation therapy with the understanding that this may not be a tumor, however, the benefits of palliating her symptoms would out weigh her chances of getting morbidity from the radiation itself. The patient would like to continue her radiation treatment at [**Hospital3 2358**] where she had it in the past. 3. Hematology: The patient had a coagulopathy initially of unclear etiology. A workup was done with a mixing study, which revealed lupus anticoagulant as the etiology of her coagulopathy and for this reason she will not be continued on any sort of anticoagulation. 4. Gastrointestinal: The patient had a significant gastrointestinal bleed with hematemesis, coffee ground emesis on Plavix. Nasogastric lavage with 1500 cc of normal saline in order to clear the coffee grounds. The patient went to the Intensive Care Unit for a day to monitor her for further bleeding, however, her hematocrit and hemodynamics were stable and she was not transfused and not endoscoped as she had just suffered an myocardial infarction. The plan was made to do an endoscopy if she were to continue bleeding significantly, however, this did not happen and endoscopy was not pursued. Bleeding did stop and the patient did not have any guaiac positive stools after this point. DISCHARGE DIAGNOSES: 1. Right cerebellar mass. 2. Inferior myocardial infarction. 3. Lupus anticoagulant coagulopathy. 4. Gastrointestinal bleed. 5. Diabetes mellitus type 2. 6. Hypothyroidism. 7. Hypertension. 8. Breast cancer history, possible metastatic disease to cerebellum. DISCHARGE CONDITION: Fair. The patient is tolerating po with no longer having symptoms of nausea, vomiting or dizziness and is to be discharged to a short term rehab facility. MEDICATIONS ON DISCHARGE: Tylenol 650 mg po q 6 prn, Maalox 30 cc po q 4 hours prn, Lipitor 20 mg po q day, Colace 100 mg po b.i.d., Bisacodyl 10 mg po prn, Decadron 4 mg po q 6 hours, Glipizide XL 5 mg po q day, Metformin 500 mg po b.i.d., Reglan prn, Levothyroxine 88 micrograms po q day, Ativan 1 mg po q 6 hours prn, Lopressor 25 mg po t.i.d., Protonix 40 mg po b.i.d., Lisinopril 10 mg po q day, Seraquel 25 mg po q.h.s., Tamoxifen 20 mg po q day, regular insulin sliding scale, NPH 6 units q.h.s., Imdur 30 mg po q day. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Doctor Last Name 9869**] MEDQUIST36 D: [**2126-11-15**] 09:06 T: [**2126-11-15**] 09:30 JOB#: [**Job Number 9870**]

