ChanBeDu/relevant_section_length · Datasets at Hugging Face

15,609

194,043

5753+5754+55697

Discharge summary

report+report+addendum

Admission Date: [**2104-2-27**] Discharge Date: [**2104-3-13**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 78 year old gentleman with coronary artery disease, status post coronary artery bypass graft times two in [**2101**], hypertension, diabetes mellitus, peripheral vascular disease, history of congestive heart failure, hypercholesterolemia, who was transferred from [**Hospital1 2025**] for respiratory distress, status post intubation. Per the outside hospital, the patient had been doing poorly over the last several days with an upper respiratory tract infection type symptoms. The patient had also reported increased worsening orthopnea for the past few days. On the day of admission, the patient had an acute decompensation with marked shortness of breath. EMS was called and he was found to be hypoxic with a pH 7.1. He was intubated in the field and brought to [**Hospital1 2025**]. At that time, his blood pressure was 190/90 with a heart rate of 120 and a chest x-ray demonstrated florid congestive heart failure. He was given 100 mg intravenous Lasix, Aspirin, Heparin intravenous, Nitroglycerin, Morphine and Versed. His blood pressure decreased to 80 to 90 systolic and the Nitroglycerin drip was weaned off. The patient put out approximately 700 ccs of urine and reportedly felt much better. Hematuria was noted at that time and Heparin drip was discontinued. On arrival from the outside hospital, the patient was without complaints and breathing more comfortably without any current chest pain. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft times two in [**2101**]. 2. Congestive heart failure. 3. Hypertension. 4. Diabetes mellitus. 5. Benign prostatic hypertrophy, status post transurethral resection of prostate. 6. Hypercholesterolemia. 7. Peripheral vascular disease. 8. Chronic mesenteric ischemia. 9. Anemia. 10. Left cerebrovascular accident. 11. Left subclavian occlusion. 12. Distal aortic occlusion. 13. Arthritis. 14. Hypothyroidism. 15. Asbestos exposure. 16. Blindness secondary to ischemic optic neuropathy. MEDICATIONS ON ADMISSION: 1. Serax. 2. Insulin-NPH. 3. Demadex. 4. Synthroid 0.125. 5. Aspirin. 6. Colace. 7. Coreg 3.125. 8. Flovent. 9. Atenolol. 10. Serevent. ALLERGIES: Tetanus. SOCIAL HISTORY: The patient is married. PHYSICAL EXAMINATION: General - The patient is chronically ill appearing male. Vital signs revealed heart rate 69, blood pressure 153/56, oxygen saturation 98% on 30% FIO2. Head, eyes, ears, nose and throat - The pupils are normally reactive, extraocular movements are intact. Neck - positive jugular venous pressure to the jaw, neck supple. Chest - crackles at the bilateral bases with expiratory rhonchi. Cardiovascular - decreased heart sounds, S1 and S2 normal, S4 present, soft systolic ejection murmur at the left sternal border. Abdomen is soft, nontender, diffuse bruits, positive bowel sounds. Extremities - 2 to 3+ edema, dorsalis pedis pulses dopplerable bilaterally. Right radial pulse is 1+, left radial pulse dopplerable. Neurologically, the patient is awake, answers questions appropriately, left arm weak. LABORATORY DATA: White blood cell count 19.9, hematocrit 33.3, platelets 294,000, with differential of 89.2 neutrophils, 11.4 lymphocytes, 2.4 monocytes. Sodium 137, potassium 3.8, chloride 93, bicarbonate 35, blood urea nitrogen 21, creatinine 1.1, glucose 154. CK 156, calcium 7.8, phosphorus 4.0, magnesium 1.9. INR 1.4. Electrocardiogram ([**Hospital1 2025**]) showed sinus tachycardia at 110 beats per minute, primary AV block, premature atrial contractions and premature ventricular contractions, ST depressions in V4 through V6, Q wave in V1 and V2, T wave inversions in leads I and aVL. Electrocardiogram on admission revealed sinus rhythm at 68 beats per minute, normal axis, first degree AV block, Q waves in V1 and V2, T wave inversions in leads I, II, aVL, V4 through V6, ST depressions of 1.0 millimeter in V4 through V6. Chest x-ray - congestive heart failure, nasogastric tube and endotracheal tube in place, left costophrenic angle with blunting. HOSPITAL COURSE: The patient is a 78 year old gentleman with a history of coronary artery disease, status post coronary artery bypass graft, hypertension, peripheral vascular disease, mesenteric ischemia, diabetes mellitus who presented with acute respiratory distress. Differential diagnoses at the time of admission included congestive heart failure, pneumonia, adult respiratory distress syndrome, myocardial infarction, myocardial ischemia, and pulmonary embolism, with a question of whether a viral illness could have contributed to the patient's symptoms. 1. Cardiovascular - The patient was known to have a history of coronary artery disease and was continued on Aspirin and Coreg. His cardiac enzymes remained flat and electrocardiogram without changes, and therefore it was felt that the patient did not experience an acute ischemic event that triggered his congestive heart failure and therefore his Heparin drip was discontinued. A cholesterol panel was checked and the patient was started on Lipitor. Over the next few hospital days, the patient underwent continuous diuresis with intravenous Lasix with significant improvement in his subjective feelings of shortness of breath. In addition, he was started on Captopril at 25 mg t.i.d. for afterload reduction in the setting of congestive heart failure. The patient's Demadex dose was held while undergoing diuresis and his Captopril was titrated up as tolerated to a maximum of 100 mg t.i.d. The patient diuresed effectively over the first four hospital day with a decreasing oxygen need and was therefore slowly restarted back on his home diuretic of Demadex. The patient's blood pressure remained stable with a systolic blood pressure in the 130s. The patient had no further cardiovascular issues over the remainder of the hospital stay. 2. Pulmonary - The patient was intubated at the time of arrival and his ventilator settings included SIMV, pressure support 10, PEEP 7.5, FIO2 30%, tidal volume 700 with a respiratory rate of 13. The patient's hypoxia was thought most likely secondary to his florid congestive heart failure and therefore he underwent aggressive diuresis. As the patient diuresed, his pressure support was decreased to as low as 5 and 5. However, the patient responded to this change with tachycardia, tachypnea and hypertension with a systolic blood pressure in the 200s. Therefore, the patient was placed back on pressure support of 15 and 5 and then rested on SIMV overnight. On the following day, [**2104-2-29**], the patient was felt to be ready for extubation. However, thirty minutes following extubation, the patient demonstrated significant respiratory distress with hypertension, tachycardia, and tachypnea. The arterial blood gases obtained at that time demonstrated pH 7.25/81/71. The patient was reintubated with a subsequent arterial blood gas of 7.45/51/163. In addition, a CT scan of the chest obtained at that time also demonstrated partial collapse of the left upper lobe secondary to an obstructing [**Location (un) 21851**] as well as bilateral mediastinal and hilar lymph node enlargement, enlargement of both adrenal glands concerning for metastatic disease, and evidence of previous asbestos exposure with pleural plaques. Therefore, given the combination of the patient's failure to wean off the ventilator, as well as the left upper lobe lung mass, a bronchoscopy was performed which revealed partial bronchial stenosis distally without intervention required as well as a left middle lobe and left lower lobe mass of which brushings and endobronchial biopsy were taken. In addition, a thoracentesis was offered to the patient given the pleural effusion seen on CT scan, however, this was refused by the patient until he could discuss it further with his wife. The patient continued to have persistent secretions which were felt to likely be contributing to the patient's failure to wean. A thoracentesis was performed on [**2104-3-2**], which demonstrated a white blood cell count of 75, red blood cells 1,980, 27 polys, 33 monocytes, glucose 232, LDH 86. Over the next few hospital days, the patient was attempted on a slow wean by decreasing his pressure support from 15 to 10 and then to 5. However, the patient did not tolerate this weaning process, demonstrating increasing acidosis, tachypnea, and tachycardia with each attempt. It was unclear exactly why the patient tolerated this wean poorly but was thought secondary to a component of segmental collapse behind the obstructing lung lesion, as well as his persistent secretions, as well as a cardiac contribution. At this time, the patient's left upper lobe mass biopsy returned as squamous cell carcinoma and this diagnosis was discussed with the patient and family. Given the patient's failure to wean after nearly a week of intubation, a tracheostomy was placed on [**2104-3-11**]. By this time, the patient had also completed a fourteen day course of Levaquin for a postobstructive pneumonia. The patient is to be continued on Flovent and Serevent as needed and can be more slowly weaned and also ventilator rehabilitation. 3. Renal - The patient's creatinine was followed closely given his history of chronic renal failure with a baseline creatinine of approximately 1.0 to 1.3. His urine output was followed closely while the patient was diuresed aggressively at the initiation of his hospital stay. The patient's creatinine remained stable despite diuresis and despite initiation of an ace inhibitor and was maintained at approximately 1.0 to 1.2 over the remainder of his hospital stay. The patient had no difficulties with urine output. The patient was noted to have a persistent metabolic alkalosis which did not seem to vary with his hydration status and did not respond to Acetazolamide treatment. It was therefore felt that the patient likely had a baseline with a bicarbonate of 30, possibly secondary to his known asbestos exposure and emphysema. At the time of discharge, the patient's bicarbonate had stabilized at approximately 28 to 30. 4. Infectious disease - The patient was noted to have an elevated white blood cell count as well as persistent secretions at the time of admission and therefore was started on Levofloxacin for a community acquired pneumonia. Once the patient was found to have an endobronchial lesion, it was felt that his pneumonia was likely secondary to postobstructive lesion. The patient completed his fourteen day course of Levaquin while in the hospital and his secretions slowly decreased in amount and color. The patient's white blood cell count remained within normal limits and he remained afebrile at the time of discharge. The patient had no growth in his urine or blood culture sent during the time of admission. 5. Gastrointestinal - The patient has a history of chronic mesenteric ischemia but had no complaints of gastrointestinal pain or discomfort during the hospital stay. He was kept on Prevacid via his gastrostomy tube for gastrointestinal prophylaxis and had no further complaints. 6. Hematologic - The patient's hematocrit was followed and was found to be low and remained relatively stable over the course of the hospital stay. A colonoscopy was discussed, however, this was refused by the patient and his wife. The patient's hematocrit did drop very slowly at one point, approximately one point per day, and he was transfused a unit of blood cells with an appropriate bump in his hematocrit which remained stable at approximately 31 to 32 over the remainder of the hospital stay. The patient had no further hematological issues over the remainder of the hospital stay. 7. Oncology - The patient was noted to have a mass in the left upper lobe on CT scan at the time of admission. Review of this with the patient's family revealed that the patient had had a mass seen in the left upper lobe on a scan back in [**2101**], however, this was not worked up secondary to the wife not wishing the patient to be aware of the possibility of a cancer. When the patient underwent bronchoscopy secondary to failure to wean and failure at extubation, an endobronchial lesion was seen and bronchial washings and biopsy were obtained. Pathology of the biopsy revealed squamous cell carcinoma and, given that the CT scan showed a mass in the bilateral adrenals, it was felt that this was likely metastatic. The biopsy results were discussed with the patient's wife given that the patient was sedated and intubated at this time. The patient's wife was adamant that she did not want the husband to know that he had cancer. However, she agreed to talk to an oncologist. A hematology/oncology consultation was obtained who suggested that given the patient's underlying poor function, he was not a candidate for palliative chemotherapy and given that the patient's family did not want to investigate the extent of the metastasis, there was no further metastatic workup performed. However, the oncology consultation did suggest that the patient might benefit from palliative x-ray therapy especially if the lesion into the segmental collapse behind it could be contributing to the patient's failure to wean. Therefore, x-ray therapy was consulted who suggested that the patient's lesion was not likely significant enough to be contributing to his failure to wean and also suggested that given the duration of knowledge of the mass as well as slow growth, it was not likely to respond to palliative treatment. However, they did feel it was worthwhile to undergo a mapping session and a trial of palliative x-ray therapy to see if the patient would respond with improvement in his pulmonary function and symptoms. At the time of this discharge summary dictation, a planning session for palliative x-ray therapy was planned for the day of discharge, Thursday, [**2104-3-13**]. Once the patient was awake and alert enough, the patient was told of the left lobe mass and of the diagnosis of squamous cell cancer. 8. Endocrine - The patient was known to have a history of hypothyroidism and was continued on his Synthroid supplementation. He was noted to have an elevated TSH and therefore his Synthroid dose was increased to 150 p.o. q.d. He will be continued on this current dose. In addition, the patient's diabetes mellitus was controlled with a regular insulin sliding scale as well as NPH with sugar ranging between 120 and 200. 9. FEN - The patient's electrolytes were checked on a daily basis and repleted as needed. An nasogastric tube was placed in order to initiate tube feeds given that the patient was intubated for such a prolonged period of time. Once it was determined that the patient would require tracheostomy placement, gastroenterology was consulted and a percutaneous endoscopic gastrostomy tube was placed without complications on [**2104-3-11**]. 10. Prophylaxis - The patient was maintained on Heparin subcutaneous as well as Prevacid per his gastrostomy tube for prophylaxis during the hospital stay. MEDICATIONS ON DISCHARGE: 1. Prevacid 30 mg per percutaneous endoscopic gastrostomy tube q.d. 2. Colace 100 mg per percutaneous endoscopic gastrostomy tube b.i.d. 3. Aspirin 325 mg per percutaneous endoscopic gastrostomy tube q.d. 4. Flovent 110 mcg two puffs MDI b.i.d. 5. Serevent two puffs MDI b.i.d. 6. Zoloft 50 mg per percutaneous endoscopic gastrostomy tube q.h.s. 7. Heparin 5000 units subcutaneous b.i.d. 8. Promote with fiber tube feeds at 65 cc/hour. 9. Captopril 100 mg per percutaneous endoscopic gastrostomy tube t.i.d. 10. Synthroid 150 mcg per percutaneous endoscopic gastrostomy tube q.d. 11. Regular insulin sliding scale. 12. Senna one tablet per percutaneous endoscopic gastrostomy tube q.h.s. 13. Free water bolus 250 ccs per percutaneous endoscopic gastrostomy tube b.i.d. 14. Coreg 1.56 mg per percutaneous endoscopic gastrostomy tube b.i.d. 15. Demadex 20 mg per percutaneous endoscopic gastrostomy tube b.i.d. CONDITION ON DISCHARGE: The patient was discharged to Root Pulmonary Rehabilitation in stable condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**] Dictated By:[**Name8 (MD) 8860**] MEDQUIST36 D: [**2104-3-11**] 17:38 T: [**2104-3-11**] 17:50 JOB#: [**Job Number **] Admission Date: [**2104-3-14**] Discharge Date: [**2104-4-4**] Service: MICU DIAGNOSIS: 1. Respiratory failure. 2. Carcinoma lung. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 22909**] is a 78 year-old man who was admitted to the Coronary Care Unit on [**2104-2-27**] with congestive heart failure. During treatment and evaluation of this congestive heart failure he was diagnosed to have nonsmall cell carcinoma of his left upper lobe. He failed to wean off the ventilator and he was requiring a tracheostomy and a percutaneous gastrostomy. He was transferred to the .................... ICU to facilitate XRT during his inpatient hospital stay. During his stay in the ................... ICU the following events took place: HOSPITAL COURSE: Pulmonary - Initially the patient was very wheezy bilaterally requiring regular metered dose inhaler of Albuterol, Atrovent and Flovent. He was on pressure support and CPAP requiring pressure controlled ventilation intermittently when his wheeze was aggressive. At first weaning was complicated by flash pulmonary edema intermittently. He was being treated with diuretics and Zaroxolyn and eventually he was started on Furosemide infusion and we managed to achieve gross negative balance, which facilitated with his weaning. At the time of discharge he probably would have been off ventilatory support for more than 48 to 72 hours. He has a Passy Muir valve with which he is coping very well and he does require 40% oxygen via the tracheostomy mask. Cardiac - Initially the patient was going into flash pulmonary edema on withdrawing of the CPAP. His therapy was escalated to Furosemide infusion and he was transfused three units of packed red blood cells and his crit was stabilized t 30 to 33. His Captopril dosage was adjusted and his Coreg dose was also adjusted. He had one episode of atrial fibrillation which resolved spontaneously. He has been in normal sinus rhythm during most of his hospital stay. Gastrointestinal - He is on tube feeds at goal via his PEG. He had some nausea and vomiting initially with commencement of XRT. This was treated with ondansetron and Reglan and his GI issues have resolved. He is absorbing his feeds. He is tolerating clear liquids po and gradually his meal is being advanced to soft puree diet which has yet to be assessed. Endocrine - He is on NPH insulin and sliding scale regular insulin and his Thyroxine levels were elevated on initial admission so his Synthroid medicine dosage was adjusted. His TSH level is pending as of today. Infectious Disease - He has MRSA in his sputum and he is on Vancomycin for possible MRSA tracheobronchitis. For access he has a peripheral IV. Oncology - His cancer of the lung is being treated by palliative XRT and he finishes his course on [**2104-4-4**]. After which he can be transferred to rehab. Prophylaxis - For prophylaxis Mr. [**Known lastname 22909**] receives Heparin 5000 units subcutaneous twice a day and Prevacid 30 milligrams po q day. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft times two in [**2101**]. 2. Congestive heart failure. 3. Hypertension. 4. Diabetes mellitus. 5. Benign prostatic hypertrophy status post transurethral resection of prostate. 6. Hypercholesterolemia. 7. Peripheral vascular disease. 8. Chronic mesenteric ischemia. 9. Anemia. 10. Left cerebrovascular accident. 11. Left subclavian occlusion. 12. Distal aortic occlusion. 13. Arthritis. 14. Hypothyroidism. 15. Asbestosis. 16. Blindness secondary to ischemic optic neuropathy. ALLERGIES: Tetanus. SOCIAL HISTORY: The patient is married and has a very devoted wife who takes care of him. MEDICATIONS AT DISCHARGE: 1. Lasix 40 milligrams po three times a day. 2. Zaroxolyn 10 milligrams po three times a day. 3. Captopril 12.5, 50; 12.5, 50 is the dosage which is given q six hours. 4. Vitamin C. 5. Zoloft 100 milligrams HS. 6. Coreg 2.125 milligrams twice a day. 7. Senna HS. 8. Synthroid 150 mics q day. 9. Atrovent 8 puffs q six hours. 10. Flovent 110 six puffs q 12 hours. 11. Serevent 4 puffs [**Hospital1 **]. 12. Prevacid 30 milligrams once a day. 13. Colace 100 milligrams twice a day. 14. Aspirin 325 milligrams once a day. 15. Heparin 5000 units subcutaneous [**Hospital1 **]. 16. Reglan 10 milligrams three times a day. 17. Tube feeds at goal. 18. Epogen 10,000 units on alternate days. 19. Vancomycin 1 gram twice a day. On [**2104-4-2**] which is day seven of ten. 20. He also received NPH insulin 12 units twice a day and sliding scale regular insulin. DISCHARGE CONDITION: The patient is awake, alert and oriented. He has a tracheostomy insitu. The site looks intact. He is using Passey Muir valve comfortably with the tracheostomy cuff down and he is on 40% oxygen via the tracheostomy mask. Hemodynamically he is stable. He is in normal sinus rhythm. He is able to move all his extremities. He is able to sit up in a chair with assist. His urine output averages 50 to 60 cc an hour and has a good response to the Furosemide infusion which is going to be changed to 40 milligrams via the PEG three times a day. He will probably be discharged on [**2104-4-4**] after his final course of XRT to enter [**Hospital **] Rehab Center. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (STitle) 22910**] MEDQUIST36 D: [**2104-4-2**] 12:58 T: [**2104-4-2**] 13:23 JOB#: [**Job Number 22911**] Name: [**Known lastname 3881**], [**Known firstname **] Unit No: [**Numeric Identifier 3882**] Admission Date: [**2104-2-27**] Discharge Date: [**2104-4-4**] Date of Birth: [**2025-11-5**] Sex: M Service: ADDENDUM: This is a Discharge Addendum with his laboratory values. His latest hematocrit on the [**11-1**] is 37.2, white cells 9.5, platelets 310. Sodium 138, potasium 3.4, chloride 88, bicarbonate 36, urea 85, creatinine 1.2. Blood sugar 107. His ALT is 18, his AST 20, alkaline phosphatase 150, total bilirubin 0.5. Albumin is 3.0, calcium 8.6, phosphate 4.1, magnesium 2.4. The TSH level is 25. The free T4 level is pending. His Vancomycin level as of [**4-2**], was 77.4. In view of this, his free T4 level and his TSH level will need to be reassessed in four to six weeks' time. The Endocrinology Fellow is aware of Mr. [**Known lastname 3883**] TSH levels and his Vancomycin is on hold. The Vancomycin random levels will need to be assessed q. 24 to 48 hours. Because of his chronic impaired renal function, his creatinine levels and BUN levels will also need to be followed. His chest x-ray from the [**10-31**] showed the tracheostomy tube was 4 centimeters above the carina and he was status post sternotomy; no pneumothorax. No significant change in the left upper and left lower lobe opacities. There is an elevated left hemi-diaphragm with pleural thickening and effusion. Old healed left rib fracture, increased interstitial markings in the right lung which is unchanged. The Endocrinology advice regarding the elevated TSH was to repeat free T4 levels and TSH levels in four to six weeks and the addition of Thyroxin supplement which is 150 micrograms of Synthroid q. day was to be given when the patient is not receiving tube feeds and to be given alone rather than mixed with any other medication, especially calcium, as calcium impairs thyroxine absorption. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3884**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2104-4-3**] 19:36 T: [**2104-4-3**] 23:05 JOB#: [**Job Number 3885**]