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Discharge summary

report

Admission Date: [**2104-8-11**] Discharge Date: [**2104-8-13**] Date of Birth: [**2046-1-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: Hypotension post PCI Major Surgical or Invasive Procedure: crdiac catheterization with drug eluting stent to the left anterior descending coronary artery. History of Present Illness: 58 yo male with CAD (s/p AMI [**10/2100**]) presenting with hypotension to the 60s-70s s/p cath today with DES. He has an extensive past cardiac history and received a proximal LAD DE-cypher stent in [**10/2100**] and 3 BMS to the circumflex in [**11/2100**], DM, HTN, HL, infarct-related cardiomyopathy ([**2-3**] TTE: EF of 30%, s/p ICD [**2-/2101**]) and presenetd for cardiac catheterisation following recurrent R-sided chest pains similar to previous anginal chest pains. He had noted recurrent chest pains occurring several times per week over the past few weeks on a background of angina over the past 2 years. His pains are R chest dull aches that radiated to the right shoulder lastimg 3-4 mins and often occurred after eating but could also occur at rest and were not associated with nausea, vomiting or light-headedness but had mild sweating. He saw a cardiologist 3-4 months ago regarding his chest pains who commenced ISMN which helped and referred him for cath. He underwent cath on [**8-11**] and found to have 100% proximal RCA with left to right and right to right collaterals. LAD with 90% in stent restenosis proximally and underwent a DES to the ostial LAD. LCx stents were patent. Cardiac Index 1.68 l/min/m2, RAP mean 12, PCWP Mean 27, PAP 59/29/42, AoP 131/89. Patient underwent cath without any immediate complications. . Upon making several attempts at a bowel movement in the bathroom, the patient was walking back to his bed and developed lightheadedness. His blood pressure was as low as 60/40mm Hg with a HR of c60s. He felt confused and presyncopal but never lost consciousness. He denied chest pain/sob/palpitations. EKG showed no new changes. He was given a 1 liter bolus of NS and his blood pressure slowly increased to 90/50. Patient was mentating well and it was unclear if he was urinating. Given his hypotension unresponsive to fluids and marked nursing concern, he was transferred to the CCU for closer monitoring. On transfer, SBP 90mmHg, pulsus was 6-8 mmHg and there was no significant difference in arm BPs. On arrival to the CCU, he was completely asymptomatic. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denied recent fevers, chills or rigors. He denied exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, or syncope. Presyncopal symptoms as above. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - inferior MI with occlusion of RCA treated with medical management ('[**89**]) - anterior wall MI [**2100-11-10**] with cypher stent to LAD -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: PCI of the proximal LAD, PTCA, rotational atherectomy, and stenting of the CX and OM2 with overlapping bare metal stents ([**11/2100**]) -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - CHF s/p ICD placement [**2101-3-1**] (Dr. [**Last Name (STitle) **] (mode switch 170) - Hyperlipidemia - HTN - GERD - DM, type 2 - OSA (nasal CPAP at home) - anxiety - s/p cholecystectomy - s/p umbilical hernia repair - ?COPD Social History: Smokes 1.5 pks/day for 30years. [**3-27**] drinks per week, history of more alcohol use. Denies drug use. Drives a zomboni at a ice hockey rink. Lives with his wife and 3 of his children, 4th child and his family live beneath them in the same building. Family History: Brother recently passed away during valvular surgery at age 55, father died of MI in his 70s, otherwise non-contributory. Physical Exam: VS: T=98.3 BP=95/62 HR=71 RR=16 O2 sat= 98% Pulsus 6mmHg. BP 86/50 L vs 90/54 in R when checked at 00:15 GENERAL: In NAD. Oriented x3. Mood, affect appropriate. Asymptomatic. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 4 cm above sternal angle. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Obese, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. No R femoral bruit. Femoral pulses palpable. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ No femoral bruits note R groin site clean. Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs [**2104-8-11**] 10:38PM WBC-8.9 RBC-4.54* HGB-13.0* HCT-39.2* MCV-86 MCH-28.6# MCHC-33.1 RDW-15.2 [**2104-8-11**] 10:38PM PLT COUNT-169 [**2104-8-11**] 07:05PM SODIUM-135 POTASSIUM-3.9 CHLORIDE-96 [**2104-8-11**] 07:05PM CK(CPK)-75 [**2104-8-11**] 07:05PM CK-MB-2 [**2104-8-11**] 07:05PM PLT COUNT-185 [**2104-8-11**] 08:45AM GLUCOSE-394* Discharge Labs [**2104-8-13**] 06:20AM BLOOD WBC-7.1 RBC-4.85 Hgb-13.9* Hct-41.3 MCV-85 MCH-28.6 MCHC-33.6 RDW-15.2 Plt Ct-175 [**2104-8-13**] 06:20AM BLOOD Plt Ct-175 [**2104-8-13**] 06:20AM BLOOD [**2104-8-13**] 06:20AM BLOOD Glucose-290* UreaN-19 Creat-0.9 Na-136 K-4.2 Cl-99 HCO3-27 AnGap-14 [**2104-8-12**] 06:02AM BLOOD CK(CPK)-79 [**2104-8-12**] 06:02AM BLOOD CK-MB-2 cTropnT-0.01 [**2104-8-13**] 06:20AM BLOOD Calcium-9.5 Phos-4.3 Mg-1.6 . Microbiology: no results pending - [**8-11**] Cardiac Cath BRIEF HISTORY: 58 yo male with CAD (s/p AMI 10/[**2100**]. He received a proximal LAD DE-cypher stent in [**10/2100**] and 3 BMS to the circumflex in [**11/2100**]), DM, HTN, HL, infarct-related cardiomyopathy ([**2-3**] TTE: EF of 30%, s/p ICD [**2-/2101**]) who presents with R-sided chest pain similar to previo us anginal chest pains. INDICATIONS FOR CATHETERIZATION: chest pain - anginal equivalent PROCEDURE: Right Heart Catheterization: was performed by percutaneous entry of the right femoral vein, using a 7 French pulmonary wedge pressure catheter, advanced to the PCW position through an 8 French introducing sheath. Cardiac output was measured by the Fick method. Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 5 French left [**Last Name (un) 2699**] catheter, advanced to the ascending aorta through a 5 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 5 French JL4 and a 5 French JR4 catheter, with manual contrast injections. Percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.29 m2 HEMOGLOBIN: 14 gms % FICK **PRESSURES RIGHT ATRIUM {a/v/m} 15/14/12 PULMONARY ARTERY {s/d/m} 59/29/42 PULMONARY WEDGE {a/v/m} 33/34/27 AORTA {s/d/m} 131/89/98 **CARDIAC OUTPUT HEART RATE {beats/min} 80 RHYTHM NSR O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 74 CARD. OP/IND FICK {l/mn/m2} 1.9 **RESISTANCES SYSTEMIC VASC. RESISTANCE 1787 PULMONARY VASC. RESISTANCE 312 FICK **% SATURATION DATA (NL) PA MAIN 60 AO 99 OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed. **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA DISCRETE 100 **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD DISCRETE 90 6A) SEPTAL-1 NORMAL 7) MID-LAD NORMAL 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 10) DIAGONAL-2 NORMAL 12) PROXIMAL CX NORMAL 13) MID CX NORMAL 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 NORMAL 15) OBTUSE MARGINAL-2 NORMAL **PTCA RESULTS LAD PTCA COMMENTS: Initial angiography revealed ostial/proximal LAD 90% in-stent restenosis (ISR). We planned to treat the lesion with PTCA/stenting and the arterial access was exchanged to a 6Fr sheath. A 6Fr XBLAD guiding catheter provided good support for the procedure and bivalirudin was started prophylactically. A Prowater wire was initially used but we were unable to cross the lesion. We then successfullly crossed the lesion with a Choice PT [**Last Name (un) **] wire with minimal difficulty. We then predilated with an Apex OTW 2.5x12mm (22atm for 20sec) followed by stenting with a Promus 3.5x18mm drug-eluting stent (15atm for 20sec). We then post-dilated with an Apex 3.5x15mm balloon (max 22atm for 22sec). Final angiography revealed 0% residual stenosis, no angiographically apparent dissection and continued TIMI 3 flow in the LAD vessel. Patient left the lab angina free and in hemodynamically stable condition. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 1 hour 18 minutes. Arterial time = 0 hour 43 minutes. Fluoro time = 14.5 minutes. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 220 ml Premedications: Midazolam 1 mg IV Fentanyl 50 mcg IV Anesthesia: 1% Lidocaine subq. Cardiac Cath Supplies Used: - [**Doctor Last Name **], PROWATER 300CM - [**Company **], CHOICE PT [**Name (NI) **] 300CM 2.5MM [**Company **], MAVERICK 12MM 3.5MM [**Company **], QUANTUM MAVERICK 15MM 6FR CORDIS, XBLAD 3.5 6FR [**First Name8 (NamePattern2) **] [**Male First Name (un) **], ANGIOSEAL VIP - ALLEGIANCE, CUSTOM STERILE PACK - MERIT, LEFT HEART KIT - MERIT, RIGHT HEART KIT - [**Doctor Last Name **], PRIORITY PACK 20/30 3.5MM [**Company **], PROMUS OTW 18MM - [**Company **], PULMONARY WEDGE PRESSURE CATHETER Intra-procedure Medications: Bivalirudin - 90 mg, gtt at 205 mg/hr Nitroglycerin - 600 mcg COMMENTS: 1. Selective coronary angiography of ths right dominant system revealead a 90% in-stent restenosis of the DES in the proximal LAD. The LCX had no angiographically-aparent flow-limiting disease. The RCA had a 100% occlusion proximally with left-to-right and right-to-right collaterals. 2. Resting hemodynamics revealed biventricular diastolic dysfunction and moderate pulmonary hypertension with a mean RA pressure of 12mmhg, and a PCWP of 27 mmhg. Systemic blood pressure was normal. 3. Successful PTCA/stenting of the ostial/proximal LAD vessel with a Promus 3.5x18mm drug-eluting stent (DES). Final angiography revealed 0% residual stenosis, no angiographically apparent dissection and continued TIMI 3 flow (see PTCA/PCI comments). 4. 6 6Fr FA access closed with angioseal closure device: no complications. FINAL DIAGNOSIS: 1. proximal LAD 90% stenosis. proximal RCA 100% occlusion with left-to-right and right-to-right collateralization. 2. biv diastolic dysfunction 3. moderate pulmonary hypertension 4. normal systemic blood pressure 5. Successful PTCA/stent of the ostial/proximal LAD with a Promus 3.5x18mm drug-eluting stent (DES) with no complications (see PTCA/PCI report above). . EKG [**8-12**] Sinus rhythm. Intraventricular conduction delay. ST-T wave abnormalities. Since the previous tracing the QRS duration is somewhat longer. TRACING #3 Intervals Axes Rate PR QRS QT/QTc P QRS T 68 150 112 426/440 25 60 45 Brief Hospital Course: 58 yo male with CAD (s/p AMI [**10/2100**] and proximal LAD DE-cypher stent in [**10/2100**] and 3 BMS to the circumflex in [**11/2100**]) presented for elective coronary angiography following increasing right-sided chest pains similar to his previous angina. Cardiac catheterisation on [**2104-8-11**] revealed a 100% proximal RCA stenosis with left to right and right to right collaterals. The LAD had 90% in-stent restenosis proximally. LCx stents were patent. He underwent a DES to the ostial LAD without immediate complications. At PCI he was treated with IV furosemide and this produced a significant diuresis. On the evening of his PCI he developed presyncope following straining to pass a bowel movement and this was associated with hypotension to c60s/40s and a normal HR. Whilst he was initially briefly symptomatic, he was placed in the head-down position and received 1L IV fluids and had no further symptoms. Unfortunately his BP did not improve following his fluids and for observation he was transferred to teh CCU on [**8-11**]. He remained asymptomatic and his BP improved without further intervention. This hypotensive event was considered to be vasovagal presymcope in the context of aggressive diuresis. He was transferred to the cardiology [**Hospital1 **] on [**2104-8-12**]. Troponin was negative and ECGs were unchanged from baseline. Other than a possible run of NSVT for which he was asleep and asymptomatic (pt has ICD and no shock delivered) he remained well and was discharged home on [**2104-8-13**] after mild hypomagnesemia (1.6) was corrected. 58M post PCI to ostial LAD (in stent restenosis prev DES to LAD and BMS to Cx) with B/G of IHD, MIx2 and ICD in situ presents with likely vagal episode in the context of diuresis and resultant prolonged hypotension admitted to the CCU for monitoring. 1 episode of possible NSVT. . # Prolonged hypotensive episode. This was felt likely due to a vagal episode in the context of diuresis following IV furosemide post cardiac catheterisation. Mr [**Known lastname 68242**] developed symptoms of pre-syncope following straining/Valsalva on the toilet and following this became profoundly hypotensive with SBP in the 60s. He was put head-down and did not develop any further symptoms but despite 1L IV N saline his BP did not significantly improve. BP was unchanged in both arms and there was no significant pulsus paradoxus. He was transferred to the CCU for observation and he remained stable and his BP improved without further intervention. HCt/Hb were unchanged and TnT was normal. Antihypertensives and Imdur were held while in hospital and gradually re-introduced prior to discharge. His BP improved and he was discharged home. . # CAD - PCI with DES to prox LAD. : Mr [**Known lastname 68242**] presented for elective coronary angiography following a several month history of worsening right-sided chest pains similar to his previous angina. At angiography there was evidence of a 100% proximal RCA stenosis with left to right and right to right collaterals. The LAD was also heavily diseased with 90% in stent restenosis proximally. LCx stents were patent. There was also evidence of biventricular diastolic dysfunction and moderate pulmonary hypertension with a mean RA pressure of 12mmhg, and a PCWP of 27 mmhg. He underwent a DES to the ostial LAD. Due to elevated filling pressures furosemide 20mg IV was administered. There were no immediate complicatiosn of her cardiac catheterisation. He was monitored on telemetry and had a presyncopal episode as above. HCt and Hb were stable and cardiac enzymes were negative. He should continue on clopidogrel for 1 year and will be followed up by Dr. [**Last Name (STitle) **] in 1 month. . # Possible NSVT: Mr [**Known lastname 68242**] had a possible episode of NSVT for which his ICD did not deliver a shock and did not recur. He was noted to have mild hypomagnesemia on [**8-12**] and this was repleted. . # Hypertension: Given his hypotensive episode, Mr [**Known lastname 68243**] anti-hypertensives were held and restarted on discharge. His Imdur was stopped. . # Hyperlipidemia: He will continue on simvastatin 80 mg daily. . # Diabetes type 2 on insulin - Metformin was held for 48 hours and his normal regime was restarted. . # GERD - Continue ranitidine 150 mg [**Hospital1 **] . # OSA - CPAP as required . PROPHYLAXIS: -He received DVT ppx with SC heparin whilst an inpatient. Medications on Admission: MEDICATIONS on transfer: Ranitidine 150 mg PO BID Insulin SC Atropine Sulfate 0.5 mg IV X1:PRN symptomatic bradycardia & hypotension Alprazolam 0.5 mg PO/NG [**Hospital1 **]:PRN anxiety traZODONE 50 mg PO/NG HS:PRN insomnia Simvastatin 80 mg PO/NG DAILY Paroxetine 20 mg PO/NG DAILY Metoprolol Succinate XL 25 mg PO DAILY Lisinopril 20 mg PO/NG DAILY Furosemide 40 mg PO/NG [**Hospital1 **] Clopidogrel 75 mg PO/NG DAILY Potassium Chloride PO Sliding Scale Aspirin 325 mg PO DAILY Simethicone 40-80 mg PO QID:PRN abdominal discomfort Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO QID:PRN indigestion Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Acetaminophen 650 mg PO Q4H:PRN fever, pain Oxycodone-Acetaminophen 1 TAB PO Q4H:PRN pain Discharge Medications: 1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual Q5MIN () as needed for chest pain: Take one tablet under tongue and wait 5 minutes. If still have chest pain take one more tab and call 911. Disp:*25 Tablet* Refills:*0* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain: for gout. 12. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) disk Inhalation twice a day. 13. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 14. Slow Fe 47.5 mg (Iron) Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 15. Mirapex 0.125 mg Tablet Sig: 1-2 Tablets PO at bedtime. 16. Byetta 10 mcg/0.04 mL Pen Injector Sig: One (1) injector Subcutaneous twice a day. 17. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day: Please restart on [**2104-8-14**]. 18. Insulin Glargine 100 unit/mL (3 mL) Insulin Pen Sig: Sixty (60) units Subcutaneous at bedtime. 19. Insulin Aspart 100 unit/mL Insulin Pen Sig: as per sliding scale units Subcutaneous four times a day. 20. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 21. Cialis Oral Discharge Disposition: Home Discharge Diagnosis: Coronary Artery disease Hypertention Diabetes Mellitus Type 2 Hyperlipidemia Chronic Systolic Congestive Heart Failure: EF 30% Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a cardiac catheterization and the stent in your left anterior descending artery was stenosed. WE opened it with another drug eluting stent and the blood flow is now improved. The stents in your ofther arteris are OK. After the catheterization, your blood pressure and heart were low because of a vagal reaction during a bowel movement. This resolved and your blood pressure and heart rate are now normal. There was no evidence of bleeding or complication from the procedure. . Medication changes: 1.Resume your home doses of insulin 2. continue to take Plavix (Clopidogrel) every day with aspirin to keep the stent open. Do not stop taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s unless Dr. [**Last Name (STitle) **] tells you to. 3. Stop taking your Imdur for now because of your low BP here. 4. Start taking Nitroglycerin as needed for chest pain. Call Dr. [**Last Name (STitle) **] if you have any chest pain at home. Do not take nitroglycerin and Cialis within 24 hours of each other as they can cause low BP when taken together. . Please see a nutritionist at [**Last Name (un) **]. Your endocrinologist was contact[**Name (NI) **] about setting up an appt for you. . Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Please subscribe to Caremark to get your medicines, you will be able to get them at reduced cost. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 132**] C. Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL GROUP Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 133**] Appointment: Wednesday [**2104-8-20**] 9:00am Department: CARDIAC SERVICES When: FRIDAY [**2104-9-5**] at 10:30 AM With: DEVICE CLINIC [**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 [**2104-9-5**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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41090