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Discharge summary

report

Admission Date: [**2163-11-25**] Discharge Date: [**2163-12-20**] Date of Birth: [**2102-11-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4365**] Chief Complaint: epidural abscess Major Surgical or Invasive Procedure: T12-S1 Laminectomy Intraoperative Foley Catheterization PICC placement Percutaneous placement of pulmonary pigtail catheter drains x2 History of Present Illness: 61 yo male with PMH significant for HTN, HL, DM, umbilical hernia repair 2 months ago who presented to an OSH on [**2163-11-25**] with severe LBP of 5 day duration, fever to 101.3, and left foot drop and was found to have an L3 epidural abscess. . He is now POD #4 s/p T12-S1 laminectomy ([**2163-11-25**]). He was of normal mental status on arrival but has had confusion and delirium since he was extubated which is the reason for transfer to medicine. Of note, pt was initiated on an anesthesia study protocol post-op due to concern of opiate/alcohol use which included ketamine infusion and ativan scheduled. He has also been receiving dilaudid po/iv prn and methocarbamol for pain control. Unclear reason why pt with abscess. He Denies IVDU. He has very poor dentition but recent dental work (most recently 5 years ago), his only recent surgery was hernia repair 2 months ago with mesh placement and does have urethral implant. . Hospital course is notable for WBC 17.6 with 18 bands on admission with recent WBC of 12.9 and no diff done. There was question of some nucal rigidity yesterday which has now resolved, no LP done given surgical site. The pt is being actively followed by ID. He received 4 doses gentamicin after his foley manipulation ([**11-24**] to [**11-27**]) and vancomycin post-operatively. While in the sicu patient was noted to have mild hand tremulousness but patient and family (per PA) deny any alcohol abuse. Hemovac wsa discontinued today. Of note pt had 6 french foley which required intraoperative placement after dilation and rigid cystoscopy by urology due to his urethral implants and artifical sphincter. Past Medical History: HTN Hyperlipidemia Prostate CA s/p prostatectomy [**2157**] s/p urethral sphincter and penile implants [**2159**] Umbilical hernia repair 2 months ago. Nephrolithiasis Sciatica Social History: He is a pharmacist. Non-smoker, rare EtOH use, denies any h/o illicit drug use. Family History: NC Physical Exam: On Transfer to medicine Vitals: T 99.4 (tmax 100.1), 170/80 (143-178/56-80), HR 118, RR 24-34, O2 93% RA 24 hour range prior to transfer: T 96.9-98, HR 52-100, BP 107-175/56-96, RR 20-35, O2 93-100% (weaned from 5 L NC to RA) General: Somnlenent, opens eyes to voice. Laying on back. Oriented to name, city and year. Says he is in a hospital. Able to answer questions but Not able to carry conversation and follow complicated commands. HEENT: EOMI (with difficulty), extinguishing lateral gaze nystagmus, PERRL Cardiac: RRR nl s1/s2 no m/r/g Pulm: Mild bibasilar crackles. Difficult to assess as patient unable to take full breaths. Abd: Soft, non-tender, mildly distended, + bs, no rebound or gaurding. Extremities: radial pulse +2, DP pulses +1, no LE edema Neuro: UE ald LE reflexes 2+, sensation grossly intact. [**4-18**] strength of UE (flex, ext, hand), [**4-18**] LE (flex, ext at hip and knee) MSK: Strength UE and LE [**4-18**], no nuchal regidity (pt states had hurt previously) Back: beefy red laminectomy scar with scallopped edges and no surrounding erythema. Also, scaterred macular, erythemtous rash of discrete lesions, some pustular. On Discharge Vitals: T 98.9, 123/70 (108-160/61-102), HR 93-94, RR 20 (down from 24-34), O2 94% RA General: NAD, AAOx3, uncomfortable on back. HEENT: EOMI, extinguishing lateral gaze nystagmus, PERRLA Cardiac: RRR nl s1/s2, no m/r/g Pulm: Mild bibasilar crackles. Worst on Left. + Egobronchophonic change at Left lung base Abd: Soft, non-tender, not distended, + bs, no rebound or gaurding. Extremities: radial pulse +2, DP pulses +1, no LE edema Neuro: UE ald LE reflexes 2+ with exection of Left upper extremity that is 4+ (One joint spread), sensation grossly intact. 5/5 strength of UE (flex, ext, hand), [**4-18**] LE (flex, ext at hip and knee). 5/5 strength on plantar flexion bilaterally, [**12-20**] dorsiflex on left, [**4-18**] dorsiflex on right Back: (progressively less) beefy red laminectomy scar with scallopped edges about the suture and no surrounding erythema. Also, scaterred macular, erythemtous rash of discrete lesions, some pustular. Pertinent Results: On admission [**2163-11-25**] 02:15PM BLOOD WBC-17.6* RBC-4.30* Hgb-12.4* Hct-37.6* MCV-88 MCH-28.9 MCHC-33.1 RDW-14.9 Plt Ct-260 [**2163-11-25**] 02:15PM BLOOD Neuts-64 Bands-18* Lymphs-10* Monos-7 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2163-11-25**] 02:15PM BLOOD PT-13.5* PTT-28.9 INR(PT)-1.2* [**2163-11-26**] 10:10AM BLOOD ESR-130* [**2163-11-25**] 02:15PM BLOOD Glucose-129* UreaN-25* Creat-1.1 Na-142 K-4.4 Cl-105 HCO3-22 AnGap-19 [**2163-11-26**] 03:44AM BLOOD Calcium-8.3* Phos-5.0* Mg-2.2 [**2163-11-26**] 10:10AM BLOOD CRP-GREATER TH Thyroid [**2163-11-28**] 02:39AM BLOOD TSH-0.58 [**2163-11-28**] 02:39AM BLOOD T4-6.9 Discharge Labs: RADIOLOGY STUDIES: CXR [**11-28**] In comparison with the study of [**11-25**], there is increasing opacification at the left base. Although much of this could merely reflect atelectasis and effusion, the possibility of supervening pneumonia must be seriously considered. Mild atelectatic changes are again seen at the right base. The PICC line appears to have been removed. Echo [**11-27**] No valvular pathology or pathologic flow identified. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. CT Head [**11-26**] 1. No acute intracranial abnormality. 2. Right maxillary sinus disease. Clinical correlation is advised. Lumbar Film [**11-24**] A single lateral view. Just submitted for report [**2163-11-26**]. Multiple surgical instruments are projected posterior to the lumbar spine. There is narrowingof the lowest lumbar-type intervertebral disc space. Degenerative arthriticchanges are present. A sharp metallic surgical instrument with a curved tip is projected posterior to the lowest lumbar-type vertebral body. MRI 12/17 L-spine: IMPRESSION: 1. Extensive fluid collection between the thecal sac and posterior musculature, with an enhancing rim. While this may represent a post-operative seroma, infection cannot be excluded. 2. More focal areas of rim-enhancing fluid within the left psoas and left posterior paraspinal musculature at the L2 level and a tiny focus of probable epidural abscess abutting the left thecal sac at the S1 level. CTA Chest/Abdomen/Pelvis: [**12-1**] IMPRESSION: 1. Within limitations described above, no evidence of pulmonary embolus in the main pulmonary artery, lobar or segmental branches. Subsegmental branches are well seen except in the inferior lower lobes, particularly on the right, and embolism can not be excluded here. 2. Partially loculated left pleural effusion with enhancing parietal pleura raises the question of infection, though an exudative effusion could also have this apperance. Volume loss in the left lower lobe with possible small area of infection inferiorly. Atelectasis in the right lower lung. 3. Allowing for differences in technique, no significant difference in known psoas abscess and appearance of the paraspinal muscles with fluid collection between the thecal sac and posterior muscles, for which infection can not be excluded. 4. Tubular intermediate density fluid in the left mediastinum adjacent to the left pleural effusion without enhancing rim. This is of uncertain etiology and attention should be paid on follow up. 5. 18 mm enhancing intramural and exophytic gastric antral mass has an appearance most consistent with a gastrointestinal stromal tumor (GIST). Endoscopic ultrasound and biopsy are recommended when the patient's condition allows. 6. Multiple well circumscribed sclerotic lesions in the right hemipelvis likely represent bone islands. However, in the setting of prior prostate cancer, if there is concern for bone metastasis, bone scan may be performed to evaluate. 7. Tiny hypodensity in the dome of the liver likely a simple cyst but too small to further characterize. Bilateral renal hypodensities, too small to further characterize but likely simple cysts. Small right thyroid lesion likely a colloid cyst. CXR: [**12-6**] - Left lateral decubitis 1. Interval removal of a pigtail pleural catheter, with one catheter remaining. 2. Small loculated left pleural effusion. There is no free effusion. 3. Moderate left basilar atelectasis, and plate like right basilar atelectasis unchanged. Chest CT (contrast): [**2163-12-11**]: IMPRESSION: 1. Persistent loculated left basal pleural effusion, which has decreased in size since prior CT [**2163-12-4**]. A pigtail catheter remains in situ at the base of the left hemithorax. 2. A small area of arterial hyperenhancement in segment [**Doctor First Name **] of the liver may represent a small hemangioma, but is too small to characterize. 3. Laminectomy is identified at the T11 and T12 vertebrae, following management of epidural abscess. Fluid is seen at the epidural area and in the subcutaneous tissues at this level, consistent with findings on MR [**2163-12-1**]. CT CHEST W/CONTRAST: [**2163-12-15**] IMPRESSION: 1. Partial drainage of the left lower lobe fluid collection, the position of the tip of the pigtail catheter may not be optimally positioned to drain the residual medial component of collection. 2. Stable bibasilar atelectasis. 3. Unchanged extrapleural, left paraspinal fluid collection of uncertain significance, could be due to a separate nidus of infection or possibly an unrealted nerve sheath tumor of mixed fat and soft tissue components. A followup CT thorax is recommended in no more than six months to assess any interval change. 4. Slight increase subcutaneous fluid collection overlying the laminectomy at T11-T12, abscess or seroma, readily accessible to percutaneous drainage. CHEST (PA & LAT): [**2163-12-17**] FINDINGS: Comparison is made to previous study from [**2163-12-16**] and [**2163-12-14**]. There is again seen plate-like linear atelectasis at the right base, stable. There are pleural parenchymal changes seen in the left base consistent with previous empyema and prior pigtail catheter placement. This is unchanged. There are no signs for overt pulmonary edema. There is again seen a small left-sided pleural effusion. There is a right-sided PICC line with distal lead tip in the distal SVC. Brief Hospital Course: SUMMARY 61 yo male with PMH significant for HTN, HL, umbilical hernia repair 2 months agos who presented to an OSH on [**2163-11-25**] with severe LBP, fever to 101.3, and left foot drop and was found to have an L3 epidural abscess. He underwent T12-S1 laminectomy. Patient was subsequently transferred to medicine for delirium. The delirium progressively resolved with rationalization of pain medication and treatment of infection which includes Strep milleri epidural abscess and LLL empyema. BY PROBLEM # Epidural abscess: Likely odontogenic infection (Strep Milleri). Treated with t12-s1 laminectomy and vancomycin. Initially treated with 4 day course of Vancomycin/Cefepime, which was switched to ceftriaxone for a six week course (end date [**2163-1-19**]). He will be followed closely by Infectious Disease in the outpatient. Laminectomy sutures removed on [**2163-12-9**]. Patient will require dental care and colonoscopy outpatient for resolution of source issues. Dental was consulted and felt teeth # 3, #15, and # 30 were non-restorable and should be extracted. A full dental exam should be performed as an outpatient. No obvious source of infection was noted. Patient should have neurosurgery follow-up as outpatient before [**2162-12-25**] with Dr. [**Last Name (STitle) **] and a follow-up MRI L-spine 4 weeks after discontinuation of antibiotics. # Left Lower Lobe PNA c/b Empyema: On transfer to medicine, patient noted to be febrile with consolidation on CXR. Given recent intubation, patient treated for HAP vs VAP initially with vancomycin and cefepime. As it was thought the empyema may have been secondarily seeded from the epidural abscess, he was switched to ceftriaxone for four weeks. Pulmonary pigtail catheter drains x2 were placed by IR on [**12-3**]. One was removed [**12-5**]. A repeat CT chest showed a persistant loculated empyema that was mildly decreased from prior. Since the second drain had minimal output, thoracic surgery was consulted. They performed injections of TPA in the catheter and pleural space attached to suction. Initially, drainage increased on day 1 and 2. On day 3, the drainage output had markedly decreased. Another repeat chest CT was performed and it showed resolution of the loculations with minimal fluid in pleural space that the position of the pigtail catheter would not be able to drain. Thus, the second drain was removed [**12-14**]. Thoracic surgery felt the remaining fluid was likely left over TPA vs. sterile fluid (as pt. has been on antibiotics). Since he remained afebrile with no elevations in white count, no further intervention was performed. Chest x-rays were followed that showed a stable pleural effusion. The patient is to follow up with Dr. [**First Name8 (NamePattern2) 40095**] [**Last Name (NamePattern1) **] in one week after discharge and obtain a non-contrast chest CT. # Incontinence: patient with deactivated urethral stricture. To be discharged on condom catheter and f/u with urologist for reactivation of urethral stricture. # Altered Mental Status: This was his reason for transfer to medicine, we feel that it was related to medications with an infectious component. Those medications include ativan, valium, ketamine and methocarbamol. To avoid worsening his condition, His pain control escalation was cautious with tramadol on [**11-28**], Oxycodone on [**11-29**] and Oxycontin with oxycodone breakthrough on [**11-30**]. His mental status cleared with pain control on Oxycontin 20/30 and prn oxycodone and resolution of his infection. # Hypertension: Labile post-operatively (SBPs 120-175), was under progressively better control as of [**11-29**]. Unclear etiology for poor control, most likely in setting of pain. Discharged on home dose of 10 mg lisinopril. # Anemia: Normocytic with normal RDW with obvious drop 37-30 after surgery but still very low to begin with. Worry about a chronic/indolent process. Iron studies likely to confirm chronic inflammation anemia or. folate replacement will confuse folate levels. Patient needs colonoscopy outpatient # Hyperlipidemia: Continued statin # Gout flare: Patient complained of right toe pain similar to previous gout flares. Resolved with colchicine treatment. No other complaints during hospital stay. # Gastric mass: noted incidentally on abdominal CT, radiographically consistent with GIST. Patient will required [**Date Range **] for work-up as outpatient once infectious issues have resolved. Medications on Admission: Lisinopril 10 mg po QD Lipitor 40 mg po Qpm Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD () as needed for pain: place on back, 1 inch away from scar. 12 hours on, 12 hours off. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): DVT prophylaxis. 12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO QAM (once a day (in the morning)). 13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO QPM (once a day (in the evening)). 14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 15. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q8H (every 8 hours) as needed for constipation. 16. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: Two (2) grams Intravenous Q24H (every 24 hours) for 4 weeks: Last Day [**2164-1-19**]. 17. Outpatient Lab Work Please obtain CBC, BMP, LFTs q monday and ESR and CRP every other Monday. Discharge Disposition: Extended Care Facility: [**Location (un) **] health care center Discharge Diagnosis: Primary Epidural Abscess Bacterial Pneumonia Delirium Secondary Hypertension Dyslipidemia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were transferred to the [**Hospital1 18**] for management of your epidural abscess. After surgery, you were delirious which was likely related to infection and medications. You were noted to have a left lower lobe infection which required placement of a drain in your lung that was placed through your skin. To ensure full drainage, Thoracic surgery was consulted and placed TPA in your drain and attached it to suction. This drained well initially, but dwindled. A repeat CT scan showed an improvement, with a small amount of fluid in your pleural space. Thoracic surgery felt no further intervention was needed at this time, as they felt the fluid was likely left over TPA. You are to follow up closely with thoracic surgery and have an appointment as below. You improved and were discharged to complete the treatment of your infection and rehabilitation. You also had a mass in your stomach noted on CT scan. When you improve, you will need an endoscopy of your stomach to evaluate this mass. This should be scheduled by your primary care physicina. NEW MEDICATION Ceftriaxone - take this medication until [**2163-1-19**] Oxycontin - this is a long acting pain medication. You will need to taper this medication with your PCP as your pain improves Oxycodone - this is a short acting medication to use as breakthrough Senna and Colace - these are medications to prevent constipation while on pain medication You should contact your primary care doctor or go to the emergency room if you experience fevers/chills, difficulty breathing, severe chest pain, confusion, or any other symptom that is concerning to you. Followup Instructions: You are to follow up with your primary care physician: [**Name10 (NameIs) **],[**Name Initial (NameIs) **]. [**Location (un) **] [**Telephone/Fax (1) 42422**] within 1-2 weeks of discharge from rehab. You need to call and make this appointment. Please tell your PCP: [**Name10 (NameIs) **] needed as outpatient to further evaluate incidental gastric mass noted on CT consistent with GIST radiographically. You need to follow up with your Urologist at [**Hospital1 2025**] within [**12-17**] weeks of discharge to have your automated urethral sphincter re-activated. You need to call and make this appointment. You are scheduled for the following appointments: Appointment #1 MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Thoracic Surgery Date/ Time: Tuesday, [**12-27**] at 9:30am Location: [**Location (un) **], [**Hospital Ward Name 23**] [**Hospital Ward Name **] [**Location (un) 24**], Reception Area A, [**Location (un) 86**], MA Phone number: ([**Telephone/Fax (1) 17398**] ***Please go to 3th floor 'RABB' building for CT chest at 8am prior to Dr.[**Name (NI) 5067**] appointment on [**2162-12-27**].*** Appointment #2 MD: Radiology Specialty: MRI Date/ Time: Tuesday, [**1-3**] at 9:55am Location: [**Hospital1 41690**], [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 121**] Complex, [**Location (un) 859**], [**Location (un) 86**], MA Phone number: ([**Telephone/Fax (1) 88**] Appointment #3 MD: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Specialty: Neurosurgery Date/ Time: Tuesday, [**1-3**] at 11:30am Location: [**Hospital Unit Name 103323**], [**Location (un) 86**], MA Phone number: ([**Telephone/Fax (1) 88**] Appointment #4: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 16976**], MD Speciality: Infectious Disease Date/Time:[**2164-1-9**] 9:00 Phone:[**Telephone/Fax (1) 457**]

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icd9cm

[ [ [] ] ]

[ "58.6", "34.04", "99.10", "34.91", "57.32", "03.09", "38.93", "57.94" ]

icd9pcs

[ [ [] ] ]

17259, 17325

10756, 13792

334, 470

17464, 17464

4607, 5244

19256, 21151

2455, 2459

15313, 17236

17346, 17443

15244, 15290

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5261, 10733

2474, 4588

278, 296

498, 2141

17478, 17585

2163, 2342

2358, 2439

26,298

197,967

1739

Discharge summary

report

Admission Date: [**2157-3-12**] Discharge Date: [**2157-3-21**] Date of Birth: [**2086-8-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: This is a 70 year old man with history of myotonic dystrophy and recent bronchitis who presents with dyspnea. He reports a nonproductive cough x 3-4 weeks. When it didn't improve, he went to his PCP and was started on azithromycin empirically for bronchitis about 2 weeks ago. He finished his Z-pack, but afterward his cough became worse. Two nights ago, he had difficulty sleeping and didn't use his bipap. He felt better the next morning, but that evening felt short of breath again and was gasping for air. He couldn't tolerate his bipap due to stuffy nose, and then had progressive dyspnea today. It became so bad he decided to come to the ED. . In the ED, he was initially found to be hypoxic room air to 77% initially. A NRB improved him to >90%, but he was switched to CPAP for improved oxygenation, but didn't tolerate it due to discomfort. He desatted to 75% on nonrebreather, and intubation was discussed. On retrial of CPAP, he improved his sats to >99? on 100% FiO2. He was given 500 mg PO levofloxacin and 40 mg IV lasix with 1500 cc urine out through the time he arrived on the floor. He was given 325 mg aspirin and started on a nitroglycerin drip for SBP aroun 200. He was admitted ot the ICU for hypoxic respiratory failure. Past Medical History: - myotonic dystrophy type II - weakness in his mid and lower back, proximal LE's - problems with his swallowing mechanism - nocturnal hypoventilation - right upper lobe and right middle lobectomy in [**2131**] for pulmonary nodules, which showed carcinoid by biopsy - restrictive ventilatory defect (FVC 52%, FEV1 50%) - BPH - constipation Social History: He is married. He is a retired engineer, having worked in the Polaroid Corporation till [**2146**]. He quit smoking many years ago after very limited pack year usage. He rarely drinks alcohol, does not use nutritional or herbal supplementation. There is limited amount of caffeine intake. Family History: Regarding myotonic dystrophy, per records: ? Father ? First cousin on father's side undergoing work-up at [**Hospital1 1012**]-[**Location (un) 9895**] ? Two brothers, now deceased ? One of his cousins' sons, approximately 50 years old, undergoing work-up in the [**State 9896**]. area. Physical Exam: V: 98.2 BP 126/90 P110 R25 95% BIPAP 10/5 40% -> 86% RA -> 97% high flow FM Gen: No distress, speaking in full sentences with BIPAP full mask on HEENT: PERRLA, EOMI Resp: coarse bilaterally with wheezes, cough nonproductive CV: tach nl s1s2 no MGR Abd: soft NTND +BS Ext: 1+ edema bilaterally symmetric, no calf tenderness Neuro: 4/5 strength deltoids, triceps, hip flexors. [**5-7**] biceps, wrist, knee flex/ext, ankle flex/ext. FTN intact bilat. 2+ patellar and biceps DTR. CN 2-12 intact Pertinent Results: CTA Chest on [**2157-3-13**]: IMPRESSION: 1. No pulmonary embolism. 2. Tree-and-[**Male First Name (un) 239**] appearance of the right bronchi and pulmonary system, combined with enlarged right hilar lymph nodes and granuloma, is suspicious for an atypical infection. TB is not excluded given the pulmonary granuloma as evidence of prior granulomatous exposure. 3. Chronic pancreatitis. Echocardiogram on [**2157-3-14**]: Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). 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. Mild to moderate ([**1-4**]+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2156-1-13**], no change. . VIDEO OROPHARYNGEAL SWALLOW [**2157-3-21**] 12:55 PM IMPRESSION: Moderate oropharyngeal dysphagia with aspiration of thin liquids demonstrated. . [**2157-3-16**] 04:46AM BLOOD WBC-7.1 RBC-4.67 Hgb-13.8* Hct-40.5 MCV-87 MCH-29.7 MCHC-34.1 RDW-14.1 Plt Ct-203 [**2157-3-12**] 08:55PM BLOOD Neuts-84.9* Lymphs-7.5* Monos-6.9 Eos-0.4 Baso-0.3 [**2157-3-16**] 04:46AM BLOOD PT-12.4 PTT-47.0* INR(PT)-1.1 [**2157-3-16**] 04:46AM BLOOD Glucose-162* UreaN-18 Creat-0.5 Na-139 K-3.7 Cl-98 HCO3-29 AnGap-16 [**2157-3-13**] 09:08AM BLOOD CK(CPK)-85 [**2157-3-12**] 08:55PM BLOOD CK-MB-10 MB Indx-6.8* cTropnT-<0.01 proBNP-160 [**2157-3-13**] 04:15AM BLOOD CK-MB-8 cTropnT-0.15* [**2157-3-13**] 09:08AM BLOOD CK-MB-NotDone cTropnT-0.14* [**2157-3-16**] 04:46AM BLOOD Calcium-10.0 Phos-3.7 Mg-2.3 [**2157-3-15**] 06:16AM BLOOD Triglyc-96 HDL-61 CHOL/HD-3.1 LDLcalc-108 [**2157-3-16**] 10:22AM BLOOD Type-ART O2 Flow-4 pO2-71* pCO2-44 pH-7.46* calTCO2-32* Base XS-6 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NC Brief Hospital Course: This is a 70M with myotonic dystrophy who presents with hypoxia and recent history of bronchitis. . #) hypoxic respiratory failure - DDx includes respiratory muscle failure, aspiration, congestive heart failure, PE. Most likely this is mucous plugging due to neuromuscular weakness resulting in inability to clear mucous. LVEF 55% with some impaired relaxation. Hypoxia improved with InExsufflator. Occasional desaturation into mid 80's after ambulation but recovers well. Stable at night with BiPap. Per recommendations of primary neurologist, continued with InExsufflator QID and rest on BiPAP for 1 hour every 3 hours during the day, and all night while patient is sleeping. Continued with PRN nebulizers. Continue with empiric levofloxacin, to complete 7-day course on [**2157-3-20**]. Viral cultures positive for parainfluenza. Sputum cultures are contaminated and urinary legionella antigen is negative. CTA is negative for PE. 2 days prior to DC patient did not require 02 or BIPAP during the day, ambulating with sats at 98% on RA. Likely viral process, parainfluenza leading to bronchitis in patient with MS leading to respiratory failure. #) Elevated CK-and troponins, MB - possible enzyme leak vs baseline from myotonic dystrophy. Cardiac enzymes elevated due to demand, no symptoms or ECG changes. Continued aspirin, and low dose beta blocker (patient not on this as outpatient and became bradycardic at night on 25mg [**Hospital1 **]). . #) myotonic dystrophy type II - Diagnosed with genetic test in [**2152**]. Can cause proximal muscle weakness, respiratory failure, cardiac abnormalities, swallowing difficulty. Supportive treatment. InExsufflator had improved clinical picture. Speech/swallow eval for recurrent aspiration. As per neuro, unclear whether respiratory state related to bronchitis picture vs progression of disease, likely mixed picture. . #) elevated blood sugar - Continue with insulin sliding scale . #) Constipation - continue agressive senna and enemas as needed. Patient having bowel movements with soft, non tender abdomen throughout admission, though bowel habits a large concern for the patient daily. Medications on Admission: sennakot 5 times daily recent Z-pack Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO 5 times daily: as outpatient. 2. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*1* 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:*1 inhaler* Refills:*0* 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:*1 inhaler* Refills:*0* 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal once a day as needed. Disp:*60 Suppository(s)* Refills:*1* 6. Inexsufflator 7. BiPAP as outpatient settings. Discharge Disposition: Home With Service Facility: Caregroup Home Care Discharge Diagnosis: Primary: Viral bronchitis, + para influenza Myotonic Dystrophy- Type II Constipation . - weakness in his mid and lower back, proximal LE's - problems with his swallowing mechanism - nocturnal hypoventilation - RU and RM lobectomy ([**2131**]) for pulm nodules, bx = carcinoid - PFTs = restrictive ventilatory defect (FVC 52%, FEV1 50%) - BPH Discharge Condition: Ambulating, 95% RA Discharge Instructions: You were admitted with shortness of breath and low oxygen saturation. You were found to have a virus. You were also treated with a course of levofloxacin, diuresis, and BiPaP throughout the day and at night, in addition to the addition of an Inexsufflator as per respiratory therapy. -Please continue to use your BiPAP machine at night and the Inexsufflator as per respiratory therapy. A respiratory therapist will be coming to your house to review how to use the inexsufflator. -Speech and swallow will set up for therapy 4 times a week. Please follow the instructions and exercises given to you by the Speech and Swallow department. -Please maintain all appointments, such as with Neurology to discuss Myotonic Dystrophy. -Please take bowel regimen as needed for constipation -Please return to the hospital if you are experiencing shortness of breath, severe wheezing, change in mentation, severe constipation or other symptoms concerning to you. Followup Instructions: Please call Dr. [**Last Name (STitle) 9897**] for follow up appointment. I attempted to call and left a message. [**Telephone/Fax (1) 9898**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9899**], M.D. Phone:[**Telephone/Fax (1) 558**] Date/Time:[**2157-3-28**] 12:00 . Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2157-6-3**] 10:10

[ "787.2", "790.6", "359.2", "V45.76", "564.00", "466.0", "518.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8097, 8147

5249, 7403

323, 330

8534, 8555

3105, 5226

9554, 10020

2288, 2577

7491, 8074

8169, 8513

7429, 7468

8579, 9531

2592, 3086

276, 285

358, 1602

1624, 1966

1982, 2272

73,211

171,469

45392

Discharge summary

report

Admission Date: [**2187-11-9**] Discharge Date: [**2187-11-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: Left sided arm pain Major Surgical or Invasive Procedure: none History of Present Illness: This is a [**Age over 90 **]-year-old gentleman with a history of hypertension, diabetes and COPD who had dull left arm pain for two to three minutes early in the morning on [**2187-11-9**]. He denied any associated chest pain, jaw pain, shortness of breath, nausea, vomiting, or diaphoresis. The patient stated that the arm pain abated on its own. During this episode of transient arm pain the patient reported that his blood pressure was lower than usual at 100/40. He went to seek medical advice in the emergency room at an outside hospital where he was found to have ST elevations in the II, III, and aVF. He was given ASA, Plavix and started on Heparin drip. No beta blocker or nitroglycerin was given secondary to HR in 40s and a low blood pressure with 100-110 systolic BP. Mr. [**Known lastname 96908**] was transferred to [**Hospital1 18**] for possible cardiac catheterization. Interventional cardiology team evaluated the patient and felt that there was no urgency or immediate indication for cardiac catheterization. This decision was made given that repeat EKG had no changes significant for STEMI. Mr. [**Known lastname 96908**] had three negative sets of cardiac enzymes as well which further corroborated the decision to defer any invasive procedures. At the time of CCU transfer the patient was asymptomatic and his Heparin drip had been discontinued. Of note, the patient does have a TIMI risk score is [**3-11**], placing him at intermediate risk for cardiac event. At baseline, the patient has very limited functional status as well and has significant co-morbidities, including COPD, Diabetes/II, and hypothyroidism. Otherwise, from a cardiac standpoint the patient denied any prior invasive cardiac interventions, MI history or stroke history. Past Medical History: CARDIAC HISTORY : Cardiac risk factors are positive for Diabetes, HTN, Obesity, but negative for hyperlipidemia. The patient has no significant past CAD morbidity per records, no prior CABG/PCIs,and Mr. [**Known lastname 96908**] has never had a pacemaker or ICD placed. OTHER PAST MEDICAL HISTORY: Hypertension Hypothyroidism COPD-on home O2 (usually 2L via NC, not continuous but PRN and during sleep PRN) Diabetes Mellitus / type 2 Social History: Mr. [**Known lastname 96908**] lives with his wife in an [**Hospital3 **] facility in [**Location (un) 620**] called [**First Name9 (NamePattern2) **] [**Doctor Last Name 363**]. The patient's tobacco history includes 120 pack year history. The patient quit smoking 30 years ago. ETOH: Occasional use at social gatherings. The patient denies any illicit drug use or history. Family History: No family history of early MI, otherwise non-contributory. Physical Exam: PHYSICAL EXAMINATION: VS: T=96.6 BP=132/30 HR=48 RR=23 O2 sat= 98% on 2LNC GENERAL: NAD. Alert and oriented to person, place and time. Mood and affect appropriate. Pleasant demeanor. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of [**8-14**] cm range. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. No S3 or S4. LUNGS: Respirations were unlabored, no accessory muscle use. Coarse breath sounds diffusely with mild wheezes noted with expirations, right > left ; at posterior fields. ABDOMEN: Soft, non-tender and non-distended. No HSM. Abdominal aorta not enlarged by palpation, no bruits. EXTREMITIES: No edema or cyanotic features. 2+ pedal pulses bilaterally SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: CARDIAC ECHO [**2187-11-10**]: Suboptimal study with limited echo window. The left ventricle is not well seen. Left ventricular function cannot be reliably assessed. The right ventricular cavity is dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. EKG [**2187-11-9**]: Sinus bradycardia, mild Right axis deviation. Rate 48. No acute ST changes. [**2187-11-9**] 04:33PM PT-13.5* PTT-27.2 INR(PT)-1.2* LABS PRIOR TO DISCHARGE: WBC 6.3, Hct 40.9 and CK 99 K 4.4, Na 138, Cl 98, HCO3 38, BUN 28 Cr 1.1 [**2187-11-9**] 04:33PM PLT COUNT-180 [**2187-11-9**] 04:33PM WBC-7.6 RBC-4.52* HGB-13.9* HCT-40.8 MCV-90 MCH-30.7 MCHC-34.0 RDW-13.6 [**2187-11-9**] 04:33PM TSH-2.8 [**2187-11-9**] 04:33PM TRIGLYCER-121 HDL CHOL-41 CHOL/HDL-3.9 LDL(CALC)-95 [**2187-11-9**] 04:33PM MAGNESIUM-2.0 CHOLEST-160 [**2187-11-9**] 04:33PM CK-MB-6 cTropnT-0.02* [**2187-11-9**] 04:33PM CK(CPK)-100 [**2187-11-9**] 04:33PM estGFR-Using this [**2187-11-9**] 04:33PM GLUCOSE-58* UREA N-31* CREAT-1.2 SODIUM-138 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-35* ANION GAP-9 OUTSIDE HOSPITAL LABS/STUDIES: At OSH: WBC 7.7 HCT 40.9 PLT 162 Na 1741 K 4.7 Cl 101 CO2 35 BUN 33 Cr 1.2 GLu 92 ALT 32 AST 20 AP 75 Tbili 0.51 Alb 3.6 CK 113 CK-MB 3 RI 2.7 TropT 0.024 (<0.01) BNP 427 . EKG: at OSH [**2187-11-9**] at 1157 Sinus brady to 40s, IVCD, approx 0.5 mm STE in II/aVF/III. Brief Hospital Course: In Summary, Mr. [**Known lastname 96908**] is a [**Age over 90 **]-year-old male who presented to CCU after [**Hospital **] transfer from outside hospital for emergent evaluation for what was thought to be an inferior STEMI after initial EKG at OSH showed minimal .5mm-1mm elevations in leads II, III, and aVF. He was given ASA, Plavix and started on Heparin drip. No beta blocker or nitroglycerin was given because of the patient's low heart rate in the high 40s -50s range in conjunction with his ongoing low blood pressures in the 100-110 systolic range. As aforementioned, the patient was evaluated by [**Hospital1 1388**] interventional cardiology team and it was felt that there was no urgency or immediate indication for cardiac catheterization given that the review of a repeat EKG had no changes significant for STEMI. Moreover, Mr. [**Known lastname 96908**] also had three negative sets of cardiac enzymes. The patient's dull, left-sided arm pain was attributed to fleeting ischemia and likely some atypical chest pain but no true cardiac infarcts. The patient's presentation and workup did not warrant any invasive procedures at this time. A lipid profile was explored and showed reasonable values with no overt hyperlipidemia as his total cholesterol was 160, HDL 41, LDL 95 and Triglycerides 121. Of note, the patient does have multiple cardiac risk factors, including age, male gender, HTN, diabetes and smoking history. TIMI risk score is [**3-11**], placing him at intermediate risk. For his entire hospital stay Mr. [**Known lastname 96908**] remained asymptomatic and denied any chest pain, shortness of breath, dizziness or palpitations.The patient had no additional episodes of left arm pain. The patient was continued on his daily Aspirin and his Metoprolol was initially held given his mild bradycardia but continued once his rate improved. He also had improvement in his low blood pressures throughout his hospital stay but it was felt that he should discontinue his HCTZ at time of discharge in order to avoid any additional BP drops and he was also advised to defer his Metoprolol dose if his heart rate dropped below 50 or his home systolic blood pressure dropped below 100. The patient was asked to discontinue his HCTZ and to start taking Lisinopril 2.5mg daily with Metoprolol 12.5mg twice daily for appropriate control of his blood pressure. He was also advised to follow-up within 1 week with his primary care physician for ongoing management of his hypertension and additional co-morbidities as outlined above. In terms of the patient's pump function, he arrived to the CCU in a euvolumic state based on lab data and clinical exam. He exhibited no signs or symptoms of CHF. The patient's heart rhythm was monitored continuously on telemetry while in the CCU and he was initially in sinus bradycardia so his beta-blocker was held and eventually continued. An ECHO (TTE) was done which was unfortunately a suboptimal study with limited echo window. The left ventricle was obscured and left ventricular function was unable to be reliably assessed. However, the right ventricular cavity was studied and found to be dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) were mildly thickened and trace aortic regurgitation was also noted. . Given the patient's history of hypothyroidism, he was continued on his usual home dose of Levothyroxine and his TSH was checked and found to be within normal limits. The patient's COPD was also monitored and he was continued on his usual intermittent levels of low flow oxygen via nasal cannula and his home medications, Advair and Spiriva were continued. Theophylline was initially held and then continued. In regards to the patient's DM2 management, he had well controlled finger stick glucose levels and was managed on a sliding scale protocol with regular insulin and his home glyburide was held during his CCU stay. He was placed on a diabetic heart healthy diet and had good PO intake throughout his hospitalization. The patient's electrolytes were also monitored daily and repleted as needed. The patient was made aware of his medical management daily and his wife, [**Name (NI) 19948**] [**Name (NI) 96908**], was also updated during the patient's stay. The patient remained a full code status throughout his hospitalization. The patient was advised at time of discharge that if he had any additional sustained left arm pains, chest pain, shortness of breath, or lightheadedness to contact his local emergency room or primary care provider as soon as possible. He was stable and clinically asymptomatic at time of discharge from CCU. Medications on Admission: Advair 250/50 daily Spiriva 18 mcg daily Glyburide 2.5 daily Theophylline 300 mg daily Levothyroxine 50 mcg daily Metoprolol tartrate 25 daily HCTZ 25 mg daily Potassium extended release 10 mEq daily . ALLERGIES: NKDA Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Do not take if systolic blood pressure is less than 100 or HR less than 50. Disp:*30 Tablet(s)* Refills:*2* 2. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: [**2-7**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: [**2-7**] Caps Inhalation DAILY (Daily). 6. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 8. Theophylline 300 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: Atypical chest pain Hypertension Diabetes / type 2 Chronic Obstructive Pulmonary Disease Hypothyroidism Discharge Condition: Stable No chest pain, shortness of breath and patient had good oral intake with meals and was able to ambulate without assistance. Discharge Instructions: You were seen for an Intensive Care Unit stay after you presented with left arm pain and EKG changes were noticed at an outside hospital which were concerning and you were given several medications to treat you for a possible heart attack. However, a follow-up EKG done at [**Hospital1 18**] showed no concerning changes on EKG and additional lab tests and cardiac enzyme checks which were all within normal limits to show that you did not suffer a heart attack and you did not need any additional procedures or cardiac catheterizations. You were treated for atypical chest pain and your blood pressure and low heart rate was monitored during your stay. After discharge, if you have any chest pain, shortness of breath, or lightheadedness please contact your local emergency room or primary care provider as soon as possible. Please discontinue your Hydrochlorathiazide (HCTZ) blood pressure medication for now and continue taking Lisinopril 2.5mg daily with Metoprolol 12.5mg twice daily for appropriate control of your blood pressure and follow-up this week with your primary care physician for ongoing management of your hypertension, diabetes, COPD and hypothyroidism history. Continue taking 81mg Aspirin daily and your usual home doses of Advair, Theophylline and Spiriva for your COPD and continue your Glyburide 2.5mg daily for diabetes and Levothyroxine 50mcg daily for your hypothyroidism. Followup Instructions: Please make a follow-up appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28003**] in [**University/College **] within 1 week's time (phone # [**Telephone/Fax (1) 41434**]) Completed by:[**2187-11-12**]

[ "491.21", "244.9", "250.00", "401.9", "786.59" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11219, 11225

5440, 10083

283, 289

11373, 11506

3965, 5417

12956, 13252

2957, 3017

10352, 11196

11246, 11352

10109, 10329

11530, 12933

3032, 3032

3054, 3946

224, 245

317, 2087

2410, 2548

2564, 2941

70,226

114,222

45494

Discharge summary

report

Admission Date: [**2181-9-20**] Discharge Date: [**2181-10-2**] Date of Birth: [**2102-1-24**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Iodine / Lisinopril / Amoxicillin Attending:[**First Name3 (LF) 2297**] Chief Complaint: SOB, lethargy Major Surgical or Invasive Procedure: Intubation PICC line placement History of Present Illness: 79 year old woman with history of severe oxygen dependent COPD, and recent diagnosis of likely metastatic lung cancer (diagnosed on imaging, no biopsy yet) who presents with 2 days of difficulty breathing, fatigue, slight confusion, and irritablity. At baseline, the patient is on [**2-24**] L O2 at home for severe COPD. Per her daughter and son, she has had increasing shortness of breath over the past 2 days with new production of green thick sputum. No observed fevers or chills. Symptoms are associated with increasing fatigue and appearance of anxiety. The patient's family increased her O2 to 6L, but symptoms continued to progress. They called her PCP who recommended admission to the hospital. In the ED, initial VS: 98.7 84 186/80 24 96% 4L. The patient was non-responsive, and was intubated for airway protection. She was started on PCV with FIO2 40%, Peep 10, Rate 18, Inspiratory pressure 35. ABG following intubation: pH 7.25 pCO2 105 pO2 422 HCO3 48. The patient underwent CXR that showed 1. New widespread right pulmonary opacities, concerning for infection versus edema. 2. Persistent right upper lobe mass. She received 1 dose of vancomycin and zosyn for likely pneumonia. She was transferred to the MICU for further management. VS prior to transfer: 98.2 76 90/51 18 98%. In regards to the patient's recent diagnosis of lung cancer, it was diagnosed in [**7-3**] by CT scan. Scan revealed an enlarging right upper lobe mass, bulkly mediastinal lymphadenopathy, and a presumed large liver metastasis. No biopsy was performed, as the patient would likely be a poor candidate for both surgery and chemotherapy. Multiple goals-of-care discussions were held between the family and the patient's PCP that resulted in "full code" status for the time being, in accordance with the patient's prior wishes. However, the family is now considering a "do not resuscitate" order given her poor prognosis. The patient was supposed to be evaluated by palliative care today, when her status changed acutely. OF NOTE, the patient is not aware that she carries a diagnosis of cancer, as the family is worried that it will make her give up hope. On arrival to the MICU, patient's VS. 98.6 108/56 83 94% on CMV with FIO2 40%, TV 350, PEEP 10. Patient was intubated and lightly sedated. Past Medical History: 1. Postherpetic neuralgia. 2. COPD. 3. Productive cough chronically. 4. Diabetes type 2. 5. Hypertension. 6. Hypothyroidism. 7. Dementia. Social History: Patient lives in a 2 family home. Her son lives with her, and her daughter lives in the house below her. She has a caretaker who comes in approximately four hours per day. Her daughter also spends a significant amount of time caring for her. She is a retired postal clerk. She has a significant smoking history of one to two packs over 50 years; however, she quit in [**Month (only) 404**] [**2178**] when she first was initiated on supplemental oxygen. No alcohol. Family History: 1. Father question of lung disease, diabetes. 2. Mother, diabetes. 3. Daughter hypertension. 4. Son prostate cancer and diabetes Physical Exam: On admission Vitals: VS. 98.6 108/56 83 94% on CMV with FIO2 40%, TV 350, PEEP 10 General: Intubated, sedated. Opens eyes and moves all 4 extremities to command; able to answer yes/no questions with nodding HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Mild right-sided crackles; prolonged expiratory phase with poor air movement Abdomen: soft, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Moves all 4 extremities on command. On discharge: expired Pertinent Results: [**2181-9-20**] 06:00PM BLOOD WBC-9.9 RBC-4.07* Hgb-11.8* Hct-40.4 MCV-99* MCH-28.9 MCHC-29.2* RDW-14.1 Plt Ct-266 [**2181-9-23**] 04:10AM BLOOD WBC-12.6* RBC-3.43* Hgb-10.7* Hct-33.4* MCV-98 MCH-31.2 MCHC-32.0 RDW-15.1 Plt Ct-211 [**2181-9-28**] 04:23AM BLOOD WBC-13.0* RBC-3.02* Hgb-8.7* Hct-28.8* MCV-95 MCH-28.7 MCHC-30.1* RDW-15.7* Plt Ct-320 [**2181-10-2**] 03:56AM BLOOD WBC-15.6* RBC-2.83* Hgb-8.0* Hct-26.9* MCV-95 MCH-28.0 MCHC-29.7* RDW-16.9* Plt Ct-349 [**2181-9-20**] 06:00PM BLOOD Neuts-92* Bands-0 Lymphs-6* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2181-9-23**] 04:10AM BLOOD Neuts-83.6* Lymphs-8.9* Monos-6.5 Eos-1.0 Baso-0.1 [**2181-9-30**] 03:49AM BLOOD Neuts-71* Bands-6* Lymphs-8* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-5* Myelos-3* [**2181-9-20**] 06:00PM BLOOD Glucose-186* UreaN-22* Creat-0.7 Na-142 K-4.4 Cl-93* HCO3-43* AnGap-10 [**2181-9-25**] 03:12AM BLOOD Glucose-251* UreaN-45* Creat-1.4* Na-133 K-5.7* Cl-99 HCO3-27 AnGap-13 [**2181-9-27**] 03:56AM BLOOD Glucose-138* UreaN-66* Creat-2.5* Na-135 K-4.6 Cl-100 HCO3-29 AnGap-11 [**2181-10-1**] 03:50AM BLOOD Glucose-121* UreaN-113* Creat-4.6* Na-132* K-6.3* Cl-95* HCO3-21* AnGap-22* [**2181-10-2**] 03:56AM BLOOD Glucose-164* UreaN-122* Creat-5.2* Na-124* K-GREATER TH Cl-96 HCO3-17* [**2181-9-21**] 03:40AM BLOOD ALT-92* AST-142* LD(LDH)-1576* AlkPhos-356* TotBili-0.9 [**2181-9-28**] 04:23AM BLOOD ALT-72* AST-84* LD(LDH)-798* AlkPhos-328* TotBili-0.7 [**2181-10-1**] 03:50AM BLOOD ALT-72* AST-98* LD(LDH)-768* AlkPhos-376* TotBili-1.0 [**2181-9-21**] 03:40AM BLOOD Calcium-8.9 Phos-2.3* Mg-1.6 [**2181-9-25**] 10:00PM BLOOD Calcium-8.8 Phos-4.2 Mg-2.6 [**2181-9-30**] 03:49AM BLOOD Albumin-2.8* Calcium-9.3 Phos-6.6* Mg-3.0* [**2181-10-2**] 03:56AM BLOOD Calcium-9.0 Phos-10.3*# Mg-3.4* Imaging: CXR (on admission): IMPRESSION: 1. New widespread right pulmonary opacities, concerning for infection versus edema. 2. Persistent right upper lobe mass. CXR ([**9-24**]): Cardiac size is normal. Patient has known right upper lobe lung mass and hilar lymphadenopathy. Diffuse heterogenous opacities in the right lung are unchanged. There is most likely complication of lung cancer , less likely pneumonia. If any there are small bilateral pleural effusions. The lungs are hyperinflated. Left lower lobe opacity is new worrisome for focus of pneumonia. There is no pneumothorax. ET tube is in the standard position. NG tube tip is in the stomach. CXR ([**10-1**]): As compared to the previous radiograph, there is minimal improvement of the extensive parenchymal opacity on the right, notably the level of the right lower lobe. Otherwise, no relevant change is seen. A slight increase in lung density on the left is caused by positional factors. Endotracheal tube, left PICC line and nasogastric tube are in unchanged position. Unchanged appearance of the cardiac silhouette. Brief Hospital Course: 79 year old woman with history of severe oxygen dependent COPD, and recent diagnosis of likely metastatic lung cancer who presents with difficulty breathing, fatigue, confusion, and irritablity; found to have hypercarbic respiratory failure and likely pneumonia. # Hypercarbic respiratory failure [**2-22**] pneumonia and pulmonary malignancy: She has baseline severe COPD and new diagnosis of lung cancer complicated by acute decompensation. She was intubated in the ED for airway protection due to unresponsiveness. Acute fluffy infiltrates on CXR (R > L), and worsening cough productive of green sputum concerning for large aspiration pneumonia as a source of decompensated lung disease. This is an addition to the diseased, cancerous lung that was likely difficult to ventilate at baseline. She completed a course of vancomycin and cefepime for pneumonia. She became very difficult to ventilate, given the 2 entirely different physiologic properties of the 2 lungs (congested, cancer-filled lung vs. hyperinflated, COPD lung). Her peak airway pressures remained quite elevated and she required a large amount of sedation in order to be comfortable. She could not ultimately be weaned off the ventilator prior to her passing. # Acute kidney injury and hyperkalemia: As her condition continued to worsen, her creatinine started to rise and her urine output dropped off precipitously. Concomitantly, her potassium increased markedly, likely secondary to the metabolic acidosis as well as severe constipation. Rather than continuing to give enemas, these measures were stopped in favor of comfort measures. Her hyperkalemia eventually caused her to become increasingly bradycardic and eventually pass away. # Goals of care: Many discussions were initiated with the family, involving Palliative Care early on. While they did not want to withdraw care (i.e. pull out the breathing tube), they did acknowledge that they wanted to maximize her comfort. Her daughter and son were by her side at the time of death, just as they would have wanted. After her passing, Dr. [**Last Name (STitle) **] was [**Last Name (STitle) 653**] with the information. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver[**Name (NI) 581**]. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 2. Fluticasone Propionate NASAL 2 SPRY NU DAILY 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 4. Gabapentin 100 mg PO HS 5. Glargine 31 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Memantine 5 mg PO DAILY 7. Methimazole 5 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Pravastatin 20 mg PO HS 10. PredniSONE 2.5 mg PO DAILY 11. Sertraline 25 mg PO HS 12. Tiotropium Bromide 1 CAP IH DAILY 13. Verapamil SR 180 mg PO Q24H Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10020, 10029