Discharge summary

report

Admission Date: [**2192-1-28**] Discharge Date: [**2192-2-15**] Date of Birth: [**2146-5-31**] Sex: M Service: MEDICINE Allergies: Biaxin / Carvedilol / clarithromycin Attending:[**First Name3 (LF) 3556**] Chief Complaint: Increased LFT's Major Surgical or Invasive Procedure: Perc cholangiogram History of Present Illness: The pt is a 45 yo male with h/o cardiac arrest and anoxic brain injury ([**6-/2189**]), hep C, cholecystitis s/p percutaneous drainage with drain in place for approx 3 months, DM II, HTN, GERD, h/o MRSA pneumonia, h/o c diff, polysubstance abuse, ? COPD. Who presented to [**Hospital 487**] hospital with 5 days of yellow stool, grimace with abd pain, and was found to have elevated LFTs. During this time his highest BS were 149. He also noticed that his vent secretions turned yellow as of today. The skin jaundice was noticed 5 days ago by his brother and 2 weeks ago by his wife. In addition he reports weight gain from 195 to 230 this last month. He has also noted that his abdomen is 5x the size as previously. . He first received care at [**Hospital 487**] hospital. His vitals at OSH wrtr BP 108/73, P79, RR18 02 sat 100% NRB. Labs were notable for Tbili 8, AST 329, ALT 201, total protein 5.3, and + UA. AP 188 Alb 2.2 WBC 7.1, HCT 38.8, MCV 94.5, plts 131, sodium 133. He received levaquin 750mg IV and flagyl 500mg IV along with his home doses of lorazepam, phenobarb, and metoprolol. . His labs were notable for a UA with 6-10 WBCs, few bacteria, [**10-28**] RBCs, lg blood, mod leuks, and neg nitrite. His labs were notable for ALT 209, AST 336, AP 176, T bili 7.6, D bili 5.9, alb 2.5. INR was 1.8. White count was normal and HCT was at baseline. He had a liver ultrasound which showed a markedly distended gallbladder without stones or wall edema. The CBD was dilated. Moderate simple fluid ascites with bilateral pleural effusions. The liver appears nodular with ascites and splenomegaly. Findings are concerning for cirrhosis and portal hypertension. She was seen by surgery who felt there was no need for surgical intervention. . In the ED he received ativan 2mg via peg x1, phenobarbital 97.2mg via peg, and [**12-11**] amp of D50 IV for a finger stick of 71. Vitals prior to transfer were 98.2 56 111/72 16 99%. . ROS: + for bright red blood per rectum on and off for past 2 weeks (does have hemorrhoids and manually disimpacted at times for constipation). No blood seen for last few days. . Review of systems: Unable to obtain review of systems as patient is non-verbal. . Past Medical History: Past Medical History: - s/p cardiac arrest and anoxic brain injury ([**6-/2190**]), at baseline can move his head and streatch his arms and legs but not on command, if commanded to wigggle his fingers he will do at baseline (unclear if just does for brother who asks him to do this in [**Name (NI) 8003**]), blocks his privates when being cleaned - Hepatitis C brother states is from needle stick diag 10 yrs ago. [**Name6 (MD) **] GI MD [**First Name8 (NamePattern2) **] [**Last Name (Titles) 7658**] Mass Dr. [**Last Name (STitle) 89569**]. Got IFN tx but did not tolerate it and viral load never responded- biopsy 5 yrs ago with mild scaring - Cholelithiasis (h/o cholecystitis s/p percutaneous drainage) - HTN - Diabetes, Type II (diagnosed 10 yrs ago) - GERD - OSA - h/o MRSA pneumonia - h/o C. diff (1 yrs ago) - h/o polysubstance abuse (etoh and heroin) - Depression/Anxiety - ? COPD - Power port placed at [**Hospital3 **] - Neuropathy - MRSA previously of trach stoma - Previous pseudomonas of the sputum - Toe infected for 3 months recently and + MRSA swab (tx with abx completed 1 wk ago) - UTI 5 day course (tx and completed 1 wk ago) - Home vent settings 600 x 16 PEEP 5 Fio2 21%, uses HME [**1-13**] mist from 9am to 9pm . Past Surgical History: - s/p trach/PEG ([**6-16**]) - s/p Left jaw reconstruction s/p MVC - s/p tonsillectomy - s/p cardiac cath - s/p percutaneous biliary tube in [**2190-6-9**]. . Allergies: brother can confirm allergy to carvedilol leading to rash only Biaxin, Carvedilol, Clarithromycin, PCNs . Social History: - Tobacco: Former tobacco user 1 PPD for 20 yrs - Alcohol: previous drinker up to 12 drinks each day on the weekend - Illicits: Distant IVDU (heroin). Was on methadone at one point. Family History: Family History: Hypertension and diabetes. Mother with [**Name2 (NI) **]. Physical Exam: Physical Exam on Admission: Vitals: T:95.6 axillary BP:97/59 P:70 R:16 O2: 96% on 400 x 16 PEEP 5 Fi02 21% General: eyes open, NAD, not responding to commands HEENT: Sclera icteric anicteric, unable to open oral pharnynx as pt biting down Neck: supple, unable to appreciate JVD Lungs: scattered rhonchi bilaterally anteriorly CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: distended, soft, g-tube, non-tender, no RUQ tenderness, no guarding, non-distended, bowel sounds present GU: no foley Ext: overall mildly cold, DP and radial pulses +2. Non pitting edema, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Physical Exam on Discharge: T: 97.5, HR 71, BP 110/64 O2 Delivery Device: Tracheostomy tube Ventilator mode: CMV/ASSIST/AutoFlow Vt (Set): 600 (600 - 600) mL RR (Set): 16 RR (Spontaneous): 0 PEEP: 10 cmH2O FiO2: 50% RSBI Deferred: PEEP > 10 General: eyes open, NAD, not responding to commands HEENT: Sclera icteric, OP clear around ETT Neck: supple, unable to appreciate JVD Lungs: coarse breath sounds and scattered rhonchi bilaterally on anterior exam CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Moderately distended but soft, bowel sounds present, does not appear to be tender, but difficult to assess GU:Foley EXT: Slightly cool distal extremities, improved from yesterday. No clubbing or cyanosis. Pitting edema 3+ bilaterally, DP and radial pulses 2+. Pertinent Results: Labs: Admission Labs [**2192-1-28**]: CBC: WBC-6.2 RBC-3.94* Hgb-12.2* Hct-37.6* MCV-95 MCH-31.0 MCHC-32.6 RDW-15.8* Plt Ct-130* Neuts-70.0 Lymphs-20.0 Monos-6.7 Eos-2.7 Baso-0.6 Coags: PT-19.9* PTT-40.9* INR(PT)-1.8* Chem 7: Glucose-111* UreaN-13 Creat-0.3* Na-136 K-3.7 Cl-104 HCO3-25 AnGap-11 Calcium-7.9* Phos-2.8 Mg-1.7 LFTs: ALT-209* AST-336* AlkPhos-176* TotBili-7.6* DirBili-5.9* IndBili-1.7 Albumin-2.5* Lactate-1.4 DISCHARGE LABS [**2192-2-14**]: CBC: WBC-13.7* RBC-3.41* Hgb-10.9* Hct-29.3* MCV-86 MCH-31.9 MCHC-37.2* RDW-17.1* Plt Ct-54* Coags: PT-23.4* PTT-41.3* INR(PT)-2.2* Chem 7: Glucose-178* UreaN-140* Creat-2.1* Na-140 K-3.8 Cl-100 HCO3-23 AnGap-21* Calcium-10.1 Phos-3.3 Mg-3.4* LFTs: ALT-48* AST-111* LD(LDH)-259* AlkPhos-94 TotBili-31.1* Cardiac Biomarkers/perfusion markers: [**2192-2-5**] 10:18AM BLOOD CK-MB-2 cTropnT-0.03* [**2192-2-5**] 06:30PM BLOOD CK-MB-2 cTropnT-0.04* [**2192-2-7**] 04:00AM BLOOD cTropnT-0.03* [**2192-1-28**] 03:31AM BLOOD Lactate-1.4 [**2192-2-12**] 03:57PM BLOOD Lactate-6.6* [**2192-2-12**] 08:50PM BLOOD Lactate-5.6* [**2192-2-13**] 05:38AM BLOOD Lactate-3.8* [**2192-2-13**] 03:06PM BLOOD Lactate-3.5* Drug Monitoring: [**2192-2-10**] 05:03AM BLOOD Phenoba-67.6* [**2192-2-14**] 03:02AM BLOOD Phenoba-57.0* [**2192-1-31**] 11:57 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2192-1-31**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Preliminary): RARE GROWTH Commensal Respiratory Flora. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. STAPH AUREUS COAG +. MODERATE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . 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. Tigecycline Susceptibility testing requested by DR. [**Last Name (STitle) **] [**2192-2-6**]. SENSITIVE TO Tigecycline (0.125 MCG/ML). Tigecycline Sensitivity testing performed by Etest. MIC interpretations are based on manufacturer's guidelines that are FDA approved (TIGECYCLINE). STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. HEAVY GROWTH. DR. [**Last Name (STitle) **], T ([**Numeric Identifier 14151**]) REQUESTED FOR WORK UP ON [**2192-2-2**]. SULFA X TRIMETH sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. TIMENTIN >=128MCG/ML RESISTANT. CHLORAMPHENICOL >=32MCG/ML RESISTANT. Levofloxacin >=8MCG/ML. sensitivity testing performed by Microscan. MINOCYCLINE AND COLISTIN SENSITIVITIES REQUESTED BY DR. [**Last Name (STitle) **] [**2192-2-6**] . SENT TO [**Hospital1 4534**] LABORATORY ON [**2192-2-7**] FOR COLISTIN. Tigecycline (0.50 MCG/ML) Sensitivity testing performed by Etest. SENSITIVE TO MINOCYCLINE. MINOCYCLINE sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | STAPH AUREUS COAG + | | STENOTROPHOMONAS (XANTHOMON | | | CEFEPIME-------------- 16 I CEFTAZIDIME----------- 4 S =>16 R CIPROFLOXACIN--------- 2 I CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 8 I <=0.5 S LEVOFLOXACIN---------- =>8 R R MEROPENEM-------------<=0.25 S OXACILLIN------------- =>4 R PIPERACILLIN/TAZO----- 16 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S R VANCOMYCIN------------ 1 S [**2192-1-31**] 6:00 pm BILE **FINAL REPORT [**2192-2-8**]** GRAM STAIN (Final [**2192-1-31**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. FLUID CULTURE OF BILE (Final [**2192-2-8**]): ENTEROCOCCUS SP.. HEAVY GROWTH. ADD ON TIGECYCLINE PER DR.[**Last Name (STitle) **] [**2192-2-6**]. Tigecycline =.125MCG/ML Sensitivity testing performed by Etest. MIC interpretations are based on manufacturer's guidelines that are FDA approved. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final [**2192-2-4**]): NO ANAEROBES ISOLATED. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2192-2-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2192-2-8**] 5:35 pm BILE BILE. **FINAL REPORT [**2192-2-12**]** GRAM STAIN (Final [**2192-2-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2192-2-12**]): ENTEROCOCCUS SP.. SPARSE GROWTH. DR. [**Last Name (STitle) **] ([**Numeric Identifier 89570**]) REQUESTED DAPTOMYCIN [**2192-2-10**]. Daptomycin SENSITIVE (1.0 MCG/ML) Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final [**2192-2-12**]): NO ANAEROBES ISOLATED. [**2192-2-9**] 1:24 pm PLEURAL FLUID GRAM STAIN (Final [**2192-2-9**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2192-2-12**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [**2192-2-11**] 7:50 pm PERITONEAL FLUID GRAM STAIN (Final [**2192-2-11**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2192-2-14**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. . Images: Liver ultrasound [**2192-1-28**]: The liver is normal in echogenicity though the contour appears somewhat nodular. No focal lesions identified. The gallbladder is markedly distended but without cholelithiasis. The common bile duct measures 9 mm and is dilated. There is no clear evidence of gallbladder wall edema. The portal vein is patent with hepatopetal flow. There is a moderate amount of ascites. Bilateral pleural effusions are noted. The partially imaged pancreas is unremarkable. Splenomegaly present with 16.8 cm spleen. IMPRESSION: 1. Markedly distended gallbladder without stones or wall edema; dilated CBD. Further evaluation could be obtained with MRCP, or a HIDA scan may be obtained if cholecystitis continues to be of clinical concern. 2. Moderate simple fluid ascites with bilateral pleural effusions. 3. Liver appears nodular with ascites and splenomegaly; suggest correlation with any possible history of liver disease or cirrhosis as findings are concerning for cirrhosis and portal hypertension. MRCP [**1-29**]: IMPRESSION: 1. Limited exam due to patient's intubated non-breathhold status, however, no evidence of biliary obstruction, choledocholithiasis or cholelithiasis. 2. Redemonstration of markedly distended gallbladder, which could be due to fasting. No secondary signs of cholecystitis such as gall bladder wall edema. 3. Large right pleural effusion and significant right lower lobe atelectasis. 4. Nodular liver suggesting cirrhosis. Evidence of portal hypertension including recanalized paraumbilical vein and splenomegaly. AP CHEST, 12:39 A.M., [**1-29**] IMPRESSION: AP chest compared to [**1-27**]: Large right and moderate left pleural effusion are slightly smaller. Persistent left lower lobe consolidation is probably atelectasis, given slight leftward mediastinal shift, but I cannot exclude pneumonia. There is no pulmonary edema. The heart is top normal size. Tracheostomy tube and right supraclavicular central venous line are in standard placements. No pneumothorax. TTE [**2192-2-6**] Conclusions The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (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 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 pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. IMPRESSION: Suboptimal image quality due to body habitus. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The right ventricle is not well seen. Mild mitral regurgitation. Unable to assess pulmonary artery systolic pressures. Chest X-Ray [**2192-2-14**] HISTORY: Multifocal pneumonia and hydrothorax. FINDINGS: In comparison with the study of [**2-13**], the tracheostomy tube remains in place. The IJ port extends to the right atrium. Diffuse haziness of the hemithoraces, especially on the right could reflect pleural effusion, though this may merely be a manifestation of extensive scattered radiation related to the body habitus of the patient. PROCEDURE DETAILS: Written informed consent was obtained outlining the risks and benefits of the procedure. The patient was brought to the angiography suite and placed supine on the imaging table. A timeout and huddle were performed per [**Hospital1 18**] protocol. A scout image of the upper abdomen was obtained which demonstrated the indwelling cholecystostomy tube. Dilute contrast was then injected through the existing cholecystostomy tube which demonstrated leakage of the contrast outside the GB lumen close to the catheter entry site in the fundus, intraperitoneally suggesting displaced side holes of the pigtail catheter or leakage from a defect catheter versus a leak from the gallbladder itself. After dicussion with the clinical team and consent was obtained from the patient's brother. The patient was prepped and draped in the usual sterile fashion, specific attention was paid to the catheter itself. A [**Last Name (un) 7648**] wire was then advanced into the catheter under fluoroscopic guidance until the pigtail end of the catheter and the catheter was carefully advanced further into the gallbladder lumen. Again dilute contrast was injected to confirm that there was no leakage outside the gallbladder lumen , the side holes being well placed within the gallbladder lumen. Contrast was seen to flow antegrade through the cystic duct and opacify the common bile duct and the duodenum. After confirmation of optimal position of the pigtail within the gallbladder lumen, the catheter was secured at the skin with StatLock and sterile dressings applied. The patient withstood the procedure well and had no immediate complications and was shifted to the floor in stable condition. IMPRESSION: Uncomplicated repositioning of cholecystostomy drain with no evidence of post-repositioning leakage of contrast outside the gallbladder. CT ABD & PELVIS WITH CONTRAST Study Date of [**2192-2-12**] 3:19 AM IMPRESSION: 1. Right psoas hematoma. No active extravasation is seen, but a short-term followup study is recommended to assess for stability if hematocrit values continue to decline. 2. Moderate abdominal ascites. 3. Status post percutaneous cholecystostomy tube placement, terminating appropriately within a collapsed gallbladder. 4. Mild nodular contour to the liver, compatible with known history of cirrhosis. The portal and hepatic veins appear patent. 5. Splenomegaly. RENAL U.S. PORT Study Date of [**2192-2-13**] 2:37 PM IMPRESSION: 1. Normal renal ultrasound. 2. Moderate intra-abdominal ascites. Brief Hospital Course: 45 yo male with h/o cardiac arrest and anoxic brain injury ([**6-/2189**]), hep C, cholecystitis s/p percutaneous drainage with drain in place for approx 3 months 1 yr ago, DM II, HTN, GERD who presented with jaundice, abnormal LFTs, dilation of the gallbladder and biliary dilation, and ? cirrhosis. He also had a UTI on admission. # Hyperbilirubinemia/Liver failure: He presented with jaundice, elevated LFTs, and an MRCP showed dilation of the gallbladder. A perc chole was placed to decompress his gallbladder [**1-31**]. His bili began to rise after and he had a cholangiogram which showed some leakage. He had ultrasound-guided repositioning of cholecystostomy tube on [**2-3**], yet bili continued to trend up. His cholecystostomy tube was noted to be draining copious amounts of fluid, on the order of liters per day that appeared to be ascitic in nature. His tube was again noted to be leaking and likely draining fluid from the peritoneal space. It was repositioned on [**2192-2-8**] and was successfully draining bile until [**2-13**] when it began draining ascitic fluid again after it was accidentally moved during repositioning. IR repositioned the tube at the bedside [**2-14**], and it was no longer draining ascitic fluid. Of note, hepatology was resconsulted after the perc chole repositioning on [**2-8**] failed to decrease pt's Tbili elevation, and they determined his increase in bilirubin was to be multifactorial in nature (details of these problems are below). There was a question on a RUQ U/S of possible main hepatic vein clot that was then shown to be only a narrowing on abdominal CT. There was likely also a component of hemolysis to his elevated T. bili given his DIC, sepsis with his multiple infections, liver decompensation in the setting of Hepatitis C, and blood degradation and resorption from his RP bleed all leading to an elevated bilirubin. . # Infections: He was + for a UTI on arrival and started on cipro. He initially presented with fever, jaundice and hyperbilirubinemia a liver ultrasound was obtained which showed a markedly distended gallbladder and dilated CBD. Percutaneous cholecystostomy tube was placed [**1-31**]. The bile culture grew VRE. Pt developed leukocytosis, hypothermia, and hypotension, and was determined to be in septic shock, for which he had at least three possible sources including bile, lungs and urine. The patient also had sputum growing Pseudomonas, MRSA and Stenotrophomas. Records from [**First Name5 (NamePattern1) 487**] [**Last Name (NamePattern1) 2580**] show patient??????s pyuria a result of resistant Pseudomonas. Patient was covered with meropenem for pseudomonas, Linezolid for MRSA and VRE and intially bactrim for stenotrophomonas, but this later turned out to be resistant to bactrim and Tigecycline was started pending more sensitivity results. The Tigecyline was eventually discontinued given concern for continued hepatic insult and increase in bilirubin and transaminases. His sensitivities for VRE came back sensitive to daptomycin and he was treated accordingly. He was continued on meropenem for pseudomonas. He developed a component of DIC with a drop in haptoglobin, increase in LDH, and a drop in fibrinogen. He was treated during his hospitalization with packed RBCs (8 units), cryoprecipitate (2 units), FFP (19 units), and platelets (2 units). His antibiotics were continued throughout his course until his transfer but the information regarding each is as follows: - UTI meropenem course finishes [**2-14**] (day 14/14), but will continue [**Last Name (un) 2830**] for pseudomonas in sputum - Vancomycin (day 1 [**1-31**]), Meropenem (day 14), and Daptomycin (day 1 [**2-10**]) per current ID recs as follows: [**Last Name (un) **] for PSA, vanco for MRSA, dapto for VRE. - decrease vanc dose as trough was 31.7, will hold and recheck a level tomorrow am - renally dose all meds [**1-11**] ARF (see