7142, 9304

342, 374

10076, 10081

4245, 7119

10133, 10139

3388, 3523

9992, 9997

10050, 10055

9330, 9969

10105, 10110

3538, 4203

4217, 4226

289, 304

402, 2714

2736, 2883

2899, 3372

27,386

143,822

27191

Discharge summary

report

Admission Date: [**2189-7-4**] Discharge Date: [**2189-7-27**] Date of Birth: [**2114-8-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: fever and hemoptysis Major Surgical or Invasive Procedure: [**2189-7-6**] Flexible bronchoscopy and EGD with biopsy of esophageal nodules. -s/p Left thoracoabdominal removal of infected ao. stent, placement of Dacron ao. graft, primary repair of iatrogenic esophageal injury, Omental wrap, G and J tubes History of Present Illness: Patient is a 74 year-old gentleman with a history of an aortic stented graft in [**2186**] with subsequent brucellosis aortitis. The patient has been complaining of hemoptysis which required the placement of another stent in [**Country **] around [**2189-2-17**]. The patient had recurrent symptoms of fever and hemoptysis and was admitted to [**Hospital1 18**] to rule out a fistulous process. Past Medical History: Endovascular stent graft placement [**2187-3-5**] for descending thoracic aortic ulcer c/b brucellosis aortitis on long term abx then stopped BPH HTN hx back surgery hx opiate use Social History: Farsi speaking only. Lives with wife. Had recent travel to [**Country **] ~2months ago and wife is experiencing similar symptoms. Family History: N/C Physical Exam: Upon discharge: Pt is alert, oriented in NAD Vital signs: 98.6, 156/77, 80-paced, 18, 100%RA Lungs- CTAB CV- RRR, no murmur abd- NABS, soft, nontender thoracoabdominal incision- clean, dry, intact, no erythema or drainage ext- no edema Pertinent Results: [**Known lastname **],[**Known firstname **] [**Medical Record Number 66712**] M 74 [**2114-8-20**] Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2189-7-3**] 10:27 PM [**Last Name (LF) 30346**],[**First Name4 (NamePattern1) 30347**] [**Last Name (NamePattern1) 30348**] EU [**2189-7-3**] SCHED CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # [**Clip Number (Radiology) 66713**] Reason: please eval for endovasc bleed, rp bleed Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 72yo M s/p recent endovascular stent placement [**3-5**] to descending thoracic aorta for ulcerating plaque. seen in [**Country **]. transported here from [**Country **] for ? leak. describes pain in LUQ/LLQ, l flank REASON FOR THIS EXAMINATION: please eval for endovasc bleed, rp bleed CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: DXAe FRI [**2189-7-3**] 11:04 PM Thick (19 mm) rind of soft tissue around the descending aorta graft with locules of air is very worrisome for graft infection. No evidence of contrast extravisation. Final Report INDICATION: 72-year-old man with endovascular stent placement 2 months ago inside old vascular stent placed on [**4-24**], presenting with left upper quadrant pain, with possible endovascular leak. COMPARISON: [**2187-4-3**]. TECHNIQUE: MDCT acquired images were obtained through the torso before and then immediately after the uneventful administration of 80 cc of IV Optiray contrast. Multiplanar reformats were reviewed. CTA CHEST: The patient is post endograft stent in the descending thoracic aorta with marked soft tissue thickening around the graft measuring 17 mm (previously 8 mm). Focal areas of air within the soft tissue, are highly concerning for infection. There is no evidence of contrast extravasation or ruptured atherosclerotic plaque. The lung parenchyma is grossly unremarkable. The airways are patent to the subsegmental level. There are no pathologically enlarged central or axillary lymph nodes. CT ABDOMEN: The liver, spleen, pancreas, gallbladder, and adrenals are grossly unremarkable. The kidneys demonstrate several subcentimeter cysts bilaterally which are stable since [**2187-4-3**]. The intra-abdominal loops of large and small bowel are unremarkable. There is no free fluid or free air. CT PELVIS: The bladder is mildly enlarged. The prostate is markedly enlarged measuring 5.6 x 6.5 cm, unchanged. Seroma in the right inguinal region has resolved. Bone windows demonstrate stable degenerative changes in the lower lumbar spine without evidence of suspicious lytic or blastic lesion. IMPRESSION: 1. 8 weeks post-op from repeat thoracic aortic stent graft with increase in the peri- aortic soft tissue rind and perigraft pockets of air suggestive of infection. Close follow-up is recomended. 2. Markedly enlarged prostate, unchanged. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 94**] DR. [**First Name (STitle) 28783**] [**Name (STitle) 28784**] DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Approved: SAT [**2189-7-4**] 2:07 PM Imaging Lab [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 66714**]TTE (Complete) Done [**2189-7-6**] at 9:42:05 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Hospital1 **] C [**Hospital Unit Name 22682**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2114-8-20**] Age (years): 74 M Hgt (in): 70 BP (mm Hg): 123/57 Wgt (lb): 185 HR (bpm): 70 BSA (m2): 2.02 m2 Indication: Aortic valve disease. ICD-9 Codes: 424.1, 424.0 Test Information Date/Time: [**2189-7-6**] at 09:42 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2008W000-0:00 Machine: Vivid i-3 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 2.7 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.0 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.7 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.9 cm Left Ventricle - Fractional Shortening: 0.31 >= 0.29 Left Ventricle - Ejection Fraction: >= 60% >= 55% Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 12 < 15 Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: *3.7 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.29 Mitral Valve - E Wave deceleration time: 207 ms 140-250 ms TR Gradient (+ RA = PASP): *25 to 27 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [**2187-4-11**]. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or vegetations on aortic valve, but cannot be fully excluded due to suboptimal image quality. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Calcified tips of papillary muscles. Mild (1+) MR. Normal LV inflow pattern for age. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is normal in size. 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 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. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mildly thickened aortic valve leaflets without obvious vegetation. Trace aortic regurgitation. Mild mitral regurgitation. Preserved regional and global LV systolic function. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Compared with the prior study (images reviewed) of [**2187-4-11**], the findings are similar. The prior echo measured the ascending aorta as 4.5cm but this was likely an OVERestimation. Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2189-7-6**] 10:59 Brief Hospital Course: [**2189-7-2**] Patient was admitted initally to medicine then to CT surgery for question of aortic /thoracic stent graft leak versus infection. CTA showed 19 mm rind of soft tissue around descending aorta graft with locules of air that were worrisome for infection. [**2189-7-3**] Vascular surgery consult-recs EGD, bronchoscopy, continue antibiotics per ID, CT surgery consult-recs BP control, bronch, and ID consults-recs vanc/gent/doxy. CTA: 8 weeks post-op from repeat thoracic aortic stent graft with increase in the peri- aortic soft tissue rind and perigraft pockets of air suggestive of infection [**2189-7-4**] CT surgery-arranged for bronchoscopy and EGD to be done on [**2189-7-6**] [**7-5**] No acute events, NPO for bronchoscopy in am. [**7-6**] EGD/Bronch to evaluate for fistula - no fistula, polyp in esophagus [**7-6**] Echo nl LV Fnx EFx >55%, thickened Ao leaflets, trace AR, mild MR, mildly dilated Asc Ao, borderline pulm art htn. [**2189-7-6**] STRESS study- No anginal symptoms or ischemic ST changes. [**7-6**] MIBI Normal mycocardial perfusion study; LVEF 69%. [**7-6**] EGD/Bronch: poylp in esophagus, no fistula, mild LLL infl [**7-7**]: MRI T-L spine: Degenerative changes in the lumbar region with mild-to-moderate spinal stenosis at L2-33 and mild spinal stenosis at L3-4 and L4-5 levels due to disc degenerative changes. No evidence of discitis or osteomyelitis. Other changes as described above. [**7-9**]: OR for Replacement of the descending thoracic aortic stent with a 24-mm Vascutek Dacron tube graft using deep hypothermic circulatory arrest; repair of aortoesophageal fistula as well as aortolung fistula replacement stent, placement intraoperative pacers, went to ICU with 3 CT, J tube, intbuated, started on epicardial pacing (intraop) for complete heart block; started on caspofungin, doxy, gent, vanco, zosyn [**2104-7-8**]: In CV ICU, on epi, neo, intubated, started on nitro for ST depression [**7-12**]: In CVICU extubated, off pressors, started on tube feeds [**7-14**]: remains in heart block, EP consult -> for temp pacer Next several days observed for rhythm recovery, possible PPM. EP,ID, and thoracic continues to follow. Tube feeds at goal. [**7-15**]: CT placed to Water seal, NTG drip weaned to off with ACE-I initiated. Some confusion persists; narcotics minimized with Methadone adjustments. [**7-16**]: PICC inserted, EP recommends temporary pacer- family refused [**7-17**]: transferred to floor, salt tabs for hyponatremia, which would eventually resolve. The pt was found to have a chylothorax, and tube feeds were adjusted accordingly. Temporary pacer was implanted on [**7-21**] with the plan to convert to permanent pacer in [**12-21**] weeks. Remaining chest tubes were discontinued without complication. The patient made progress with physical therapy and was ambulating with minimal assistance before discharge. The patient was discharged to rehab on POD 18 with plans to follow up with cardiology for an internal pacer, and with thoracics for a barium swallow study, and infectious disease for further anti-microbial management. Medications on Admission: Flomax Atenolol methadone, dose? opium hx. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Acetaminophen 160 mg/5 mL Solution Sig: [**11-19**] PO Q4H (every 4 hours) as needed. 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). 10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO QHS (once a day (at bedtime)) as needed. 11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for pain. 12. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Pantoprazole 40 mg IV Q24H 15. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 4 days: through [**7-30**]. 16. Gentamicin 40 mg/mL Solution Sig: Five (5) mL Injection Q24H (every 24 hours) for 4 days: through [**7-30**]. 17. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 19. Ondansetron 4 mg IV Q8H:PRN 20. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 4 days: through [**7-30**]. 21. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO once a day: BEGIN ON [**2189-7-31**]. 22. Caspofungin 50 mg Recon Soln Sig: One (1) Intravenous once a day for 4 days: through [**7-30**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: -s/p Left thoracoabdominal removal of infected aortic stent, placement of Dacron aortic graft, primary repair of iatrogenic esophageal injury, Omental wrap, G and J tubes -[**7-9**] -desc. thoracic ao. ulcer, HTN,BPH, Brucellosis aortitis Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 1504**], and Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 44777**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointments on the same day. Dr. [**Last Name (STitle) 111**] ([**Telephone/Fax (1) 457**]) in the infectious disease clinic, [**2189-8-21**], 9:00am, [**Hospital Unit Name **], [**Last Name (NamePattern1) 439**], basement, [**Location (un) 86**], [**Numeric Identifier 718**] Barium Swallow Study- you will be called for appointment Dr. [**Last Name (STitle) 11482**] [**Name (STitle) 1533**] ([**Telephone/Fax (1) 11763**] call for appt. on the same day as Barium Swallow Study. **if you will require an interpreter for any of the appointments, please request at the time you make the appointment** Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Completed by:[**2189-7-27**]

[ "401.9", "E878.2", "441.2", "530.20", "426.0", "998.0", "457.8", "447.2", "600.00", "998.2", "530.89", "996.62", "023.9", "276.1", "510.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "39.61", "33.22", "38.93", "38.44", "45.13", "45.16", "33.42", "43.19", "42.84", "46.39", "37.78" ]

icd9pcs

[ [ [] ] ]

14764, 14843

9533, 12653

340, 587

15126, 15133

1660, 2189

15647, 16579

1379, 1384

12747, 14741

2229, 2452

14864, 15105

12679, 12724

15157, 15622

1399, 1399

280, 302

2484, 9510

1415, 1637

615, 1012

1034, 1215

1231, 1363

22,624

179,606

43872

Discharge summary

report

Admission Date: [**2118-5-7**] Discharge Date: [**2118-5-12**] Date of Birth: [**2070-8-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12174**] Chief Complaint: Melena Major Surgical or Invasive Procedure: EGD Radiofrequency ablation of liver lesions History of Present Illness: 47 yo man with h/o etoh/HCC cirrhosis, esophageal varices with melena with black emesis and dark tarry stools [**5-6**]. He states the melena started [**5-5**]. He also had some lightheadedness. He notes some abdominal pain during the ambulance ride that improved with zofran. His partner encouraged him to go to the [**Name (NI) **]. At [**Doctor First Name 8125**] hct 37.2. In the ED VS: 98.7 76 117/75 18 99% on 2L NC. He 2L NS. 2 Melenic, guaiac + stools. HR 80, SBP 120, hemodynamically stable. Was initially to go to floor, housestaff uncomfortable. ROS: no wt change, change in abdominal girth, fevers, chills, head ache, chest pain, sob, palpitations, sob, dysuria, hematuria, confusion, rash. Past Medical History: - Etoh/HCV cirrhosis with varices, ascites, and previous episodes of encephalopathy, Last viral load 7,340 IU/mL [**2117-2-26**]. The patient has not had a liver biopsy nor has the patient had any treatment to date for his hepatitis C followed by Dr. [**Last Name (STitle) 497**] (last seen [**4-11**]). EGD [**2115-12-23**] revealing varices at the lower third of the esophagus, with two bands placed, and portal gastropathy. Grade 3 esophageal varices with multiple admissions for GIB, banding in past; last EGD [**9-11**] varices too small to band. - Ethanol abuse with history of DTs: + hallucinations in the past but no intubations or seizures. - h/o Nephrolithiasis. - MVA [**2113-5-4**] with two fractured lumbar vertebrae, torn rotator cuff, and humeral head fracture. - h/o coagulopathy, anemia (baseline Hct ~30), thrombocytopenia - foot surgery - facial reconstruction as a child - leg cramps - asthma - Hep B SAg/sAb negative ; Hep A immune - HIV negative [**2115-7-5**] - AFP 1.81 [**2117-2-4**], U/S [**2117-2-25**] with 1.1cm echogenic focus in left lobe, f/u MRI limited Social History: He has a long history of alcohol abuse (since high school). currently drinking a pint of vodka per day with some mixed drinks, last drink [**5-6**] am. He has a history of DTs, no seizures or intubations for this but + hallucinations. He currently smokes less than a pack per day and has smoked 30+ years. He is unemployed but used to work as a carpenter. He has a history of IVDU (cocaine and heroin) but last use 15 years ago. He has a history of incarceration in the past. Family History: He does not know of any liver disease or colon cancer. Father with a history of alcoholism Physical Exam: VS: T 97.9 HR 89 BP 129/82 RR 24 Sat 93% on RA GEN: NAD HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: protuberant, soft, NT, ND, + BS, no obvious HSM on percusion, ? small fluid wave, no caput EXT: warm, dry, +2 distal pulses BL, no femoral bruits Skin: spider angiomas on chest, scattered [**Last Name (LF) 94195**], [**First Name3 (LF) **] damage NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis. PSYCH: appropriate affect, no anxiety, tremulousness, diaphoresis Pertinent Results: Admission labs: [**Age over 90 **]|105|10 -----------<128 3.7|25|0.6 Ca: 7.5 Mg: 1.3 P: 2.6 ALT: 38 AP: 124 Tbili: 4.9 Alb: 2.3 AST: 111 . 11.8 7.5>--<152 33.9 PT: 19.6 PTT: 35.6 INR: 1.8 Fibrinogen: 256 D EGD: no actively bleeding vessels (please see full report in OMR for further details) Radiofrequency ablation: 1. Successful radiofrequency ablation of the patient's liver tumor. [**2118-5-12**] 05:45AM BLOOD WBC-6.0 RBC-2.72* Hgb-10.1* Hct-28.6* MCV-105* MCH-37.1* MCHC-35.2* RDW-17.0* Plt Ct-91* [**2118-5-12**] 05:45AM BLOOD Plt Ct-91* [**2118-5-12**] 05:45AM BLOOD Glucose-169* UreaN-8 Creat-0.6 Na-130* K-3.4 Cl-96 HCO3-29 AnGap-8 [**2118-5-12**] 05:45AM BLOOD ALT-29 AST-92* LD(LDH)-276* AlkPhos-107 TotBili-3.6* [**2118-5-12**] 05:45AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.4* Brief Hospital Course: 46 yo man with alcoholic cirrhosis, known esophageal varices admitted with melena and emesis. The patient was hemodynamically stable throughout his admission. He had no further episodes of melena during this hospital course. The patient was initially maintained with two large bore IVs with a plan to transfuse for a hematocrit less than 28. He had an EGD which did not demonstrate any actively bleeding lesions. The patient was actively drinking prior to admission. Although he denied a history of withdrawal seizures he was tachycardic, hypertensive and nauseated on admission. He was maintained on a q2 hour CIWA scale, with decreasing benzo requirements throughout his admission. The patient was also maintained on thiamine, folate and a multivitamin. His clonidine was discontinued on admission and restarted once the patient was called out to the floor. The patient has a coagulopathy secondary to his chronic cirrhosis. His disease is secondary to ETOH with HCC, and he is followed by Dr. [**Last Name (STitle) 497**]. His disease is complicated by portal hypertension, hypertensive gastropathy, esophageal varices s/p banding and melena in the past, as well as ascites, thrombocytopenia, anemia, and coagulopathy. His medications were initially held but once it was clear the patient was not actively bleeding, his nadolol, furosemide, spironolactone and lactulose were restarted. The patient had a stable thrombocytopenia. He did receive FFP prior to a planned RFA for three liver lesions. The procedure went well and the patient was discharged the following day. The patient was continued on his outpatient pain regimen of Neurontin and a lidocaine patch. He also had a chronic stable anemia which was macrocytic, likely multifactorial given GIB, EtOH use and liver disease. Vitamin B12 1787 [**4-12**], folate 11.8 [**4-12**]. The patient was a full code throughout this admission. Communication was as follow: mother [**Name (NI) **] (HCP) [**Telephone/Fax (1) 94196**], Partner [**Name (NI) **] (h) [**Telephone/Fax (1) 94197**], (c) [**Telephone/Fax (1) 94198**]. Medications on Admission: Pt poor historian, unable to verify meds Clonidine 0.1 mg PO TID Fluticasone 50 mcg/Actuation Nasal [**Hospital1 **] Folic Acid 1 mg PO DAILY Furosemide 40 mg PO DAILY Gabapentin 300 mg PO Q8H Lactulose 10 gram/15 mL ThirtyML PO four times a day - only takes when constipated Nadolol 40 mg PO DAILY Pantoprazole 40 mg PO Q24H - states [**Hospital1 **] Ferrous Sulfate 325 mg PO DAILY Hexavitamin PO DAILY - not likely taking Thiamine HCl 100 mg PO DAILY Lidocaine 5 %(700 mg/patch) Topical DAILY Spironolactone 100 mg PO DAILY Nicotine 21 mg/24 hr Transdermal DAILY Discharge Medications: 1. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 7. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on for 12, off for 12 hours. 12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: Alcoholic cirrhosis GI bleed Secondary: HCV Liver lesions Asthma Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital with concern for gastrointestinal bleeding. While you were in the hospital, you had an EGD which did not demonstrate any actively bleeding vessels. You also had radiofrequency ablation of the lesions in your liver. Your blood counts have been stable since your admission to the hospital. Please take all of your medications as prescribed. Please call your physician or come to the emergency room with anyfevers, vomiting, blood in your stool or your vomit, confusion or other symptoms you find concerning. Followup Instructions: Please call [**Telephone/Fax (1) 250**] to schedule an [**Telephone/Fax (1) 648**] with your primary care doctor to follow up after discharge. Please call the Liver Center at ([**Telephone/Fax (1) 1582**] to set up an [**Telephone/Fax (1) 648**] with Dr. [**Last Name (STitle) 497**] within several weeks of discharge.

[ "281.9", "572.3", "719.41", "571.2", "287.5", "V13.01", "537.89", "155.0", "578.1", "070.70", "787.01", "305.1", "493.90", "291.81", "286.9", "456.21" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.13", "94.62", "99.07", "50.24" ]

icd9pcs

[ [ [] ] ]

8123, 8129

4387, 6484

321, 368

8247, 8256

3569, 3569

8849, 9172

2725, 2817

7101, 8100

8150, 8226

6510, 7078

8280, 8826

2832, 3550

275, 283

396, 1103

3585, 4364

1125, 2215

2231, 2709

49,315

122,228

11141

Discharge summary

report

Admission Date: [**2200-9-17**] Discharge Date: [**2200-9-21**] Date of Birth: [**2142-5-30**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Aortic regurgitation Major Surgical or Invasive Procedure: [**2200-9-17**] Aortic valve replacement with a [**Street Address(2) 17009**]. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**] tissue valve, serial #[**Serial Number 35898**], reference number [**Serial Number 35899**]. History of Present Illness: 57M was sent for echo after his PCP heard [**Name Initial (PRE) **] systolic murmur. Echo demonstrated aortic stenosis/aortic regurgitation, possibly secondary to a bicuspid valve. Pt was asymptomatic wtih rare episodes of palpitations and occasional episodes of postural lightheadedness that resolve spontaneously within seconds. Catheterization demonstrated severe AR and normal coronary arteries. Past Medical History: Aortic stenosis/regurgitation Left ventricular hypertrophy, Heart murmur Hypertension Hyperlipidemia Diabetes mellitus type 2 (newly diagnosis ed [**3-/2200**]) S/P remote MVC with injury to liver as child Left shoulder pain (going to PT with improvement) Hemorrhoids Social History: Race: Caucasian Last Dental Exam: 2 months ago, he will have dental clearance faxed to office Lives with: Wife Contact: [**Name (NI) **] [**Name (NI) **] (wife) Phone# [**Telephone/Fax (1) 35900**] Occupation: Works in office Cigarettes: Smoked no [] yes [X] Hx: Quit tobacco 13 years ago, smoked for 25 years 1-2ppd Other Tobacco use: [**1-6**] cigar weekly ETOH: [**1-6**] glasses wine couple times per week Illicit drug use: Denies Family History: Father with diabetes and ESRD, eventually died of MI at age 56. Sister with bicuspid aortic valve. Daughter with murmur and dilated cardiomyopathy at birth. Physical Exam: VSS Height:6' Weight:200 lbs General: Well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [x] 2/6 systolic 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 [X] Pulses: Femoral Right: p Left: p DP Right: p Left: p PT [**Name (NI) 167**]: p Left: p Radial Right: p Left: p Carotid Bruit Right: - Left: - Pertinent Results: [**2200-5-14**] cardiac cath: 1. Selective coronary angiography of this right dominant system demonstrated no epicardial coronary artery disease. The LMCA, LAD, LCx, and RCA were without angiographically apparent flow-limiting stenosis. 2. Limited resting hemodynamics revealed systemic arterial normotension with central aortic pressure of 117/59 mmHg. There were normal left and right-sided filling pressures with LVEDP of 10 mmHg, PCWP mean of 5 mmHg, and RVEDP of 7 mmHg. 3. Supravalvular aortogram showed severe aortic regurgitation, a dilated left ventricle, and moderately reduced LVEF. [**2200-9-17**] echo: Pre-Bypass: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is mild global left ventricular hypokinesis (LVEF = 45-50 %). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There are simple atheroma in the ascending aorta, aortic arch, and descending thoracic aorta. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. There is no aortic valve stenosis. Moderate to severe (3+) aortic regurgitation is seen. Vena contracta 0.46cm. Pressure [**1-6**] time 359msec. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post-Bypass: Patient is on a phenylephrine infusion s/p AVR. There is a well seated #25 bioprosthetic aortic valve. There is no evidence of a perivalvular leak. There is trace central AI. Peak/mean gradients are measured at 21/11mm/Hg with a cardiac output of 8.5. Left ventricular function is preserved with an estimated EF-50%. No wall motion abnormalities are noted. Trace MR [**First Name (Titles) **] [**Last Name (Titles) 1506**]. There is no echocariographic evidence of an aortic dissection post-decannulation. The remainder of the exam is [**Last Name (Titles) 1506**]. CXR [**2200-9-19**]: There is still some enlargement of the cardiac silhouette with left effusion and atelectatic changes at both bases. No vascular congestion. On the lateral view, there is gas in the region of the retrosternal tissues, presumably related to the recent surgery. No evidence of pneumothorax. [**2200-9-20**] WBC-10.7 RBC-3.99* Hgb-12.0* Hct-35.7* MCV-89 MCH-30.1 MCHC-33.7 RDW-13.5 Plt Ct-108* [**2200-9-21**] Glucose-114* UreaN-16 Na-136 K-4.1 Cl-100 HCO3-29 [**2200-9-17**] UreaN-18 Creat-1.0 Na-145 K-4.5 Cl-111* HCO3-29 [**2200-9-21**] Mg-2.3 [**2200-9-17**] MRSA SCREEN (Final [**2200-9-19**]): No MRSA isolated. Brief Hospital Course: Mr. [**Known lastname **] on [**2200-9-17**] underwent Aortic valve replacement with a [**Street Address(2) 17009**]. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**] tissue valve, serial #[**Serial Number 35898**], reference number [**Serial Number 35901**]. Postoperatively, he was admitted to the CVICU, where he was successfully extubated and weaned off pressors. On POD 1, he was transferred to the floor and his chest tubes were removed. A beta blocker was started. On POD 2, his pacing wires were remmoved. He was gently diuresed toward his preop weight. He was seen by PT and cleared for d/c home. On POD 4 he was discharge to home with [**Location (un) 86**] VNA. He was hemodynamically stable, ambulating, tolerating a PO diet, and his pain was controlled with PO medication. He will follow-up as an outpatient. Medications on Admission: ATORVASTATIN 10 mg Daily LISINOPRIL 20 mg Daily GINKGO BILOBA [GINKGO] 2 tablets daily MULTIVITAMIN 1 tablet daily Discharge Medications: 1. Atorvastatin 10 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Acetaminophen 325-650 mg PO Q4H:PRN pain/temp 4. Aspirin EC 81 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain RX *hydromorphone 2 mg [**1-6**] tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 7. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*2 8. Lisinopril 10 mg PO DAILY RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: aortic regurgitation Hypertension Hyperlipidemia Diabetes mellitus type 2 (newly diagnosis ed [**3-/2200**]) Left ventricular hypertrophy Heart murmur S/P remote MVC with injury to liver as child Left shoulder pain (going to PT with improvement) Hemorrhoids Past Surgical History: None Past Cardiac Procedures: None Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Shower daily including washing incisions gently with mild soap, no baths or swimming NO lotions, cream, powder, or ointments to incisions Daily weights: keep a log No driving for approximately one month and while taking narcotics No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**],Date/Time:[**2200-9-25**] 10:00 in the [**Hospital **] Medical Building [**Last Name (NamePattern1) **] Surgeon Dr. [**Last Name (STitle) **], [**2200-10-23**] 1:45, [**Telephone/Fax (1) 170**] in the [**Hospital **] Medical Building [**Last Name (NamePattern1) **] Please call to schedule the following: Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**4-10**] weeks Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 8506**] in [**4-10**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2200-9-21**]