below) . # Septic shock: A few days into his admission he had hypotension which required fluid boluses and pressors. Was subsequently weaned of pressors over 2 days and remained hemodynamically stable w/o pressors. He had significant fluid overload secondary to fluid resucitation. . # Retroperitoneal bleed: He had a precipitous drop in his hematocrit on [**4-10**] which was proven to be a spontaneous RP bleed into his right psoas, as well as a component of hemolysis with evidence of DIC (Hapto <5, fibrinogen 137). There was no triggering procedure. He was managed with a total of 19units FFP, 8 units of PRBCs, 2 units of cryo, and 2 units of platelets. He was managed with a goal of Plts >50, fibrinogen >200, and a HCT of 30, in that his lactate rose to 6.6 with persistent HCT in the 20s. His nadir was 19 (HCT) and we were able to maintain him at ~30, [**2-12**] and beyond. . # Acute Kidney Injury: Baseline renal function of ~0.5. He had an acute rise in creatinine 1.1 on [**2-11**] then 1.5, 1.8, and 2.1 on subsequent days. He became anuric on [**2-12**] in the afternoon. Renal was consulted, and the differential diagnosis was thought to be ATN in the setting of his decreased blood volume given his bleed vs. hepatorenal syndrome all compounded by a dye load for CT abdomen/pelvis immediately prior to increase in creatinine. He was treated as if he had a GFR of zero, and his medications were dosed accordingly (particularly antibiotics). Renal believed that dialysis was not indicated due to quality of life and overall severity of illness. His goals of care are clearly stated by his brother that he would want everything done even if it extended his life for only a short period of time. He was transferred to the [**Hospital1 112**] to accomodate these goals of care. . # Respiratory: patient at base line trached, on trach mask 3-4L at home during the day and CMV at night 600 x 16 PEEP 5 Fio2 21%. During his hospital stay developed increasing respiratory demand likely [**1-11**] to his pneumonia as well as fluid overload. Was thus ventilated for full respiratory support. He tolerated pressure support for long periods of time, and required ventilatory support with CMV which largely fluctuated with volume status. His fio2 requirement went up most recently from 21% to 50% on [**2192-2-12**]. . # Anoxic brain injury (7/[**2189**]). He is on metoprolol at home for his cardiac arrest which is being held in the setting of his septic picture. Baseline neuro status at his best at home he can move his hands if asked to in [**Year (4 digits) 8003**] (he is doing this at [**Hospital1 **]). He also at home will cover his privates when being washed up (he is not doing this here). He can move his head and legs spontaneously but has no other meaningful interaction witnessed by us here, after an anoxic brain injury several years ago in the setting of cardiac arrest. . # Seizure disorder: Patient has a history of seizure disorder. He is on phenobarbital for that, and with his decrease in liver function, a phenobarbital level was checked. It was ~67. It was held, and pharmacy helped to develop the plan of restarting when his level dropped to <45 and restart at a dose of 45mg [**Hospital1 **], goal level is [**9-27**]. He also is on benzos at home for his seizure d/o and tremors. . Medications on Admission: ASA 81 mg po daily Lopressor 50 mg Tab Oral 1 Tablet(s) Twice Daily (takes if SBP>100 and DBP>70) Ativan 2 mg Tab Oral 1 Tablet(s) q 8 hours (has increased seizure activity if goes off) phenobarbital 97.2 mg Tab Oral 1 Tablet(s) q 8 hours fentanyl 25 mcg/hr Transderm Patch Transdermal 1 Patch q 72 hours Lantus: 75 units subq Solution(s) Twice Daily (sometime gives only 65 [**Hospital1 **] depending on BS) No ISS Centrum MVI liquid daily Tube feeds: Osmolite Cal 1.2 65ml/hr) may change back to jeuity cal 1.2 (was only on for 3 days but switched due to dev of change in bowel consistency Get a total of 8 ounces of free water not including med administration in which he gets additional 11 ounces. . . Discharge Medications: 1. influenza vaccine tr-s 10 (PF) 45 mcg (15 mcg x 3)/0.5 mL Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One Dose). 2. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q8HRS (). 3. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 5. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 8. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 9. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-11**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 10. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 11. insulin glargine 100 unit/mL Cartridge Sig: Thirty (30) units Subcutaneous twice a day: 30 units of glargine at breakfast and at bedtime. 12. Humalog 100 unit/mL Cartridge Sig: sliding scale Subcutaneous every six (6) hours. 13. phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 doses. 14. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 16. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 17. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Mid-line, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 19. Pantoprazole 40 mg IV Q12H 20. Daptomycin 648 mg IV Q48H day 1=[**2-10**] 21. Thiamine 100 mg IV DAILY Duration: 3 Days 22. Meropenem 500 mg IV Q12H d1 [**2192-1-31**] Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Retroperitoneal Hematoma Acute Kidney Injury Hyperbilirubinemia Sepsis Secondary: Anoxic Brain Injury s/p cardiac arrest Type 2 Diabetes Mellitus Hepatitis C Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: You were seen in the hospital for an enlarged gallbladder. A drain was placed in your gallbladder, but you became sick from multiple infections in your lung, gallbladder and urine. You were treated with antibiotics, but the bacteria of your infections was very resistant. Your liver started to show signs of failure and because of this your kidneys also started to fail. You were transferred to [**Hospital6 13753**] to get dialysis to help with your kidney problems. If you experience worsening liver failure, kidney failure, fevers/chills or any other symptoms that concern you, your health care proxy should inform the doctors [**First Name (Titles) **] [**Name (NI) **]. Please follow the instructions of your doctors [**First Name (Titles) **] [**Last Name (Titles) **] with regards to your medications and outpatient follow-up appointments. It was a pleasure taking care of you on this hospitalization. Followup Instructions: Per [**Hospital6 13753**] recs [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