[ "272.4", "424.1", "401.9", "746.4", "V15.82", "250.00", "429.3" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

7059, 7108

5442, 6293

331, 578

7468, 7624

2557, 5419

8109, 8946

1769, 1928

6459, 7036

7129, 7387

6319, 6436

7648, 8086

7410, 7447

1943, 2538

271, 293

606, 1008

1030, 1300

1316, 1753

22,677

130,874

5175

Discharge summary

report

Unit No: [**Unit Number 21167**] Admission Date: [**2171-2-13**] Discharge Date: [**2171-2-26**] Date of Birth: [**2108-10-29**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 62-year-old gentleman who was admitted to the transplant surgical service with abdominal pain. He was seen at an outside institution with a history of bacterial peritonitis over the month of [**Month (only) 1096**] related to his peritoneal dialysis. His PD catheter was malfunctioning on [**2-8**] and it was removed and replaced. During this time, he was converted to hemodialysis. A repeat CT scan performed on [**2-13**] demonstrated evidence of small amount of free air and he was transferred to [**Hospital1 **] for further medical evaluation. HOSPITAL COURSE: Upon reviewing his CT scan and reviewing his clinical examination, he was taken to the operating room where he was identified as having mesenteric ischemia. Extensive gangrenous changes were noted in the terminal ileum and right colon and then generally ischemic changes out the entire small bowel on the antimesenteric border. He underwent a right colectomy and terminal ileectomy and we left the bowel ends closed. He was then taken emergently to the angiography suite where he underwent stenting of his SMA. He was returned to the operating room on the 11th where he underwent a second look laparotomy and the small bowel was much improved. He underwent an enteroenterostomy and closure of the abdominal cavity. He recovered nicely from this and was managed with aspirin and Plavix. Over the course of his first hospital week, he did demonstrate a rising white count. He underwent a CT of the abdomen on the 20th which was looking to evaluate for a source of his increasing white blood cell count. He was found to have a small amount of free air within the abdomen but patent stent and some thickening in the small bowel and stomach concerning for mesenteric ischemia. Over the next 48 hours, his white count continued to climb. He was taken back to surgery on the day after the CT scan for exploratory laparotomy by Dr. [**Last Name (STitle) 816**]. He did not. There was no evidence of mesenteric ischemia. The bowel was thickened but did not demonstrate any gangrenous changes. There was some "turbid fluid" within the abdomen and this was suctioned and lavaged. The anastomosis was intact. On the morning of [**2-26**], the patient was found unresponsive with posturing of his upper extremities. He was sent for an emergent head CT that demonstrated a large parenchymal hemorrhage with mass effect and herniation. This was not believed consistent with survival. Neurosurgery consultation was obtained. He was made CMO and expired later that day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern4) 3433**] MEDQUIST36 D: [**2171-7-30**] 18:45:48 T: [**2171-7-30**] 19:29:58 Job#: [**Job Number 21168**]

[ "285.9", "432.9", "403.91", "567.22", "571.5", "348.4", "345.90", "070.54", "997.02", "998.59", "585.6", "557.0" ]

icd9cm

[ [ [] ] ]

[ "39.90", "54.59", "96.71", "00.40", "45.62", "54.62", "99.15", "45.91", "00.45", "38.95", "96.04", "39.95", "88.47", "88.42", "39.50" ]

icd9pcs

[ [ [] ] ]

777, 2999

177, 759

21,256

149,059

43400

Discharge summary

report

Admission Date: [**2109-6-20**] Discharge Date: [**2109-6-25**] Date of Birth: [**2055-8-22**] Sex: F Service: MICU/GREEN HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 53 year-old female with a complicated past medical history notable for recurrent enterocutaneous fistula, and cirrhosis on chronic total parenteral nutrition who had a three month hospital stay at the [**Hospital1 69**] completed on [**2109-6-13**] on the surgical service after an attempted fistula repair with the hospital course complicated by MRSA bacteremia and pseudomonal urinary tract infection. She was discharged to [**Hospital **] [**Hospital **] Hospital and returns on [**6-20**] with hypertension, fever and pus draining from her right internal jugular catheter, which is being used for chronic total parenteral nutrition. PAST MEDICAL HISTORY: 1. Status post appendectomy. 2. Cholecystectomy at age 15. 3. Multiple exploratory laparotomies. 4. Cirrhosis questionable etiology. 5. Multiple enterocutaneous fistulas. 6. Splenomegaly. 7. Thrombocytopenia. 8. Several deep venous thromboses status post [**Location (un) 260**] filter. 9. Peptic ulcer disease. 10. Chronic abdominal pain. 11. Question Munchausen syndrome. MEDICATIONS ON TRANSFER: 1. Ursodiol 300 mg po t.i.d. 2. Spironolactone 200 mg po q.d. 3. Hydroxy 25 mg po t.i.d. 4. Trazodone 25 mg po q.d. 5. Lansoprazole 30 mg po q.d. 6. Iron gluconate 325 mg po q.d. 7. Regular insulin sliding scale. 8. Dilaudid 1 mg po q 2 hours prn pain. ALLERGIES: 1. Intravenous dye, no fistulogram has ever been done, because of the allergy to intravenous contrast. 2. Compazine. 3. Benzodiazepines. 4. Local non-steroidal anti-inflammatory drugs except for Marcaine. 5. Betadine. 6. Sulfa. Reactions are uncertain. SOCIAL HISTORY: She denied any alcohol abuse. Long history of tobacco use. Still currently smoking. PHYSICAL EXAMINATION: On presentation in the MICU the patient had the following vital signs, temperature 99.4. Pulse 98 and regular. Blood pressure 112/34 on Levophed. Respirations 22. Sating 99% on 2 liters nasal cannula. General, jaundiced woman lying supine in no acute distress. HEENT icteric. Oropharynx dry with dry mucous membranes and dried blood on her tongue. Neck was supple. The right IJ site was nontender, nonerythematous. No jugulovenous distention. Cardiovascular tachycardic, irregular, III/VI systolic murmur at the left sternal border radiating to the axilla. No rubs or gallops. Lungs decreased breath sounds right lower lobe. Abdomen: She has a two prominent fistula sites both midline and infraumbilical. The superior one is surrounded by an area of ulcer roughly 4 by 5 cm with granulation tissue. The fistula is draining a large amount of bilious guaiac positive fluid. The belly was nondistended, diffusely tender to palpation greatest in the epigastrium. There is no rebound or guarding. She had 2+ pitting edema in bilateral feet. Neurological lethargic, oriented only to person. Extraocular movements intact. No facial asymmetry. She is moving all extremities symmetrically. Sensation is grossly intact. She has a flap and her deep tendon reflexes were 2+ and symmetric throughout. Her urinalysis was notable for the presence of feculent material. LABORATORY: White blood cell count on admission was 8.0 with a hematocrit of 31.5, platelets 39, polys 88%, bands 9%, lymphocytes 0%, monocytes 3%. [**Name (NI) 2591**] PT 19.2, PTT 69.1. Urinalysis was 1.011, cloudy, large blood, positive nitrite, trace protein, negative ketone, large bilirubin, moderate leukocyte esterase, 2 to 5 reds and 11 to 20 white blood cells, many bacteria, but 6 to 10 epi. Sodium 137, K 3.5, chloride 104, bicarb 21, BUN 71, creatinine 1.6, baseline is roughly 1.1. Glucose 108. Calcium 9.2, mag 2.1, phos 2.8, ALT 66, AST 104, alkaline phosphatase 110, amylase 27, Cortisol 26.3. Blood cultures one out of four bottles of MRSA and right IJ tip grew MRSA. Bilirubin 30.7 on admission and rose to 37.5 with direct 26.1 and indirect 11.4. She had a urine sodium less then 10 and a FENA .10. Urine creatinine 64. The patient had urine cultures times two from Foley specimen both showing multiple species of bacteria consistent with fecal contamination. The patient had an echocardiogram of the heart which demonstrated an ejection fraction of roughly 75% with no vegetations. The patient also had a renal ultrasound that showed a right kidney at 13.9 cm, left kidney 10.5 cm, no evidence of hydro or stones. Clinically limited due to body habitus. The patient's electrocardiogram on admission was notable for sinus tachycardia at 108, normal axis and normal intervals, biphasic T waves in V4 and V5. No ischemic changes. She had a chest x-ray, which showed no pulmonary vascular congestion, effusions or pneumothorax. The retrocardiac density that was seen on the prior film was clear. There was a persistent hazy opacity at the right base improved in the interval with atelectasis versus infiltrate with a differential diagnosis. On the day of discharge the patient's laboratories were as follows: White blood cell count 4.8, hematocrit 33.3, platelets 28, PT 20.0, PTT 55.2 and INR 2.6. Sodium 137, K 3.5, chloride 103, bicarb 23, BUN 75, creatinine 1.9, glucose 94. Calcium 6.7, mag 2.6, phos 3.9. Vanco level is 28.1. HOSPITAL COURSE: 1. Infectious disease: The patient presented with hypertension and a systolic blood pressure of 80 and a fever of 103.4. She was subsequently grew Methicillin resistant Staphylococcus aureus from her right IJ site and blood bottle. Her sepsis due likely to this organism from lack of contamination. She was treated with Vancomycin dose for a planned 14 day course with the last day of treatment [**2109-7-3**]. After two days she became afebrile and her norepinephrine drip was weaned. She also grew out fecal organisms in her urine, suspect a Foley specimen likely from enterovesicular fistula. She should not receive antibiotics through the course unless culture data demonstrates infections with persistent colonization. 2. Cardiovascular: The patient's hypertension resolved after two days of antibiotics and support with norepinephrine. Her blood pressure remained around 95/40 likely due to her underlying liver disease. However, at this blood pressure the patient had persistent urine output at greater then 30 cc an hour. 3. Gastrointestinal: The patient had multiple recurrent high output enterocutaneous fistula now with a new enterovesicular fistula, not a surgical candidate. She requires chronic total parenteral nutrition and intravenous fluids to keep up the high output of her fistula. She remains NPO. She has a double lumen PICC placed for total parenteral nutrition and intravenous fluids. She has a history of cirrhosis which is unclear. This was stable during her hospital stay. The liver service has arranged for her to be seen at the liver clinic as an outpatient for liver biopsy to work up the cirrhosis. The patient also has chronic abdominal pain and was continued on her prior dose of Dilaudid 2 mg q 2 to 4 hours prn for pain. Her abdominal pain was stable during her hospital stay and no further workup was initiated. 4. Renal: The patient presented with acute renal failure and was seen by the renal service who felt this was primary due to ATN from her hypertension. She had no indication for dialysis. Her creatinine remained elevated above her baseline and at discharge was 1.9. However, there is no indication for hemodialysis. Her renal function should be monitored on a regular basis and her medications should be dosed accordingly. 5. Neurological: The patient remained disoriented, but able to answer questions appropriately. Her confusion likely results from both her uremia and her hepatic encephalopathy. Lactulose was not used given the modest output from the fistula. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: Back to [**Hospital1 **]. DISCHARGE DIAGNOSES: 1. MRSA sepsis. 2. Cirrhosis of unknown etiology. 3. Enterocutaneous enterovesicular fistulas. 4. Acute renal failure. 5. On chronic total parenteral nutrition. 6. Hepatic encephalopathy. DISCHARGE MEDICATIONS: 1. Vancomycin 1 gram q 12 hours to q 24 hours to be dosed for levels of less then 15 on a daily basis. 2. Hydroxyhemin 25 mg po q 8 hours prn. 3. Octreotide 100 micrograms subq b.i.d. 4. Trazodone 25 mg po q.h.s. prn. 5. Ferrous gluconate 300 mg po q.d. 6. Oxybutynin 5 mg po b.i.d. 7. Regular insulin sliding scale q.i.d. 8. Miconazole powder 2% to the groin b.i.d. 9. Dilaudid 2 to 4 mg intravenous q 2 hours prn pain. 10. Ursodiol 300 mg po t.i.d. FOLLOW UP PLANS: The patient is to call the liver clinic here at [**Hospital1 69**] at [**Telephone/Fax (1) 2422**] to confirm an appointment to hve her liver biopsied. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 8038**] Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2109-6-25**] 01:43 T: [**2109-6-28**] 12:30 JOB#: [**Job Number 93406**]

[ "569.81", "584.5", "571.5", "707.0", "996.62", "038.11", "572.2", "276.5", "596.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

8045, 8240

8263, 9170

5399, 7946

1932, 5382

168, 838

1271, 1805

860, 1246

1822, 1909

7971, 8024

21,233

197,446

28828

Discharge summary

report

Admission Date: [**2172-3-14**] Discharge Date: [**2172-3-24**] Date of Birth: [**2094-6-12**] Sex: M Service: SURGERY Allergies: Lorazepam Attending:[**First Name3 (LF) 2597**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: Drainage of peripancreatic fluid collections Swan-Ganz catheter placement History of Present Illness: Mr. [**Known lastname **] is a 77 year old man who presented to [**Hospital1 18**] 25 days after undergoing a femoral-bipopliteal bypass graft of an abdominal aortic aneurysm. with fevers to 102F and chills. Past Medical History: PMH: afib, GERD; echo [**10-8**] EF 55%, biatrial enlargement; stress [**10-8**] inf wall reversible defect, EtOH abuse Social History: Remote smoker, quit 10 years ago ETOH daily. Quit ETOH 2 weeks prior to surgery. Family History: N/C Wife and children RN Physical Exam: On Admission: Vitals: 104.0 F, HR 102, BP 125/76, RR 27, O2 sat 100% 2L Mucous membranes moist Tachycardic, regular Decreased breath sounds at the bases Abdomen is obese, soft, with RUQ tenderness to palpation., minimal lower abdominal discomfort. VAC in place in the lower portion of the abdominal wound. Good granulation tissue noted on removal of VAC sponge. Bilateral groins incision sites clean, no discharge Bilateral lower extremity edema Right calf rash - psoriatic per patient Rectal: normal tone, guiac negative Pertinent Results: [**2172-3-14**] 09:40PM WBC-20.6*# RBC-3.71* HGB-12.0* HCT-35.3* MCV-95 MCH-32.3* MCHC-34.0 RDW-13.7 [**2172-3-14**] 09:40PM NEUTS-83* BANDS-3 LYMPHS-4* MONOS-2 EOS-1 BASOS-0 ATYPS-7* METAS-0 MYELOS-0 NUC RBCS-1* [**2172-3-14**] 09:40PM PT-18.3* PTT-29.2 INR(PT)-1.7* [**2172-3-14**] 09:40PM GLUCOSE-111* UREA N-11 CREAT-0.7 SODIUM-133 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14 [**2172-3-14**] 09:40PM ALT(SGPT)-45* AST(SGOT)-29 CK(CPK)-29* ALK PHOS-168* AMYLASE-30 TOT BILI-0.6 [**2172-3-14**] 09:40PM LIPASE-37 RADIOLOGY: [**3-14**]: CT Abdomen/Pelvis 1. Ahaustral colon filled with fluid; findings are nonspecific but can be seen in C. difficile colitis. Please correlate clinically. 2. Multiple peripancreatic fluid collections more coalescent since the last examination. 3. Evidence of aortofemoral bypass, without leak. 4. Similar appearance of renal lesions. 5. Similar appearance of bilateral lower lobe atelectasis. [**3-14**]: U/S liver/gallbladder Small amount of fatty sparing around the gallbladder. [**3-14**]: CXR Linear atelectasis/scarring in the left lung base. PA and lateral is recommended for better characterization. [**3-16**]: Echocardiogram LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. No resting LVOT gradient. RIGHT VENTRICLE: Borderline normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Minimally increased gradient c/w minimal AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate [[**2-4**]+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular systolic function is borderline normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. [**3-16**]: CXR Swan-Ganz catheter remains in place, but distal tip is difficult to visualize due to technical factors of the examination. Cardiac silhouette is enlarged but stable. Aorta remains tortuous. There has been decrease in degree of pulmonary vascular engorgement and perihilar haziness, consistent with resolving interstitial edema. Patchy and linear opacity in the left lower lung region has similar appearance to earlier radiograph dating back to [**2172-2-3**] and favors an area of atelectasis over an infectious consolidation [**3-17**]: CXR Lateral aspect of the left lower chest is excluded from the examination as the patient is turned to the right. Interstitial edema has worsened. Severe left mid lung atelectasis is more pronounced. Moderate enlargement of the heart and distension of mediastinal vessels is exaggerated by patient positioning. Tip of the right jugular sheath is at the junction of the brachiocephalic veins transmitting a catheter that can be traced as far as the right atrium, but is obscured more distally. No pneumothorax. [**3-20**]: CXR Right PICC line tip is seen in the cavoatrial junction. Discoid atelectasis in the left lower lobe are unchanged. There is no pleural effusion. There is no pneumothorax. Cardiac size top normal. CULTURES: [**3-14**]: Urine CX: Skin contamination [**3-14**]: Blood Cx: Negative [**3-15**]: Abdominal swab: MRSA [**3-15**]: Urine Cx: Negative [**3-15**]: C. diff: Negative [**3-15**]: Abdominal fluid: Negative [**3-16**]: Blood Cx (x2): Negative [**3-16**]: C. diff: Negative [**3-17**]: C. diff: Negative Brief Hospital Course: Mr. [**Known lastname **] was admitted to [**Hospital1 18**] after experiencing fevers at home, 25 days after undergoing an aorto-bifemoral graft repair of an abdominal aortic aneurysm. A course of Vancomycin, Zosyn, and Flagyl was instituted. He was initally admitted to the vascular surgery floor, but was transferred to the Surgical Intensive Care Unit after a CT scan demonstrated a peripancreatic fluid collection that was thought to be the etiology of these fevers and he demostrated blood pressure instability. While in the ICU initially, he required pressor support to maintain a systolic blood pressure over 100 mmHg. On HD3, to more accurately assess his volume and cardiac status, a Swan-Ganz catheter was placed. His Dopamine drip was weaned off. His abdominal wound was packed with damp gauze. On HD4, he also had the peri-pancreatic fluid collection drained. On HD5, he was transferred out of the SICU, and back to the [**Hospital1 **]. On HD6, input from Infectious disease was requested, and Mr. [**Known lastname **] antibiotic course was determined to be 4 weeks or Vancomycin and Zosyn. A PICC line was placed and his central line was removed. Diuresis was continued, and he remained stable. Due to elevated blood glucose and the peri-pancreatic fluid collection, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was requested to evaluate whenther Mr. [**Known lastname **] might need home insulin. Discharge planned for home with VNA for VAC care, PICC care, IV antibiotics and physical therapy. He will continue on Vanco and Zosyn for an additional 18 days for a total of 4 weeks. Labs weekly will be obtained and faxed to [**Hospital **] clinic. He will follow up with both ID and Dr. [**Last Name (STitle) **]. Medications on Admission: Lasix 20mg daily Potassium Chloride 20 meq daily Lopressor 50 mg TID Coumadin 6.5 mg daily MVI Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg mg Intravenous Q 12H (Every 12 Hours) for 18 days: Check through weekly and fax to [**Hospital **] clinic [**Telephone/Fax (1) 432**]. Disp:*36 1* Refills:*0* 3. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 g Intravenous Q8H (every 8 hours) for 18 days. Disp:*QS * Refills:*0* 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*QS * Refills:*0* 6. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime): As directed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 3183**]. Disp:*50 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Packet Sig: Three (3) PO once a day. Disp:*90 packets* Refills:*2* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 9. Outpatient Lab Work Please check Vancomycin trough prior to the AM dose on [**2172-3-25**]. Call or fax results to [**Hospital **] clinic (phone [**Telephone/Fax (1) 14774**], fax [**Telephone/Fax (1) 432**]) Please check CBC, BUN, Creatinine, Potassium, LFTs and Vanco through weely. Fax results to [**Telephone/Fax (1) 432**]: [**Hospital **] Clinic) Please check PT/INR weekly and send results to Primary Care MR- Dr. [**Last Name (STitle) **] (manages anticoagulation) [**Telephone/Fax (1) 3183**] 10. PICC line PICC line care per CCS protocol Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Fever, CT abdomen [**3-15**] - fluid collection around the pancreas PMH: afib, GERD; echo [**10-8**] EF 55%, biatrial enlargement; stress [**10-8**] inf wall reversible defect, EtOH abuse PSH: s/p Aortobifem [**2-18**] for 6.3cm infrarenal AAA Discharge Condition: Good INR 1.6 Discharge Instructions: Please call the Vascular Surgery office or return to the Emergency Room if you experience: --Fever greater than 101.5 F --Fever with shaking chills --Increasing pain, redness, or discharge from your incision sites --Foul smelling drainage from your incision sites --Blue toes --Any other concerns Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in [**2-4**] weeks. You may call his office at [**Telephone/Fax (1) 3121**]. Follow up [**Hospital **] Clinic- [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2172-4-6**] at 1145am. [**Hospital Unit Name 3269**]-Basement. RN Phone: [**Telephone/Fax (1) 14774**] Clinic phone [**Telephone/Fax (1) 457**] Fax: [**Telephone/Fax (1) 457**] Completed by:[**2172-3-24**]

[ "E878.2", "428.0", "427.31", "996.62", "305.01", "530.81", "458.9", "998.31" ]

icd9cm

[ [ [] ] ]

[ "54.91", "38.93", "38.91", "89.62", "89.64" ]

icd9pcs

[ [ [] ] ]

9482, 9553

5961, 7732

276, 352

9841, 9856

1432, 5938

10201, 10633

847, 873

7877, 9459

9574, 9820

7758, 7854

9880, 10178

888, 888

230, 238

380, 589

902, 1413

611, 732

748, 831

15,450

183,819

13469

Discharge summary

report

Admission Date: [**2145-1-5**] Discharge Date: [**2145-1-11**] Date of Birth: [**2083-3-26**] Sex: M Service: Vascular Surgery HISTORY OF PRESENT ILLNESS: Patient is a 60-year-old male, who presents with symptoms of near syncopal episodes since [**2144-12-15**] with progression of frequency of the symptoms for the one week prior to admission. Symptoms constitute near syncopal episodes less than 15-20 seconds while sitting up to eat, but denies loss of consciousness with the episodes. Episodes are associated with weakness in the right hand and a new left hand tremor. Patient also experienced episodes with standing and limited ambulation complaining of extreme dizziness and falling towards the right. Episodes have been increasing in frequency for seven days prior to admission approximately at 2-3x/day. Past carotid ultrasounds demonstrated a right carotid artery disease of 65%, a left carotid disease with plaque at the origin of the ICA and common carotid artery. PAST MEDICAL HISTORY: 1. Coronary artery disease status post MI in [**2135**]. 2. Congestive heart failure with an EF of 30%. 3. Diabetes mellitus type 2. 4. Obesity. 5. Peripheral vascular disease. 6. Osteoarthritis. 7. Chronic anemia. 8. Mitral regurgitation. 9. Rheumatoid arthritis. 10. Dyslipidemia. PAST SURGICAL HISTORY: 1. CABG in [**2135**]. 2. Right fem-[**Doctor Last Name **] bypass in [**2137**]. 3. Left below the knee amputation. 4. Cholecystectomy. 5. Bilateral carpal tunnel release. 6. Lumbosacral laminectomy x2. 7. Multiple cardiac catheterizations with stent placements. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q.d. 2. Prilosec 20 mg p.o. b.i.d. 3. Iron sulfate 325 mg p.o. b.i.d. 4. Methotrexate 2.5 mg p.o. q.5. days. 5. Folic acid 1 gram p.o. q.d. 6. Digoxin 0.125 mg p.o. q.d. 7. Procrit 40,000 units subQ q week. 8. Lipitor 10 mg p.o. q.d. 9. Imdur 60 mg p.o. q.d. 10. Prednisone 5 mg p.o. q.d. 11. Lasix 10 mg p.o. q.d. 12. Insulin 70/30 6 units q.a.m. and q.p.m. 13. Plavix 75 mg p.o. q.d. 14. Diovan 80 mg p.o. q.d. 15. Meridia 10 mg p.o. q.d. 16. Multivitamins. PHYSICAL EXAMINATION: On physical exam, patient is an obese male in no apparent distress alert and oriented times three. Head was normocephalic, atraumatic with no scleral icterus. Neck was large, soft, and supple. No masses noted. Bilateral carotid bruits. Chest was clear to auscultation bilaterally. Heart was regular rate and rhythm with a 3/6 systolic ejection murmur at the base with no radiation. Abdomen was obese, nontender, and nondistended. Bowel sounds x4 and no pulsatile mass noted. Rectal examination was guaiac negative. Extremity examination was significant for well-healed scars on the legs and a well-healed sternotomy scar. Pulse examination was significant for 1+ carotid pulses bilaterally with carotid bruits. Radial pulses were dopplerable bilaterally. Femoral pulses were 2+ on the right and dopplerable on the left. Extremity pulses: Right graft was palpable, 3+, and DP and PT were dopplerable. SUMMARY OF HOSPITAL COURSE: Patient was admitted to the Vascular Surgery service, Dr. [**Last Name (STitle) 1391**] attending, and was scheduled for bilateral carotid ultrasound. It was also noted on admission that the patient's fingerstick glucose levels ranging between 280 and 400 were very poorly controlled. Patient was placed on insulin drip to titrate for a sugar less than 200 and [**Last Name (un) **] was consulted for sugar management. In addition, Dr. [**Last Name (STitle) **], patient's cardiologist was consulted in order to clear the patient for surgery incase a carotid endarterectomy was necessary. Carotid ultrasounds performed on [**2145-1-6**] revealed significant bilateral plaque. On the right, there is an 80-99% carotid stenosis. On the left by velocity criteria, there is also an 80-99% carotid stenosis. However, this may be artifactually elevated due to the high grade stenosis on the contralateral side. After initial treatment, repeat ultrasound on the left side would be recommended. Patient, after interpreting these results, was made preoperative for right carotid endarterectomy. Patient was taken to the OR on [**2145-1-7**] after adequate cardiac clearance and preoperative workup. On [**2145-1-7**] the patient was taken for a right carotid endarterectomy by Dr. [**Last Name (STitle) 1391**]. For more detailed account, please see operative note. Postoperatively, patient went to the Vascular ICU, where patient's postoperative course was remarkable for 2 unit blood transfusion requirement. Also postoperatively, patient's sugars were well controlled ranging from 150-200 on the new sliding scale and fixed insulin doses arranged for by the [**Last Name (un) **] consult. On postoperative day #4, patient was doing well with no complaints. The right neck wound was clean, dry, and intact with some moderate ecchymoses but no swelling and no neurological deficits noted. The patient was deemed well enough to be discharged home at this time. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSES: 1. Bilateral carotid stenosis. 2. Coronary artery disease. 3. Congestive heart failure. 4. Insulin dependent-diabetes mellitus. 5. Obesity. 6. Peripheral vascular disease. 7. Chronic anemia. 8. Dyslipidemia. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Protonix 40 mg p.o. q.d. 3. Ferrous sulfate 325 mg p.o. b.i.d. 4. Folic acid 1 mg p.o. q.d. 5. Neurontin 100 mg p.o. b.i.d. 6. Plavix 75 mg p.o. q.d. 7. Multivitamin one p.o. q.d. 8. Benadryl 25 mg p.o. b.i.d. prn. 9. Lipitor 10 mg p.o. q.d. 10. Isosorbide mononitrate 60 mg p.o. q.d. 11. Methotrexate 7.5 mg p.o. on Tuesdays. 12. Epogen 40,000 units subQ on Thursdays. 13. Digoxin 0.125 mg p.o. q.d. 14. Valsartan 80 mg p.o. q.d. 15. Carvedilol 6.25 mg p.o. b.i.d. 16. Lasix 40 mg p.o. q.d. 17. NPH insulin 50 units subQ q.a.m., q.p.m. and Humalog sliding scale as directed. FOLLOW-UP INSTRUCTIONS: Follow up with Dr. [**Last Name (STitle) 1391**] in [**12-25**] weeks for scheduling of future left carotid endarterectomy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Name8 (MD) 7190**] MEDQUIST36 D: [**2145-1-11**] 12:37 T: [**2145-1-11**] 12:38 JOB#: [**Job Number 40808**]

[ "458.29", "V45.81", "998.11", "433.30", "V45.82", "414.01", "428.0", "250.52", "362.01" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.12" ]

icd9pcs

[ [ [] ] ]

5089, 5298

5321, 5929

1624, 2108

1333, 1598

3072, 5068

2131, 3043

177, 1004

5954, 6339

1026, 1310

1,662

180,788

29197

Discharge summary

report

Admission Date: [**2171-3-28**] Discharge Date: [**2171-4-7**] Date of Birth: [**2095-11-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: Tachycardia, Tachypnea, Hypoxia, Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: 75 y/o female with history of Schizophrenia, s/p frontal lobe resection, and recurrent UTI last hospitalized [**12-12**], sent from [**Hospital **] Nursing Home with altered mental status. She was found nonresponsive, with RR 40, HR 130, O2 sat 79-80%, thought likely aspiration given vomiting vs seizure - not witnessed. Was arousable soon after, but continued hypoxia. . In ED, Afebrile, Tacycardic to 120-130's, Tachypneic to 30's, Hypoxic to 80% sat on RA, improved to 100% on non-rebreather. Given 2 L NS, vanco 1g, ceftriaxone 1g, and clindamycin 600mg. Past Medical History: Schizophrenia s/p frontal lobe resection recurrent UTI's HTN seizure disorder anemia cystic kidney disease with CRI (baseline Cr 1.5) h/o diverting colostomy [**2-8**] obstruction Social History: Family lives in [**State 760**], - TOB, - ETOH, - IVDA Family History: Non-Contributory Physical Exam: General: Elderly white female with significant scoliosis, intermittantly responsive T 97.2, 131/89, 87, 22, 95% 1.5LNC HEENT: Eyes closed, Mouth dry, tracks to name NECK: No cervical LAD. CHEST: CTAB HEART: Regular rhythm. No audible murmurs or gallops. ABD: Left sided colostomy. Non distended. Good bowel sounds. Non tender. [**State **]: No edema. Good peripheral pulses. NEURO: Sleepy. Responds with 1-3 word phrases to simple questions. Had spontaneous conversation with sister. [**Name (NI) **] [**Name2 (NI) **] reflexes symetric. SKIN: resolving fungal Rash on feet. Pertinent Results: [**2171-4-6**] 12:35PM BLOOD WBC-10.8 RBC-3.20* Hgb-9.3* Hct-29.1* MCV-91 MCH-29.0 MCHC-32.0 RDW-15.4 Plt Ct-353# [**2171-4-6**] 12:35PM BLOOD Plt Ct-353# [**2171-4-6**] 12:35PM BLOOD Glucose-84 UreaN-9 Creat-0.9 Na-148* K-3.8 Cl-110* HCO3-19* AnGap-23* [**2171-4-6**] 12:35PM BLOOD Calcium-9.5 Phos-2.6* Mg-2.0 [**2171-3-28**] 06:30PM BLOOD VitB12-689 Folate-11.7 [**2171-3-28**] 06:30PM BLOOD TSH-3.8 EEG [**2171-3-30**]: IMPRESSION: This is an abnormal EEG due to the right more than left centrotemporal sharp waves and the slow and disorganized background rhythm. The first abnormality suggests bilateral centrotemporal foci of potential epileptogenesis. The second abnormality suggests a moderate encephalopathy, which may be seen with infections, toxic metabolic abnormalities or medication effect. CXR [**2171-3-29**]: IMPRESSION: Virtually uninterpretable film due to respiratory motion. Possible bibasilar opacities and new left effusion or consolidation. Recommend repeat chest x-ray when patient is more clinically stable. MRI BRAIN [**2171-3-29**]:FINDINGS: No evidence of acute infarct seen on diffusion images. There are diffuse periventricular hyperintensities identified. Bilateral temporal areas of chronic encephalomalacia are noted. There is no midline shift or hydrocephalus seen. Moderate brain atrophy is identified. Chronic right- sided corona radiata infarct with chronic blood products are visualized. IMPRESSION: Periventricular hyperintensities due to small vessel disease and chronic right corona radiata lacune with chronic blood products. Bilateral temporal cystic encephalomalacia. No evidence of acute infarct, mass effect or hydrocephalus. CXR [**2171-3-28**]: IMPRESSION: Question of interstitial process at right base (ie interstitial pneumonia) though repeat film is recommended for further evaluation to confirm. Brief Hospital Course: On arrival patient noted to be markedly unstable, so was initially admitted to the [**Hospital Unit Name 153**] on the [**Hospital Ward Name **], with presumed aspiration pneumonia vs. pneumonitis. Neurology consulted as there was concern over hypertonia and rigidity. Neurology was consulted, who felt that the patient was having severe dystonia due to haldol, for which they recommended immediate cessation. An EEG was performed as above, which did not demonstrate status epilepticus. A brain MRI was performed as above, with no new lesions. The alteration in mental status was felt to be due to medication effects combined with delerium from aspiration pneumonia and hypoxia. For her pneumonia the patient was given vancomycin and ceftriaxone IV with resolution of her leukocytosis and her hypoxia improved over the admission. She was also noted on [**4-1**] with impacted cerumen for which she received debrox drops. However on [**2171-4-2**] the patient had essentially not improved, was responsive only to painful stimuli. There seemed little recovery to her mental status, and since her EEG did not show a cause, and in discussion with the family she had not been doing well prior to the admission, it was decided the patient would be made CMO. Palliative care was consulted, along with social work for family coping. In keeping with this, IV hydration, food and non-comfort medications were withdrawn. The patient continued this way when on [**4-5**] in the evening her family returned from [**State 760**], when the patient awoke and had conversation with the family. Initially this was thought to be a brief moment of lucidity prior to death, however it persisted through the evening into the following morning. Given this we withdrew the CMO order, and returned to full treatment. Given that she had recieved no hydration, there was still marked concern at that point that her kidneys had likely failed in the meantime and would likely be unsalvagable, however for inexplicable reasons, her createnine was 0.9 and she has been urinating well. Family concurred that she should be returned to [**Location **] Manor. 1. Schizophrenia - Off all antipsychotics for now given dystonic reaction - patient has been stable emotionally 2. Epilepsy - Solely on keppra - EEG as above 3. Impacted Cerumen - Debrox completed 4. Aspiration Pneumonia - Completed course of Vancomycin and Ceftriaxone - Aspiration Precautions - Thickened liquids, puree diet 5. CODE status - DNR/DNI 6. MISC - Would use DVT prophylaxis per your institutional protocol Medications on Admission: Catapres-TTS 3 patch 1/week Haldol decanoate 50mg IM qmonth Lactulose 30mL [**Hospital1 **] Benztropine 0.5mg QHS Bisacodyl 10mg QOD Ativan 1mg q6h prn for agitation Milk of Magnesia 30 mL QHS Iron Sulfate 325 mg daily Duoneb 8Qh Levaquin 250 mg daily Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Benztropine 1 mg/mL Solution Sig: One (1) mg Injection DAILY (Daily). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q6H (every 6 hours) as needed for agitation. Discharge Disposition: Extended Care Facility: [**Location (un) **] Manor Discharge Diagnosis: Aspiration Pneumonia Schizophrenia Epilepsy Impacted Cerumen Discharge Condition: GOOD Discharge Instructions: Return to the hospital for severe coughing, shortness of breath, increasing oxygen requirements, marked change in metnal status (patient waxes and wanes over day) Followup Instructions: Would recommend patient be seen by her PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 608**] within 2 weeks

[ "401.9", "295.90", "380.4", "285.9", "780.39", "507.0", "263.0", "345.90", "737.10" ]

icd9cm

[ [ [] ] ]

[ "89.14" ]

icd9pcs

[ [ [] ] ]

7175, 7228

3766, 6323

370, 376

7332, 7338

1887, 3743

7549, 7702

1258, 1276

6626, 7152

7249, 7311

6349, 6603

7362, 7526

1291, 1868

276, 332

404, 966

988, 1170

1186, 1242

20,248

117,497

3807

Discharge summary

report

Admission Date: [**2120-10-4**] Discharge Date: [**2120-10-10**] Date of Birth: [**2068-2-26**] Sex: M Service: CARDIOTHORACIC Allergies: Toradol Attending:[**First Name3 (LF) 1505**] Chief Complaint: DOE Major Surgical or Invasive Procedure: LV lead placement via left thoracotomy/ICD generator change on [**2120-10-4**] History of Present Illness: 52 y/o male with Ischemic CM and class III heart failure. Percutaneous attempt to place LV lead was unseccessful x 2. He now presents for surgical placement. He remains symptomatic despite medical therapy. Past Medical History: Ischemic Cardiomyopathy/Congestive Heart Failure w/ EF of 35% Coronary Artery Disease s/p Myocardial Infarction [**2115**] s/p thrombectomy and stent to OM1 Intraventricular Conduction Defects (IVCD) s/p Dual Chamber pacer [**12-20**] Hypertension Hyperlipidemia Cervical disc herniation s/p surgery x 2 s/p lumbar disc surgery x 2 s/p Cholecystectomy s/p Left shoulder surgery s/p Left total knee replacement s/p pericarditis [**2115**] Osteoarthritis Social History: Tobacco: 70pack/yr hx, IPPD currently ETOH: denies Family History: Father w/ CABG at 57. Brother w/ Myocardial Infarction at 42. Physical Exam: VS: 154/98 63 6'8" 260# General: WDWN male in NAD Skin: Good turgor, well healed incisions HEENT: PERRL, EOMI, Oropharynx benign Neck: Supple, -JVD, -Bruit Chest: CTAB -w/r/r Heart: RRR, -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -edema, left varicosities Neuro: A&Ox3, CN 2-12 intact, MAE, FROM, 5/5 strength Pulses: BFA 2+, BDP 1+, BPT 1+, BRA 2+ Pertinent Results: [**2120-10-4**] 11:26AM BLOOD WBC-11.4* RBC-3.37* Hgb-11.8* Hct-34.8* MCV-103* MCH-35.1* MCHC-34.0 RDW-13.1 Plt Ct-290 [**2120-10-9**] 06:10AM BLOOD WBC-11.9* RBC-2.91* Hgb-10.2* Hct-29.7* MCV-102* MCH-35.1* MCHC-34.5 RDW-12.9 Plt Ct-273 [**2120-10-7**] 07:00AM BLOOD PT-13.6* PTT-23.4 INR(PT)-1.2 [**2120-10-8**] 06:30AM BLOOD PT-12.9 PTT-23.1 INR(PT)-1.1 [**2120-10-5**] 03:00AM BLOOD Glucose-122* UreaN-13 Creat-0.7 Na-139 K-3.7 Cl-102 HCO3-28 AnGap-13 [**2120-10-7**] 07:00AM BLOOD Glucose-101 UreaN-20 Creat-0.8 Na-141 K-4.1 Cl-101 HCO3-32 AnGap-12 Brief Hospital Course: Pt. was a same day admit and was brought directly to the operating room where he underwent an LV lead placement via left anterior thoracotomy and ICD generator change. Pt. was brought to the PACU in stable condition and was extubated without incident. Later on operative day, patient had oxygen desaturation along with incisional pain and labored breathing. Oxygen was given via NRB and anesthesia was called. CXR was obtained which revealed a small left apical pneumothorax, collapse of the right upper lobe (raises the possibility of a centrally obstructing mass, and an 1-cm linear density projecting over the left glenoid. Pt. was eventually converted to nasal cannula from NRB after better oxygen saturation. On POD #1 a bronchoscopy was performed and large amount of secretions was found and RUL plugs suctioned. On POD #2 repeat CXR revealed changes consistant with the day before. A chest CT was performed which showed soft tissue mass obstructing the right upper lobe bronchus causing complete collapse of the right upper lobe with mediastinal lymphadenopathy, atelectasis in the left lower lobe likely secondary to secretions, and a very small left-sided pneumothorax. Thoracic surgery was consulted and saw pt on POD #3 (see chart for A/P). Recommended multiple radiology studies(can be done as outpt) and a repeat bronchoscopy with biopsies. Blood, urine and sputum cultures were taken secondary to increased WBC. A repeat bronchoscopy was performed on POD #4. This revealed patent RUL with no obstruction. A TBNA, washing, and brushing from RUL was sent to cytology. Repeat CT also done on this day revealed resolution of right upper lobe atelectasis, with residual patchy ill-defined opacity, and an interval increase in size of left-sided pneumothorax compared to the CT scan of [**2120-10-5**]. After cytology results, Thoracic surgery noted that RUL collapse was likely due to mucus plug and unlikely to be a malignancy. On POD #5 chest tube was removed. Final CXR before discharge revealed a small residual left-sided pneumothorax and previously noted atelectatic changes in the left lower lung zone and pleural thickening along the left chest wall are unchanged. On POD #6 pt was doing well. He was hemodynamically stable with good vital signs and stable labs. He was discharged home with appropriate f/u appointments. Medications on Admission: 1. Coreg 50mg [**Hospital1 **] 2. Diovan 160mg [**Hospital1 **] 3. Spirolactone 25mg [**Hospital1 **] 4. Hydralazine 25mg tid 5. Lasix 40mg [**Hospital1 **] 6. Protonix 40mg qd 7. Prilosec 40mg qd 8. ASA 325mg qd 9. Digoxin 0.125mg [**Hospital1 **] 10. Clonidine 0.1mg [**Hospital1 **] 11. Lipitor 40mg qd Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4* 3. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 5. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*2* 8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Failed percutaneous lead placement s/p LV lead placement via Left Anterior Thoracotomy/ICD generator change RUL collapse s/p bronchoscopy Ischemic Cardiomyopathy/Congestive Heart Failure w/ EF of 35% Coronary Artery Disease s/p Myocardial Infarction [**2115**] s/p thrombectomy and stent to OM1 Intraventricular Conduction Defects (IVCD) s/p Dual Chamber pacer [**12-20**] Hypertension Hyperlipidemia Cervical disc herniation s/p surgery x 2 s/p lumbar disc surgery x 2 s/p Cholecystectomy s/p Left shoulder surgery s/p Left total knee replacement s/p pericarditis [**2115**] Osteoarthritis Discharge Condition: good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fevers greater then 100.5 Followup Instructions: with Dr. [**Last Name (STitle) 17107**] in [**12-17**] weeks with Dr. [**Last Name (STitle) 17108**] in [**1-18**] weeks with Dr. [**Last Name (STitle) 17109**] in 1 week ([**Telephone/Fax (1) 1504**] Completed by:[**2120-10-10**]

[ "401.9", "414.8", "518.0", "934.1", "412", "512.1", "V43.65", "305.1", "428.0", "272.4", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "33.27", "33.24", "00.51", "88.72", "96.05", "34.04" ]

icd9pcs

[ [ [] ] ]

6196, 6258

2192, 4531

279, 359

6892, 6898

1614, 2169

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Discharge summary

report

Admission Date: [**2169-3-28**] Discharge Date: [**2169-4-10**] Date of Birth: [**2090-5-12**] Sex: M Service: NEUROLOGY Allergies: Oxycontin / Lamictal / Levaquin Attending:[**First Name3 (LF) 19817**] Chief Complaint: seizure Major Surgical or Invasive Procedure: none History of Present Illness: Per ED resident: Mr [**Known lastname 19816**] is a 78 year-old man with long standing history of focal epilepsy and AFib in coumadin, presented to the Ed in status epilepticus. Patient was found this morning by his wife in generalized clonic seizures. The seizure lasted for 10minutes then stopped and he had another continue another seizure. His wife called 911, and he was brought to the closest ED where he received 7mg of Ativan and 2g of Fosphenytoin. He continue to present left foot clonic movements for at least more 4 hours. In the ED [**Hospital1 18**] patient was confused, obtuned, and with persistent left foot clonic movements. Past Medical History: - focal epilepsy - history of head trauma from boxing in his youth - cervical spinal stenosis - BPH - HLD - OA - gout - L TKR - HTN - A-fib - glaucoma - Sleep Apnea Social History: Patient in his baseline walk with cane\walker, appropriate speech, likes to read magazines. -lives w/ girlfriend, divorced, retired -former alcoholic and tobacco use -no drug use Family History: There is no family history of premature coronary artery disease or sudden death. Brother with possible history of seizures Physical Exam: Examination on admission (per Neuro ED resident): VS: stable vital signs Genl: confused obtuned. Not in acute distress CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops Chest: CTA bilaterally, no wheezes, rhonchi, rales Abd: +BS, soft, NTND abdomen Ext: No lower extremity edema bilaterally Neurologic examination: Mental status: confused, non-verbal, following very simple commands such as squiz the hands. Cranial Nerves: Fundoscopic examination reveals sharp disc margins. Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Extraocular movements intact bilaterally without nystagmus. Facial movement symmetric. Motor: Normal bulk and tone bilaterally. Moving all extremities antigravity Sensation: withdraw of the four limbs. Reflexes: 2+ and symmetric throughout. Toes downgoing bilaterally. Gait: not tested Exam at time of discharge: Pertinent Results: Labs: [**2169-3-28**] 01:35PM BLOOD WBC-12.2* RBC-4.77 Hgb-14.9 Hct-44.4 MCV-93 MCH-31.3 MCHC-33.7 RDW-14.8 Plt Ct-192 [**2169-3-28**] 01:35PM BLOOD Neuts-83.5* Lymphs-10.4* Monos-5.2 Eos-0.5 Baso-0.3 [**2169-3-28**] 01:35PM BLOOD PT-24.3* PTT-29.6 INR(PT)-2.3* [**2169-3-28**] 01:35PM BLOOD Glucose-122* UreaN-17 Creat-1.3* Na-144 K-3.9 Cl-102 HCO3-33* AnGap-13 [**2169-3-28**] 01:35PM BLOOD Calcium-9.1 Phos-3.1 Mg-1.6 [**2169-3-28**] 01:35PM BLOOD Carbamz-0.6* Urine studies [**2169-3-28**] 09:03PM URINE Blood-MOD Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2169-3-28**] 09:03PM URINE RBC-0-2 WBC-[**3-31**] Bacteri-MOD Yeast-NONE Epi-0-2 [**2169-3-28**] 09:03PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 Imaging/Studies: CT head [**3-28**]: FINDINGS: There is a small subgaleal hematoma and soft tissue swelling overlying the left frontal bone. There is no acute intracranial hemorrhage, edema, mass effect, or infarct. The ventricles and sulci are prominent, consistent with age-related atrophy. Supratentorial and periventricular white matter hypodensities reflect sequelae of chronic small vessel ischemic disease. There is bilateral calcification of the cavernous carotid arteries. There is mild mucosal thickening throughout the paranasal sinuses. The mastoid air cells are clear. There are no fractures. The orbits are unremarkable. IMPRESSION: No intracranial hemorrhage or fracture. CXR: [**3-28**] FINDINGS: In comparison with study of [**2167-8-31**], there is continued enlargement of the cardiac silhouette without definite vascular congestion or pleural effusion. No evidence of acute focal pneumonia. EEG [**3-29**]: IMPRESSION: This telemetry captured two pushbutton activations which were described above. Routine sampling showed a mildly slow and disorganized background consisting of mixed theta frequencies. There were no definite electrographic seizures seen on this recording; however, retrospectively, one of the pushbuttons showed some associated subtle right central rhythmic activity. EEG [**3-30**]: IMPRESSION: This telemetry captured no pushbutton activations. Routine sampling showed a mildly slow and disorganized background consisting mostly of mixed theta frequencies. There were no areas of prominent focal slowing and there were no epileptiform features seen. EEG [**3-31**]: IMPRESSION: This telemetry captured two pushbutton activations for twitching with no electrographic correlate. The background activity showed focal slowing in the right central and left temporal areas suggestive of subcortical dysfunction in these areas. There were no clear epileptiform features EEG [**4-1**]: IMPRESSION: This telemetry captured no pushbutton activations. There were a few generalized sharp waves, but these had more of a triphasic appearance than a spike and slow wave morphology. The background was mildly slow throughout, and there was modest frontal slowing, as well. EEG [**4-2**]: IMPRESSION: This telemetry captured no pushbutton activations. Routine sampling and automated detection programs showed no clear epileptiform discharges or electrographic seizures. The routine sampling showed mild slowing of background frequencies throughout. There were no prominent focal findings. CXR [**3-30**]: A Dobbhoff tube is coiled within the esophagus. The cardiac silhouette is enlarged, unchanged from prior. There is no evidence of pulmonary or interstitial edema. The mediastinal silhouette, hilar contours and pleural surfaces are normal. There is a small left pleural effusion and associated atelectasis. The remaining lungs are well expanded and clear. Repeat: FINDINGS: In comparison with the earlier study of this date, the Dobbhoff tube tip now lies within the upper stomach, just distal to the esophagogastric junction. Little change in the appearance of the heart and lungs. CXR [**4-3**]: FINDINGS: In comparison with the study of [**4-1**], there are lower lung volumes, which most likely accounts for the increased prominence of the transverse diameter of the heart. Basilar atelectatic changes are seen, but no evidence of acute focal pneumonia. The Dobbhoff tube has been removed. Discharge Labs 140 | 103 | 10 ---------------< 95 3.3 | 29 | 1.1 Ca: 8.8 Mg: 1.8 PO4: 2.5 14.5 13.9 >-------< 190 42.5 PT: 21.4 PTT: 30.5 INR: 2.0 Brief Hospital Course: 78 yo man with PMH of focal epilepsy, status epilepticus, Afib on coumadin, CAD, HTN, HL, OSA admitted to the neuro ICU for focal motor seizure with generalization. At OSH/[**Hospital1 **] ED he received 7mg IV Ativan, 2gm Dilantin, 1 gm Keppra, 100mg Oxcarbazepine, 130mg PHB, his focal motor seizure abated. NEURO: At time of admission he still intermittently had left foot clonus, a few seconds at a time. He was lethargic and inattentive. Focal seizure exacerbation and generalization were attributed to 1. wean of zonegran by his wife and 2. UTI. Remaining infectious w/up was negative (CXR). He received 1g of Keppra IV load in ICU folled by 1g [**Hospital1 **] for 1 day. Given persistent somnolence and episodes of apnea (30-45 seconds) with bradycardia, and relatively rare L foot myoclonus, keppra was decreased to 500mg [**Hospital1 **]. On this regimen MS improved, he became more alert and oriented to [**Hospital1 18**] and year, however remained sedated. He was continued on oxcarbazepine 300mg [**Hospital1 **], increase in which in the past has caused increasing fatigue and somnolence. The Keppra was later tapered off, and the oxcarbazepine was increased to 600mg [**Hospital1 **]. The occasional focal left foot myoclonus was not found to have an EEG correlate. CV. Initially volume overloaded, however, as PO intake decreased and maintenance dose of diuretic was continued, he reached euvolemia. He is currently on Coumadin for his Afib, and given his current diarrhea, his INR should be followed every 2-3 days until his diarrhea has resolved. PULM. Multiple, frequent episodes of apnea while asleep and sedated, at times reaching 40-45 seconds in duration with bradycardia to 40s without desaturation. Previously diagnosed with OSA however unable to tolerate CPAP due to discomfort. Patient was maintained on BiPAP while at night and improved. It was felt that significant contribution to fatigue and somnolence were contributed to by hypercarbia ID. UTI, treated with CFTX IV x 10 days. UCx was initially contaminated, however did have hx of frequent UTIs. On [**4-4**] he was noted to have rising WBC count, and diarrhea. Repeat U/A and CXR were negative, however given the diarrhea, stool was sent for c diff and he was started on PO vancomycin, to be continued through [**4-17**]. Based on discussion with his PCP, [**Name10 (NameIs) **] may benefit from standing Macrobid in the future for UTI prevention, but will hold off on this plan for now given the current c diff infection. FEN: He was evaluated by speech and swallow, and approved for regular solids, nectar thick liquids and crushed pills. He is able to take thin liquids between meals. Medications on Admission: LATANOPROST [XALATAN] - 0.005 % Drops - 1 gtt ou at bedtime METOPROLOL TARTRATE - 100mg 1 5tab once a day SIMVASTATIN - 40 mg Tablet once a day WARFARIN - 5 mg Tablet - once a day Oxcarbazepine 300mg [**Hospital1 **] Allopurinol 150mg once a day Ranitidine 150mg [**Hospital1 **] Amlodipine 10mg daily Chlorthalidone 25mg [**1-28**] tab every other day Discharge Medications: 1. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) dose PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Oxybutynin Chloride 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day). 5. Simvastatin 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 6. Latanoprost 0.005 % Drops [**Month/Day (2) **]: One (1) Drop Ophthalmic HS (at bedtime). 7. Amlodipine 5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily). 8. Chlorthalidone 25 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. Oxcarbazepine 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 11. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4 PM. 12. Vancomycin 125 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every 6 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital 4470**] HealthCare Discharge Diagnosis: Primary: Status epilepticus Secondary: Atrial fibrillation C difficile colitis Hypertension Hyperlipidemia Discharge Condition: Fluent speech, however will occasionally refuse to answer questions. Able to follow commands with significant encouragement. Can move all extremities and retracts from pinch. Small degree of asterixes. Discharge Instructions: You were admitted to [**Hospital1 18**] with status epilepticus. This was felt to be due to tapering of one of your medications (zonegran) and a urinary tract infection. You were started on Keppra. With this treatment, the status resolved and you had intermittent shaking of L foot without generalization. The following changes were made to your medications: - Zonegran discontinued - Trileptal 600mg [**Hospital1 **] If you notice any of the concerning symptoms listed below, please call your doctor or return to the emergency department for further evaluation Followup Instructions: Neurology - Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2169-4-12**] 4:00 PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name (STitle) 1313**] on Tuesday, [**4-25**] at 1pm. Phone: [**Telephone/Fax (1) 7318**] Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2169-7-3**] 2:00