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icd9cm

[ [ [] ] ]

[ "38.97", "51.02", "54.91", "96.6", "87.54", "34.91", "96.72" ]

icd9pcs

[ [ [] ] ]

29515, 29530

19331, 26560

313, 333

29742, 29742

5911, 7578

30822, 30985

4361, 4421

27318, 29492

29551, 29721

26586, 27295

29882, 30799

3848, 4126

4436, 4450

7619, 12998

5123, 5892

2501, 2565

258, 275

361, 2482

4464, 5095

13317, 19308

29757, 29858

2609, 3825

4142, 4329

15,042

198,354

27931

Discharge summary

report

Admission Date: [**2182-9-3**] Discharge Date: [**2182-9-12**] Date of Birth: [**2117-1-19**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Acute exacerbation of right lower quadrant abdominal pain s/p L hepatic lobectomy Major Surgical or Invasive Procedure: [**2182-9-4**] ex lap, small bowel resection, jejunojejunostomy History of Present Illness: Mr. [**Known lastname 957**] is a 65-year-old male with cirrhosis and recently underwent a left hepatic lobectomy secondary to a segmental Caroli disease. His postoperative course was uneventful. He returned to the emergency room on the afternoon of [**2182-9-3**] with abdominal pain and not feeling well. He underwent workup in the emergency room to include a CT scan, which demonstrated what appeared to be portal and SMV thrombus. Delayed images on the venous phase were not obtained on this CT scan and he went down for a subsequent CT scan that confirmed the presence of SMV and portal venous thrombosis. At this time, with a normal white count, now nonacidotic and no significant abdominal discomfort or peritonitis, he was treated with anticoagulation. Over the evening of [**9-3**] and the early morning of [**9-4**], he became more tachycardic and his white count increased to 14,000. On examination he began experiencing some abdominal discomfort. Based upon the clinical picture and the examination and our suspicion for mesenteric ischemia, he was taken to the operating room for exploration. Past Medical History: s/p liver lobectomy [**2182-8-16**] Caroli's disease hemochromatosis Social History: Lives with wife [**Name (NI) **] 3 children Family History: mother died of metastatic colon cancer at age 61 father died of cardiac disease at age 56 one brother with colonic polyps and hypertension Physical Exam: On Admission: VS: 96.1, 106, 152/95, 18, 97% RA Gen: Appears uncomfortable, skin color/temp WNL Lungs: CTA bilaterally Card: Reg rhythm, sl tachy Abd: Soft, non-distended, no tympany, + Tenderness Left LQ, no rebound or guarding. Incision healing well w/o erythema. JP drain with bilios looking output. Pertinent Results: On Admission: [**2182-9-3**] 02:45PM GLUCOSE-180* UREA N-7 CREAT-0.7 SODIUM-132* POTASSIUM-6.0* CHLORIDE-97 TOTAL CO2-22 ANION GAP-19 ALT(SGPT)-30 AST(SGOT)-68* ALK PHOS-158* TOT BILI-1.3 LIPASE-21 LACTATE-3.4* OTHER BODY FLUID TOT BILI-11.1 WBC-9.6 RBC-4.23* HGB-13.7* HCT-38.8* MCV-92 MCH-32.4* MCHC-35.4* RDW-12.8 NEUTS-88.4* LYMPHS-6.7* MONOS-4.6 EOS-0.1 BASOS-0.1 PLT COUNT-426 [**2182-9-4**] Cryoglb: NO CRYOGLOBULIN DETECTED HBsAg: Negative, HBsAb: Negative HBcAb: Negative HAV Ab: Negative ANCA: NEGATIVE BY INDIRECT IMMUNOFLUORESCENCE CRP: 18.71 HIV SEROLOGY HIV Ab: Negative Hepatitis C: Negative ACA IgG : 13.31 ACA IgM: 8.01 Brief Hospital Course: Patient admitted with increasing abdominal pain. U/S showed a portal vein thrombosis. CT of abdomen revealed findings consistent with extensive portal venous and superior mesenteric venous thrombosis with a long segment of markedly abnormal jejunum, highly concerning for bowel ischemia. There was also a small amount of ascites. Patient taken to the OR for Exploratory laparotomy, small bowel resection and jejunojejunostomy. 40 cm of the jejunum was resected. Postoperatively the patient did well. He was admitted to the SICU and placed on a heparin gtt. Due to patient history of varices and cirrhosis, heparin was initially d/c'd, however it was restarted with monitoring, Hct's stable, no events. Goal PTT 50-70. Metronidazole and cefazolin were started for prophylaxis. Lactate dropped to normal range. -Rheumatology consulted to evaluate for vasculitis which was seen on the preliminary biopsy of the small bowel: "Extensive acute necrotizing vasculitis involving both arteries and veins. The vasculitic changes appear to be primary rather than secondary. Systemic vasculitic syndromes should be considered" Rheum recommended multiple [**Month/Day/Year **] tests as well as MRA/MRV to assess for further evidence of vasculitis. MRA showed Thrombosis of the portal and superior mesenteric veins. Overall, the appearance is similar to the [**2182-9-4**] CT angiogram and persistent small bowel wall thickening and edema. -Coumadin was started on POD 3 with heparin bridge and patient will be discharged on anticoagulation. Hem-Onc recommends anticoagulation with Coumadin for at least 6 months given acute, potentially life-threatening thrombotic event. -Patient began taking PO's, but nutritional status was in question due to poor PO intake. N-J tube was placed and the plan was to start cycled Tube feed which would be continued at home. Home teaching was provided by [**Hospital1 5065**]. -Left upper arm U/S was completed on [**9-12**] for antecubital swelling, warmth and discomfort. Reported acute venous thrombosis within the basilic vein extending from the antecubital fossa more proximally to the mid upper arm. Other examined veins were grossly patent. As patient already anticoagulated with coumadin, no further action at this time. -On [**9-12**] in the early evening during rounds, it was decided to send patient home. He would start tube feeds on Friday, coumadin to be held for INR 4.1. On Friday the patient was to proceed to outpatient [**Month/Year (2) **] for recheck of PT/INR and coumadin recommendations for the weekend. He will then be having PT/INR drawn Mon/Thurs with results sent to [**Hospital 1326**] clinic. Follow up visits with surgery and Rheum. Patient will also be having follow up visit with PCP once surgical issues/healing are resolved. Medications on Admission: Dilaudid 3 mg qd Colace Pepcid MVI Discharge Medications: 1. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 17 doses. Disp:*17 Tablet(s)* Refills:*0* 5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Do NOT take coumadin [**9-12**]. Disp:*60 Tablet(s)* Refills:*2* 6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day). Disp:*90 Packet(s)* Refills:*2* 8. Tube Feedings Promote with fiber at 120cc/hour cycled from 6pm to 6 am via nasogastric feeding tube. Supply:1 month, Refills:2 Bags Pump Syringes for flushes 9. Outpatient [**Name (NI) **] Work PT/INR every Monday & Thursday Fax results to [**Telephone/Fax (1) 697**] attn: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22956**] RN Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: SMV/portal vein thrombus s/p resection of 40 cm jejunum [**2182-9-4**] h/o L hepatectomy/ccy for duct stricture [**1-24**] hemachromatosis Discharge Condition: good Discharge Instructions: Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 673**] if fevers, chills, jaundice, increased abdominal pain, drainage/bleeding from drain sites, malfunction of tube feedings or any questions. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2182-9-18**] 2:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2182-9-16**]

[ "571.5", "453.8", "275.0", "751.69", "557.0" ]

icd9cm

[ [ [] ] ]

[ "45.62" ]

icd9pcs

[ [ [] ] ]

6902, 6964

2909, 5694

394, 460

7147, 7154

2243, 2243

7407, 7736

1764, 1905

5779, 6879

6985, 7126

5720, 5756

7178, 7384

1920, 1920

273, 356

488, 1595

2257, 2886

1617, 1687

1703, 1748