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Discharge summary

report

Admission Date: [**2199-9-1**] Discharge Date: [**2199-9-20**] Date of Birth: [**2136-11-30**] Sex: F Service: MEDICINE Allergies: Lisinopril / Metoclopramide Attending:[**Doctor First Name 3290**] Chief Complaint: abdominal distention Major Surgical or Invasive Procedure: upper endoscopy History of Present Illness: 62F transferred from [**Hospital3 2558**] with tachycardia, hyperglycemia, respiratory distress and increased abdominal distension. The recent history of her presentation is unavailable. She was intubated on arrival for a RR of 50 and unobtainable SaO2. Nasotracheal intubation performed. Initially only IV access available was right foot. NGT placed for gastric distension seen on CXR and >2L coffee ground output. TLC placed but had to be converted to cordis as crossed to left subclavian. IVF resuscitation begun. Lactate elevated, ARF, anuria on foley placement. Continued NGT output, almost 3L. In total 4L LS, 2U PRBC. Per the patients family the patient is typically A&Ox3 and is ambulatory at her center. She is a [**Hospital3 2558**] resident for the past year due to a history of "nervous breakdown" in the setting of a psych diagnosis (?schizophrenia) and a need for supervision with her medications. Prior to her admission there, she was hospitalized for pulmonary issues. Her psych issues began late in life after her father passed away in [**2193**]. Past Medical History: Past Medical History: Schizophrenia-like disorder HTN h/o PNA chronic pulmonary disease DM LE edema Lichen Planus Past Surgical History: Hysterectomy BSO Ventral hernia repair (?mesh) "Cyst excision" (after her ovarian resection) Social History: Social History: 20 pk year smoking, no current. Denies ETOH or IVDU. Living in [**Hospital3 **]. Mother and brothers occasionally visit. Family History: Family History: mother w/ DM. No h/o cancer or significant CAD Physical Exam: ADMISSION: 97 118 115/100 18 97 (HR 98 SBP 110 after 2L LR) Nasotracheally Intubated, moves head to command, squeezes hand to command, does not nod or shake head to questioning Lungs w/ slight wheeze b/l and basilar rales RRR Abd distended, soft, tympanic, nontender (does not wince with deep palpation) DRE with no palpable masses, soft brown stool in vault, guaiac negative (repeat by RN after BM later was guaiac +) No LE edema DISCHARGE: Vitals: Tm 98.3, Tc 97.9, HR 76, HR range 66-82, BP 156/84, BP range 156/84-170/90, RR 18, O2 sat 95%Bipap 24H I's po 440 IV -- O's urine 1600+inc other -- 8H I's po -- IV -- O's urine larg inc other -- General: Obese female, awake with eyes open, makes eye contact, then looks away, BIPAP on, not answering questions, NAD HEENT: MMM Neck: obese, supple, unable to appreciate JVP Lungs: no use of accessory mm of breathing, anterior lung fields clear without crackles or wheezes CV: RRR, nl S1 S2, no murmurs, rubs, gallops Abdomen: +NABS, obese, soft, non-tender, no rebound or guarding Ext: no [**Location (un) **], distal LE's cool but 2+ DP pulses, L PICC without erythema, warmth or tenderness, slight coolness to both upper extremities, symmetric, decreased swelling, pulses palpable bilaterally, slightly decreased L compared to right Neuro: awake, follows with eyes, not answering orientation questions Pertinent Results: Admission Labs: [**2199-9-1**] 12:03 COMPLETE BLOOD COUNT White Blood Cells 9.1 4.0 - 11.0 K/uL PERFORMED AT WEST STAT LAB Red Blood Cells 4.30 4.2 - 5.4 m/uL PERFORMED AT WEST STAT LAB Hemoglobin 12.5 12.0 - 16.0 g/dL PERFORMED AT WEST STAT LAB Hematocrit 39.2 36 - 48 % PERFORMED AT WEST STAT LAB MCV 91 82 - 98 fL PERFORMED AT WEST STAT LAB MCH 29.0 27 - 32 pg PERFORMED AT WEST STAT LAB MCHC 31.8 31 - 35 % PERFORMED AT WEST STAT LAB RDW 14.0 10.5 - 15.5 % PERFORMED AT WEST STAT LAB DIFFERENTIAL Neutrophils 84* 50 - 70 % PERFORMED AT WEST STAT LAB Bands 4 0 - 5 % Lymphocytes 6* 18 - 42 % PERFORMED AT WEST STAT LAB Monocytes 5 2 - 11 % PERFORMED AT WEST STAT LAB Eosinophils 0 0 - 4 % PERFORMED AT WEST STAT LAB Basophils 0 0 - 2 % PERFORMED AT WEST STAT LAB Atypical Lymphocytes 0 0 - 0 % Metamyelocytes 0 0 - 0 % Myelocytes 1* 0 - 0 % RED CELL MORPHOLOGY Hypochromia NORMAL Anisocytosis NORMAL Poikilocytosis NORMAL Macrocytes NORMAL Microcytes NORMAL Polychromasia NORMAL BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Smear NORMAL Platelet Count [**Telephone/Fax (3) 87339**] K/uL [**2199-9-1**] 17:29 Report Comment: Source: Line-aline RENAL & GLUCOSE Glucose 212* 70 - 100 mg/dL IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES PERFORMED AT WEST STAT LAB Urea Nitrogen 82* 6 - 20 mg/dL PERFORMED AT WEST STAT LAB Creatinine 2.3* 0.4 - 1.1 mg/dL PERFORMED AT WEST STAT LAB Sodium 140 133 - 145 mEq/L PERFORMED AT WEST STAT LAB Potassium 4.6 3.3 - 5.1 mEq/L PERFORMED AT WEST STAT LAB Chloride 109* 96 - 108 mEq/L PERFORMED AT WEST STAT LAB Bicarbonate 16* 22 - 32 mEq/L PERFORMED AT WEST STAT LAB Anion Gap 20 8 - 20 mEq/L CHEMISTRY Calcium, Total 7.7* 8.4 - 10.3 mg/dL PERFORMED AT WEST STAT LAB Phosphate 3.8 2.7 - 4.5 mg/dL PERFORMED AT WEST STAT LAB Magnesium 2.5 1.6 - 2.6 mg/dL . Discharge Labs: [**2199-9-20**] 06:14 Report Comment: Source: Line-L PICC COMPLETE BLOOD COUNT White Blood Cells 7.1 4.0 - 11.0 K/uL PERFORMED AT WEST STAT LAB Red Blood Cells 2.73* 4.2 - 5.4 m/uL PERFORMED AT WEST STAT LAB Hemoglobin 8.0* 12.0 - 16.0 g/dL PERFORMED AT WEST STAT LAB Hematocrit 25.2* 36 - 48 % PERFORMED AT WEST STAT LAB MCV 92 82 - 98 fL PERFORMED AT WEST STAT LAB MCH 29.2 27 - 32 pg PERFORMED AT WEST STAT LAB MCHC 31.5 31 - 35 % PERFORMED AT WEST STAT LAB RDW 16.4* 10.5 - 15.5 % PERFORMED AT WEST STAT LAB BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Count 484* 150 - 440 K/uL . Glucose 199* 70 - 100 mg/dL IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES PERFORMED AT WEST STAT LAB Urea Nitrogen 22* 6 - 20 mg/dL PERFORMED AT WEST STAT LAB Creatinine 1.5* 0.4 - 1.1 mg/dL PERFORMED AT WEST STAT LAB Sodium 141 133 - 145 mEq/L PERFORMED AT WEST STAT LAB Potassium 4.0 3.3 - 5.1 mEq/L PERFORMED AT WEST STAT LAB Chloride 105 96 - 108 mEq/L PERFORMED AT WEST STAT LAB Bicarbonate 27 22 - 32 mEq/L PERFORMED AT WEST STAT LAB Anion Gap 13 8 - 20 mEq/L CHEMISTRY Calcium, Total 8.2* 8.4 - 10.3 mg/dL PERFORMED AT WEST STAT LAB Phosphate 2.9 2.7 - 4.5 mg/dL PERFORMED AT WEST STAT LAB Magnesium 1.8 1.6 - 2.6 mg/dL PERFORMED AT WEST STAT LAB . . IMAGING: CT abd/pelvis ([**2199-9-1**]): IMPRESSION: 1. Findings concerning for early/partial small bowel obstruction with possible transition point in mid abdomen (2:50). No current evidence of perforation, pneumatosis, or bowel wall thickening. 2. Trace hyperdense material within second portion of duodenum may represent ingested material. For definite evidence of ulcer, direct visualization by endoscopy is recommended when patient is able to tolerate procedure. 3. Bibasal atelectasis and/or infection/aspiration, particularly in view of patulous esophagus with layering fluid. 4. Probable tiny upper pole left renal angiomyolipoma. CT head ([**2199-9-1**]): IMPRESSION: No acute intracranial process. CT abd/pelvis ([**2199-9-3**]): IMPRESSION: 1. Significant decrease in dilatation of proximal small bowel loops suggestive of resolving SBO. Currently there is no clear transition point that can be visualized. There is no evidence of perforation, pneumatosis or bowel wall thickening throughout the bowel. 2. Increased bibasilar atelectasis with the left greater than the right. KUB ([**2199-9-4**]): IMPRESSION: Similar dilated proximal small bowel loops. Oral contrast has passed distally into the colon. KUB ([**2199-9-5**]): marked dilation of several loops of bowel, possibly small and large bowel, new compared to the prior study. No free air identified. large amount of stool noted in the colon and rectum. CT may be obtained for further evaluation. EGD ([**2199-9-5**]): Erythema and friability in the whole stomach compatible with gastritis (biopsy). Retained fluids in stomach. Gastroscope converted to pediatric colonoscope with good visualization to the proximal jejunum. Large amount of bile noted in the duodenum. No obstructing lesion noted to the proximal jejunum. Esophageal erosion. Otherwise normal EGD to proximal jejunum. . CT head w/o [**2199-9-11**]: IMPRESSION: No acute intracranial process . Renal U/S [**2199-9-11**]: IMPRESSIONS: Moderately severe left hydronephrosis, probably unchanged from prior CT studies dating back to [**2199-9-1**], which were limited in assessment due to lack of IV contrast administration. There is no dilatation of the left proximal ureter, with possible etiologies for obstruction including UPJ obstruction. If further evaluation is warranted, MRI may be performed. . EEG [**2199-9-12**]: IMPRESSION: This EEG monitoring captured no pushbutton activations. It showed a widespread encephalopathy throughout. There were also dozens of individual generalized sharp waves. These did not have prominent following slowing or appear particularly epileptiform. No focal discharges were evident. There were no electrographic seizures. . TTE [**2199-9-16**]: Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. 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 structurally normal. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Valves not well visualized. No vegetations seen, however, the absence of a vegetation by 2D echocardiography does not exclude endocarditis . KUB [**2199-9-16**]: IMPRESSION: Air and stool are seen within the colon with a nonspecific small bowel gas pattern without definitive evidence of obstruction. . CT chest w/o [**2109-9-16**]: IMPRESSION: Moderately large right pleural effusion with associated atelectasis. Mild left pleural effusion with mild left atelectasis. Global cardiac enlargement. No evidence of pneumonia . LUE Doppler [**2199-9-18**]: IMPRESSION: No evidence of DVT. The left cephalic vein is not visualized. Brief Hospital Course: This is a 62 year old female with schizoaffective disorder, DM2, COPD on 2L of home 02, morbid obesity, and OSA who was admitted for SBO and subsequently transferred to the MICU for altered mental status and hypercabic respiratory acidosis in the setting of acute renal failure, now with improving mental status and renal function. . Small bowel obstruction: She was admitted to the trauma SICU for evaluation and management of SBO. IVF resuscitation was initiated. The patient was given fleets and soap suds enemas with good effect. A repeat CT scan on performed [**2199-9-3**] (HD3) and showed improvement in the dilation of the small bowel without evidence of a transition point suggesting resolution of partial SBO. After the CT scan, the patient was extubated. She was treated conservatively with an NGT for decompression. On transfer to the medicine floors, a repeat KUB showed gas in the colon. She was started on tube feeds briefly. The patient became more alert and pulled her NGT. She was evaluated by Speech and Swallow and passed. She was started on a regular diet, which she tolerated well. She was passing small stools. Her abdominal exam remained benign, without further concern for obstruction. . Respiratory failure: She presented with altered mental status and respiratory distress. A meeting with the patient's family was held regarding the patient's code status and it was determined that the patient was full code. She was initially intubated nasally, and on hospital day 2, the patient was placed on oral intubation. A bronchoscopy was performed and sputum from the BAL eventually grew E. coli and coagulase positive staph aureus. The patient was started on vanc/cefepime/flagyl. On [**9-7**], the patient was switched from Vancomycin to Nafcillin (For MSSA in sputum) and continued on Cefepime for E. Coli in sputum culture. Urine Cx from [**9-3**] was finalized with Cefepime sensitive E. Coli on [**9-7**]. From [**9-7**] through [**9-10**] she was continued on Nafcillin and Cefepime for MSSA and E. Coli PNA (Nafcillin 3 days plus Vancomycin since [**9-4**], and Cefepime since [**9-4**]). She was started on a trial of BIPAP at night for her OSA. She will continue this on discharge. . Gastrititis: Her NGT put out what appeared to be old blood, no bright red blood. GI was consulted, and she had an EGD, which showed gastritis and a large amount of retained gastric juice and bile, but no ulcer or active bleeding. She was started on IV Protonix 40mg [**Hospital1 **]. Biopsies were taken and sent to pathology, which showed no abnormalities. She was started on methylnaltrexone, reglan and erythromycin to hopefully improve gastric emptying. In addition, treatment for H.pylori was initiated. This was later stopped once the H. pylori resulted as negative. She was switched to oral protonix to continue on discharge. Her Aspirin was discontinued. . Altered mental status: According to the transfering teams the patients mental status has declined over a few days (baseline interactive but flat, able to eat, currently opens eyes and moans, no taking PO). Psychiatry was consulted today because baseline psychosis was thought to be possibly contributing. Medical evaluation and holding sedating medications was recommended. All antibiotics were also stopped out of concern for contributing to renal failure. The patient was increasingly lethargic following transfer from the surgical to medicine team on [**9-10**]. The patient was not withdrawing to pain. At that time the patient underwent an ABG while on 2L and found to be 7.23/45/112. The patient was subsequently transfered to the MICU. In the MICU, a CT head was unremarkable, and an EEG was non-specific and consistent with encephalopathy. Infectious workup was unrevealing. Her mental status gradually improved, and at the time of transfer to the floor on [**9-14**], she was beginnning to answer simple questions. On the medical floors she continued to improve, and began talking more. She remained guarded with a flat affect, but appeared closer to her baseline. Psychiatry continued to follow the patient on transfer to the medicine floors. Her Seroquel continued to be held. This medication was restarted on the day of discharge per psychiatry recommendations. Further evaluation and management of her psychiatric history will need to be followed-up and managed on discharge. . Renal failure: She was anuric on presentation, with worsening acute on chronic renal failure (baseline creatinine unknown). Renal service was consulted. Microscopic examination of her urine showed granular casts c/w ATN, etiology unclear. Renal ultrasound showed hydronephrosis, but both renal and urology consults did not think urgent intervention was indicated. She has post-ATN diuresis, resulting in hypernatremia. She was treated with 1/2NS and free water flushes. Her creatinine gradually improved, and was 1.5 on discharge. Her post-ATN diuresis also improved with no further hypernatremia. . Hydronephrosis: Demonstrated by renal ultrasound that was consistent with prior CT scan. She was evaluated by urology who did not feel intervention was indicated. She will followup with urology as an outpatient for further evaluation. . Fevers: Beginning history as above (under respiratory failure). On transfer to the medicine floors on [**9-14**], she spiked a fever to 103. Blood cultures were sent, in addition to urine cultures. She was restarted on Vancomycin, Cefepime and Flagyl. She denied any localizing symptoms. A TTE was negative for vegetations. Cultures up to [**9-11**] were negative; BCx from [**9-14**] and [**9-15**] were still pending on the day of discharge. All antibiotics were discontinued on [**2199-9-18**]. She continued to be afebrile for 48 hrs off of antibiotics. She had no leukocytosis. She was hemodynamically stable on the day of discharge and afebrile. . Anemia: Studies were consistent with anemic of chronic inflammation, but was likely a mixed picture in the setting of gastrititis and guaiac positive stools, suggestive of iron deficiency. Her hematocrit was trended and remained stable. She was hemodynamically stable on the day of discharge. ***She was guaiac positive, and did not have a colonoscopy during this admission. The EGD showed gastritis, but without acute bleeding. Evaluation and management for her anemia will need further follow-up on discharge.*** Hypertension: Her home medications of Enalapril, Diovan and HCTZ were held in the setting of acute renal failure and concern for sepsis. On transfer to the medicine floors, her blood pressure was elevated to ~160 systolic. She was started on Metoprolol and Amlodopine, to continue on discharge. She was instructed to discontinue Enalapril, Diovan, and HCTZ. She will need follow-up with her physician regarding when it would be appropriate to restart these medications. Diabetes, Type2: Her oral hypoglycemics and Metformin were held in the setting of acute renal failure. She was started on an insulin sliding scale. She will continue on this insulin sliding scale on discharge, given her continued renal failure. She will need to follow-up after discharge regarding when/if her oral hypoglycemics can be restarted. Medications on Admission: ASA 81 mg daily Simvastatin 20 mg daily Diovan 160 mg daily Enalapril 10 mg daily HCTZ 12.5 mg daily Seroquel 12.5 mg daily Neurontin 300 mg daily Regular insulin SS [**Hospital1 **] Glipizide 10 mg daily Metformin 850 mg [**Hospital1 **] Acetaminophen 1 g qhs Senna 2 tabs qhs Discharge Medications: 1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for rash. Disp:*1 bottle* Refills:*0* 3. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 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 epigastric pain. Disp:*1 bottle* Refills:*2* 9. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO once a day. 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 11. Insulin Lispro 100 unit/mL Cartridge Sig: per sliding scale units Subcutaneous four times a day: Per sliding scale. Disp:*1 cartridge* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnoses: 1. Partial small bowel obstruction 2. Gastritis 3. Fevers 4. Altered mental status Secondary Diagnoses: 1. COPD 2. Anemia 3. Diabetes 4. Schizoaffective disorder Discharge Condition: Mental Status: flat affect, confused at baseline Minimally interactive due to shizoaffective disorder but will answer some questions. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [**Known lastname 15352**], It was a pleasure taking care of you during this admssion. You were admitted to the Acute Care Surgery Service for management of your partial small bowel obstruction and gastritis. You were treated with bowel rest and a tube in your nose. You later had some trouble breathing and were transferred to the medical ICU. You required intubation. You were found to have a pneumonia and were treated with antibiotics. During your stay your kidneys were not functioning well, but this gradually improved. You had some fevers that were treated with antibiotics and got better. The following medications were changed during this admission: - STOP Diovan and Enalapril. You should have your kidney function rechecked next week, and your doctors [**Name5 (PTitle) **] decide if they want to restart these medications at that time. - STOP Glipizide and Metformin. You doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 9004**] to restart these medications as your kidney function improves. - STOP Neurontin - STOP Hydrochlorothiazide **These medications were stopped due to worsening kidney function, you will need to follow up with your doctor regarding when it is safe to restart these medications.** - START Humalog per sliding scale. This will replace your previous regular insulin sliding scale. - STOP Aspirin - START Pantoprazole 40mg by mouth daily. ** Please continue for treatment of Gastritis for 6-12 weeks. Your Aspirin is being held in the mean time. Please follow-up with your doctors when it is ok to restart the Aspirin.** - START Metoprolol succinate 50mg by mouth daily - START Amlodopine 2.5mg by mouth daily - START Acetaminophen 650mg by mouth four times daily as needed for pain (STOP 1 g at night) - START Docusate sodium 100mg by mouth twice daily as needed for constipation - START Senna 8.6mg by mouth as needed for constipation - START Miconazole powder in groin area and under breast as needed for itching - CONTINUE Simvastatin 20 mg by mouth daily - CONTINUE Seroquel 12.5 mg by mouth daily Followup Instructions: Please follow-up with the following appointments: Please follow-up with the doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] for further care. ***You had anemia during this admission. You had an upper endoscopy that showed gastritis but no bleeding. You will need further workup for this anemia when you leave. You will most likely require a colonoscopy.*** Completed by:[**2199-9-20**]

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icd9cm

[ [ [] ] ]

[ "38.91", "96.71", "45.16", "38.93", "33.24", "96.04" ]

icd9pcs

[ [ [] ] ]

19825, 19895

10905, 13792

310, 328

20121, 20121

3341, 3341

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250, 272

356, 1436

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1723, 1847

46,398

106,073

9802

Discharge summary

report

Admission Date: [**2184-8-21**] Discharge Date: [**2184-8-24**] Date of Birth: [**2115-8-20**] Sex: M Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 2297**] Chief Complaint: Chief complaint: GI bleed Major Surgical or Invasive Procedure: Blood transfusion Colonoscopy History of Present Illness: Mr. [**Known lastname 33000**] is a 69 year old male with CAD, HTN, HL, Type 2 DM, PAF on coumadin, hypothyroidism, PUD, who presented to OSH ED with BRBPR x 3 last night. He reports that the toild bowl was filled with blood. He denied lightheadedness, chest pain, fevers, chills, chest pain, or any other concerning symptoms. He has never had BRBPR, but has had melena two years ago secondary to PUD. He had a colonoscopy two years ago which showed diverticulosis. He denies hematasis, melena. . Upon arrival to the [**Hospital1 **] ED, his vitals were 138/83, 62, 16, 98.1. He was given 1 (?or 2) units of PRBCs at OSH and 2.5 mg of vitamin K PO. He underwent EGD and [**Last Name (un) **] at OSH. EGD was negative for bleeding, but colonsocopy showed significant amount of bleeding but there were unable to localize source of bleed due to significant amounts of blood. They were unable to pass the scope beyond the sigmoid colon due to the extent of bleeding. After the EGD/[**Last Name (un) **], he was hypotensive to the 70s. There were no ICU beds and no IR physicians available to embolize, so he was trasnferred to [**Hospital1 18**]. He was started on a protonix drip and octreotide drip at [**Hospital1 **]. He got 2 units of FFP though his INR was 1.6. His Hct at [**Hospital1 **] on arrivals was 30.9. . In the ED, vitals on arrival were T 96.5, BP 108/70, 16, 100% on RA. He was evaluated by GI and surgery who recommended tagged RBC scan. He was not hypotensive in the ED. He was transfused 1 unit of PRBCs in the ED. He continued to have large amounts of bright red blood while in the ED. He was taken directly to tagged RBC scan which was positive for sigmoid/rectal bleeding. . Upon arrival to the floor, patient denies lightheadedness, chest pain, shortness of breath, fevers, chills. He reports abdominal cramping prior to bloody bowel movements. Past Medical History: CAD s/p RCA stent in [**2175**] Hypertension Hyperlipidemia NIDDM Paroxysmal atrial fibrillation/flutter s/p pulmonary vein isolation CVA Hypothyroidism PUD . Social History: Patient denies alcohol, tobacco or drug use. Family History: Mother with diabetes. Physical Exam: VS: BP 85/50, HR 77, RR 16, 100% on RA, afebrile Gen: NAD, lying in bed, comfortable HEENT: EOMI, o/p clear CV: RRR, no m/r/g Pulm: CTA bilaterally Abd: soft, NT, ND, bowel sounds present Ext: cool extremities, no peripheral edema Neuro: AxOx3, answering questions appropriately Pertinent Results: [**2184-8-21**] 08:22PM HCT-23.6* [**2184-8-21**] 08:22PM PT-17.8* PTT-33.1 INR(PT)-1.6* [**2184-8-21**] 06:20PM WBC-5.2 RBC-2.88* HGB-8.0* HCT-24.7* MCV-86 MCH-27.8 MCHC-32.3 RDW-15.8* [**2184-8-21**] 06:20PM PLT COUNT-168 [**2184-8-21**] 06:20PM PT-18.0* PTT-31.6 INR(PT)-1.6* [**2184-8-21**] 03:34PM URINE HOURS-RANDOM [**2184-8-21**] 03:34PM URINE GR HOLD-HOLD [**2184-8-21**] 03:34PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2184-8-21**] 03:34PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2184-8-21**] 01:23PM COMMENTS-GREEN TOP [**2184-8-21**] 01:23PM GLUCOSE-198* [**2184-8-21**] 01:23PM HGB-10.5* calcHCT-32 [**2184-8-21**] 01:10PM GLUCOSE-199* UREA N-22* CREAT-1.1 SODIUM-135 POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-19* ANION GAP-15 [**2184-8-21**] 01:10PM estGFR-Using this [**2184-8-21**] 01:10PM ALT(SGPT)-23 AST(SGOT)-25 CK(CPK)-170 ALK PHOS-50 TOT BILI-1.3 [**2184-8-21**] 01:10PM LIPASE-132* [**2184-8-21**] 01:10PM CK-MB-3 cTropnT-<0.01 [**2184-8-21**] 01:10PM CALCIUM-8.4 [**2184-8-21**] 01:10PM WBC-5.3 RBC-3.30* HGB-9.3* HCT-28.3* MCV-86 MCH-28.3 MCHC-33.0 RDW-16.7* [**2184-8-21**] 01:10PM NEUTS-58.2 LYMPHS-32.8 MONOS-5.8 EOS-2.5 BASOS-0.7 [**2184-8-21**] 01:10PM PLT COUNT-200 [**2184-8-21**] 01:10PM PT-17.0* PTT-30.1 INR(PT)-1.5* . Colonoscopy: no active bleeding, but evidence of colitis and diverticulosis. Brief Hospital Course: Mr. [**Known lastname 33000**] is a 69 yo male with CAD, HL, PAF on coumadin, s/p CVA, hypothyroid, who is admitted for lower GI bleed localized to sigmoid/rectum. # GI bleed/colitis: His GI bleed was localized to the sigmoid colon or rectal colon on tagged RBC. Over the course of his admission, he required a total of 11 units of PRBC and 2 units of FFP. His hematocrit nadired at 24 but was 31 at the time of discharge and remained stable. He underwent colonoscopy that demonstrated diverticulosis and mild colitis of the sigmoid colon of unknown etiology, but no active source of bleeding was identified. He was started on cipro/flagyl empirically to manage his colitis. He also underwent an angiography study that was also unable to localize the bleeding source. # Atrial fibrillation with rapid ventricular resopnse: He is anticoagulated at baseline and had an INR of 1.6 on the day of presentation. He was reversed at an outside hospital with FFP and vitamin K, and anticoagulation was subsequently held. He was scheduled to see his cardioglist on [**2184-9-3**] to further discuss options for thromboembolic prophylaxis, as he has a CHADS score of at least 4 with diabetes, HTN, and a prior stroke. He was discharged off coumadin. He also had episdoes of a. fib with RVR and required a dilt drip intermittently but was placed back on metoprolol once his heart rate stabilized, as he takes this at home. # Type 2 DM: stable, started on ISS. Medications on Admission: Medications: (will need to confirm med list with pharmacy or wife) Coumadin Aspirin 81 daily Tricor 145 mg 1 tab daily Toprol XL 250 mg 1 tab daily Glipizide 10 mg 1 tab [**Hospital1 **] Doxazosin 2 mg 1 tab daily Levoxyl 25 mcg 1 tab daily Omeprazole 20 mg 1 tab daily Fluoxetine 20 mg 1 tab daily Insulin ?NPH Discharge Medications: 1. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Insulin Lispro 100 unit/mL Solution Sig: AS DIRECTED Subcutaneous ASDIR (AS DIRECTED). 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Disp:*21 Tablet(s)* Refills:*0* 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Acute lower gastrointestinal bleed Atrial fibrillation with rapid ventricular response Diabetes mellitus Sigmoid colitis Discharge Condition: Good Discharge Instructions: You were admitted for bleeding in your gut. We treated you with blood transfusions and also performed a colonoscopy, which showed that you have some inflammation in a small part of your colon. This may be related to the bleeding. Please take all of your medications as prescribed. Please keep all of your follow-up appointments. Changes to your medications: STOP warfarin and aspirin for now. You will need to discuss risks and benefits of continuing to take a blood thinner with your cardiologist. DECREASE metoprolol to 150 mg daily Followup Instructions: Name: [**Last Name (LF) 1295**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: HEART CENTER OF [**Hospital1 **] Address: [**Location (un) **],2ND FL, [**Location (un) **],[**Numeric Identifier 7398**] Phone: [**Telephone/Fax (1) 6256**] Fax: [**Telephone/Fax (1) 33001**] [**2184-9-3**] 3:30 P.M. Please call Dr. [**First Name (STitle) **] [**Name (STitle) **] to schedule a follow-up appointment with GI at [**Hospital1 18**]. ([**Telephone/Fax (1) 2233**] Completed by:[**2184-8-24**]

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icd9cm

[ [ [] ] ]

[ "99.07", "45.23", "88.47", "99.04" ]

icd9pcs

[ [ [] ] ]

7163, 7169

4313, 5776

295, 327

7334, 7340

2823, 4290

7931, 8484

2485, 2508

6139, 7140

7190, 7313

5802, 6116

7364, 7908

2523, 2804

246, 257

355, 2224

2246, 2407

2423, 2469

48,388

161,382

18080

Discharge summary

report

Admission Date: [**2158-10-20**] Discharge Date: [**2158-11-2**] Date of Birth: [**2099-12-5**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Lisinopril / Cefepime / Levaquin Attending:[**First Name3 (LF) 633**] Chief Complaint: fever and hypotension Major Surgical or Invasive Procedure: placement of Triple Lumen Catheter / central line (ICU) PICC line placement History of Present Illness: The patient is a 58 year old gentleman with a past medical history of suspected sarcoidosis vs autoimmune granulomatous disorder, prior splenectomy, PCV, recurrent diverticulitis leading to sigmoid resection with a complex course of anastomotic leak requiring multiple surgical interventions and prolonged antibiotic therapy who presented for a planned abdominal CT today. He was noted to be febrile to 101, c/o chills and found to be hypotensive to 90/60 and was referred to the emergency department. The CT was performed as previously planned without contrast given recent new renal faillure. In the emergency department, he received vanc and zosyn, and 4 liters of IVF. Admission was planned for the floor, however given his persistent hypotension an ICU bed was requested and a central line was placed for pressors though after 5-6L IVF he had no pressor requirement. ID called Dr. [**Last Name (STitle) **] and recomended Meropenem and linezolid and this was passed on to us. EKG was checked with a sinus rate of 96 ST depressions in II rSR'. CXR was checked and revealed no acute source of infection. . The patient was last hospitalized in [**5-3**] after being found to have a recurrent leak with intra-abdominal abscess requiring drainage. He was treated with vanco/ertapenem until [**6-28**] when a repeat scan on [**6-28**] showed resolution of the previous colonic anastomotic leak, complete collapse without residual fluid involving both abscess cavities. His drains were clamped at that time and pulled on [**7-4**]. His antibiotics were also discontinued on [**7-4**]. . When he was last seen in [**Hospital **] clinic on [**10-16**] he was feeling well. His had returned to work. He was c/o left shoulder which he attributed to a shoulder injury he sustained while at physical therapy and has noted left shoulder pain with movement since that time. He denies redness/swelling/erythema of the joint. MRI eval the same day was c/w tedinopathy. . Of note he is on chronic steroids and did receive flu vaccine [**10-16**]. . Past Medical History: (1) Splenectomy in [**2151-11-24**] when he had resection of a pancreatic mass at [**Hospital1 2025**]. (2) Thrombocythemia: 800,000 - 1,000,000. No clotting or bleeding. bone marrow biopsy on [**2153-3-1**] consistent with myeloproliferative disorder...abnormal karyotype with deletion 20q in 3 out of 20 metaphases. (3) Immune-mediated granulomatous disease. He is followed by Dr. Massarotti at [**Hospital1 112**]. (4) Hypertension. (5) Chronic renal insufficiency of unclear etiology. Baseline Cr 1.9 - 2. (6) High-risk adenocarcinoma of the prostate treated with radical prostatectomy on [**2151-5-31**], with no evidence of disease recurrence since that time. Path revealed granulomas. (7) Diabetes mellitus. (8) Gastritis, detected on EGD in [**2153-6-30**]. (9) In [**5-31**], he developed a perianal abscess with bacteremia. (10) h/o thrombophlebitis in left leg (11) uveitis (12) C4-C5 radiculopathy (13) HLD (14) HTN (15) recurrent autoimmune pericarditis (16) h/o benign pancreatic cyst s/p resection . PSH: [**2150**]: Splenectomy and benign pancreatic mass resection at [**Hospital1 2025**]. [**2150**]: Radical prostatectomy [**2157-3-6**]: Periumbilical hernia repair (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 112**]) [**2157-8-22**]: sigmoid colectomy, diverting ileostomy [**2157-9-12**]: ex-lap, removal of mesh from previous hernia repair, abdominal washout [**2157-9-13**]: emergent exlap, hematoma evacuation, abdominal packing, temporary closure [**2157-9-14**]: exlap, removal of packing, closure fascia [**2157-9-19**]: exlap, hematoma evacuation, closure of leak site at anastomosis [**2157-9-22**]: left index finger amputation [**2157-12-11**]: new drain placement [**2157-12-16**]: drain replaced (due to cracked tube) [**5-5**] & [**2158-5-6**] drain placement [**2158-5-12**] drain placement (due to tube dislodgement) - removed [**2158-7-4**]. [**2158-5-19**] split-thickness skin graft to abdominal surgical wound. . Social History: lives with wife, has grown children. Has pet dog. Works as attorney. He has three children, two males and one female, all healthy. Family History: Non-contributory, no history of recurrent infection Physical Exam: On admission to ICU: Vitals: 97 98/63 66 12 98% RA General Appearance: Well nourished Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, midline scar, with intact skin graft, colostomy bag with well-formed stool CDI Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Musculoskeletal: No redness, inflamation, tenderness of Left shoulder, [**2-25**] biceps tendon and rotator cuff strength on that side Skin: Warm, multiple bruises c/w coumadin Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Purposeful, Tone: Normal, see MSK for strenght findings Pertinent Results: . EKG [**10-20**]: Sinus rhythm with baseline artifact. Compared to the previous tracing of [**2158-5-4**] the rate has increased. . CT abdomen/pelvis without contrast [**2158-10-20**]: CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Centrilobular nodular densities are again seen in the right middle lobe of the lung, unchanged compared to [**2158-5-5**] and gradually increasing in conspicuity since [**2157-12-10**]. This may represent chronic infectious or inflammatory change. The linear atelectasis or scar at the right lung base laterally, which has been previously described, is stable, and there is slight left posterolateral atelectasis or scarring. A nodular density adjacent to the left hemidiaphragm measuring 5 mm is also stable (2:22). The non-contrast appearance of the heart and pericardium appear unremarkable except to note coronary artery and mitral annular calcifications. . Lobulated soft tissue density in left upper quadrant measuring 5.8 cm, most likely represent splenosis in this patient with history of prior splenectomy. A couple of nodules adjacent to the greater curvature of the stomach, one of which is calcified (2:31), also unchanged, may represent calcified lymph nodes or small splenules. In the porta hepatis, there is a tortuous prominence of vasculature suggestive of cavernous transformation of the portal vein, though this is not fully evaluated on this non-contrast enhanced examination. The appearance is unchanged. The gallbladder is collapsed containing hyperdense material within the lumen, which could represent stones. The bilateral adrenal glands are unchanged with calcification of the left gland. The kidneys appear lobulated consistent with scarring. A 9-mm hypodensity in the interpolar region of the left kidney measures 5 Hounsfield units consistent with a cyst. The patient is status post prior partial colectomy with loop ileostomy in the right lower quadrant. There is no evidence of free intraperitoneal air or abnormal dilation of bowel to suggest a bowel obstruction. Hyperdensity along the left flank laterally, representing the residual of the previously drained collection where a pigtail catheter had been seen on [**6-28**], appears similar. There is a ventral abdominal wall defect, with close protrusion of multiple loops of small bowel beneath the cutaneous surface and diastasis of the rectus musculature. . CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Suture line in the rectosigmoid junction is compatible with prior colonic anastomosis. Multiple surgical clips are seen within the deep pelvis and the site of prior prostatectomy. The urinary bladder and rectum appear unremarkable. The appendix is air filled throughout its length and appears normal (a small amount of hyperdensity is present at the appendiceal base and may represent an appendiculus). A few loops of small bowel in the upper pelvis protrude toward the skin surface at the site of a ventral abdominal wall defect. There is no free fluid or free air and no evidence of organized collection in the pelvis. . BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are identified. Degenerative change of the lumbar spine with grade 1 anterolisthesis of L4 on L5. . IMPRESSION: 1. No evidence of bowel perforation or obstruction, or of intra-abdominal abscess, as questioned. The collapsed cavity of a previously drained abscess is again seen in the left mid abdomen appearing stable. 2. Centrilobular nodular densities in right middle lobe of the lung, present over multiple previous examinations, may represent chronic atypical infectious or inflammatory process. 3. Non-contrast CT findings are suggestive of cavernous transformation of the portal vein. 4. Prior splenectomy with soft tissue nodule in the left upper quadrant, felt likely to represent splenosis or accessory spleen. . CXR [**2158-10-20**]: FINDINGS: Single frontal view of the chest was obtained. Left costophrenic angle is not fully included on the image. Opacity at the left costophrenic angle is not fully evaluated, but a small pleural effusion is not excluded. The right lung is clear. The cardiac and the mediastinal silhouettes are unremarkable. No overt pulmonary edema is seen. . . MRI Cervical Spine ([**10-22**]): FINDINGS: On the sagittal images, there is no malalignment or loss of vertebral body height. There is a retention cyst in the sphenoid sinus. The craniovertebral junction is unremarkable. The cord is normal in signal intensity. Axial images at C2-C3 demonstrate no significant abnormality. . At C3-C4, there is a disc osteophyte complex with mild right foraminal narrowing. At C4-C5, there is a disc osteophyte complex with severe bilateral foraminal narrowing and moderate to severe canal stenosis and mass effect on the thecal sac.There is stable mild increased signal in the anterior disc space at C4-C5 which is unchanged from [**2158-1-17**]. Degenerative changes appear to have progressed slightly since the previous examination of [**2158-1-17**]. On the STIR images, however, no significant marrow edema is noted and there is no progression of increased signal within the anterior disc to suggest that this represents infection rather than DJD. However, clinical correlation is advised. At C5-C6, there is a left eccentric disc bulge with severe left foraminal narrowing and mild-to-moderate central stenosis. At C6-C7, there is mild left foraminal narrowing. At C7-T1, there is mild left foraminal narrowing. There is scoliosis of the cervical spine to the left. . IMPRESSION: Multilevel degenerative changes are relatively stable compared to the previous examination. Degenerative end plate irregularity at C4-C5, appears to have progressed compared to the prior examination with a Schmorl's node at C5. There are no associated findings to suggest that this is infectious in etiology; however, clinical correlation is advised. No epidural abscess is noted. . CT Chest/Abdomen/Pelvis with contrast ([**10-24**]): CT OF THE CHEST WITH CONTRAST: Thyroid gland is normal in appearance with symmetric enhancement. The aorta and major branches are patent with a normal three-vessel arch. There is no axillary, supraclavicular, hilar, or mediastinal adenopathy. The heart and pericardium are unremarkable. There is dense atherosclerotic calcification in the LAD and circumflex arteries. There is no pericardial or pleural effusion. The esophagus is unremarkable. The trachea and central airways are patent to the segmental level. Centrilobular nodular densities are again seen in the right middle lobe and are unchanged from most recent comparison. Linear scarring is also seen in the lateral right lower lobe, similarly unchanged from the prior study. Left basal nodule is not well seen on the current study likely due to slice selection. . CT ABDOMEN WITH CONTRAST: The liver is normal in attenuation without focal lesion, intra- or extra-hepatic biliary dilatation. The hepatic veins appear patent. Cavernous transformation of the portal vein is noted. The splenic and superior mesenteric veins appear patent. The gallbladder is completely decompressed. There is focal hyperdensity within the gallbladder lumen, which could reflect a tiny gallstone. The pancreas is relatively atrophic but otherwise unremarkable. The patient is status post splenectomy with lobulated enhancing structure in the left upper quadrant likely reflective of splenosis. The adrenal glands are unremarkable. The kidneys are somewhat atrophic, but enhance and excrete contrast symmetrically. The stomach, small and large bowel are unremarkable with changes of prior partial colectomy and loop ileostomy in the right lower quadrant. Free flow of contrast is seen into the ileostomy without evidence of obstruction. There is no free intraperitoneal air or fluid. There is no mesenteric or retroperitoneal pathologic adenopathy with scattered nonenlarged nodes noted. There is no focal fluid collection. The aorta and major branches appear patent. The abdominal wall defect is again noted with close proximity of multiple loops of small bowel beneath the cutaneous surface and diastasis of the rectus musculature as previously mentioned. . CT OF THE PELVIS WITH CONTRAST: Foci of air in the bladder suggest prior catheterization. Correlation with history is recommended. The rectum is normal. The patient is status post prostatectomy. There is no free pelvic fluid. There is no pelvic or inguinal pathologic adenopathy though the patient is status post pelvic side wall lymph node dissection. . OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion concerning for osseous malignant process. . IMPRESSION: 1. No evidence of obstruction, perforation or intra-abdominal abscess. 2. Centrilobular nodular densities in the right middle lobe are again noted and present over several examinations that could reflect chronic infectious or inflammatory process. 3. Portal vein thrombosis with cavernous transformation of the portal vein. 4. Prior splenectomy with splenosis/accessory spleen likely in the left upper quadrant. . . Echocardiogram ([**10-27**]): Similar to prior study on [**2157-9-2**]. Suboptimal study. No vegetations seen. The left atrium is moderately dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 65%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 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 arch 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 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. . [**10-31**] CXR: IMPRESSION: 1. No evidence of pneumonia or other explanation for patient's fever. 2. Tiny bilateral pleural effusions. . PET Scan [**10-31**] MPRESSION: 1. Multiple abnormal foci of muscular FDG-avidity, including in the right gluteus maximus muscle adjacent to the coccyx and at the inferior aspect of the left rectus abdominus muscle just superior to the pubic symphysis with associated small nodular hyperdensities. These could represent an infectious or inflammatory process and may be amenable to biopsy. Additional focus of FDG-avidity within the left serratus anterior muscle is also present although no corresponding CT abnormality is definitively seen. 2. Small focus of increased FDG-avidity at the inferior aspect of the thyroid isthmus corresponding with a 7 mm nodule, concerning for thyroid malignancy. Fine needle aspiration is recommended. 3. Multiple retroperitoneal and mesenteric lymph nodes, most of which are not FDG-avid above background, and likely reactive. At least onemesenteric lymph node is mildly FDG-avid and may also be reactive although close attention on follow up is recommended. 4. Mildly increased FDG-avidity along the proximal right humerus of uncertain significance. 5. No abnormal pulmonary uptake to suggest pulmonary sarcoid. . MICROBIOLOGY: [**2158-11-1**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2158-10-30**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2158-10-30**] SEROLOGY/BLOOD LYME SEROLOGY-FINAL INPATIENT [**2158-10-30**] URINE URINE CULTURE-FINAL INPATIENT [**2158-10-30**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2158-10-28**] URINE URINE CULTURE-FINAL INPATIENT [**2158-10-28**] Immunology (CMV) CMV Viral Load-FINAL INPATIENT [**2158-10-28**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2158-10-28**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2158-10-26**] SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-FINAL INPATIENT [**2158-10-25**] URINE Legionella Urinary Antigen -FINAL INPATIENT [**2158-10-23**] URINE URINE CULTURE-FINAL INPATIENT [**2158-10-23**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2158-10-23**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2158-10-21**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2158-10-21**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2158-10-20**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2158-10-20**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] [**2158-10-20**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] . labs: [**2158-11-2**] 07:52AM BLOOD WBC-5.4 RBC-2.66* Hgb-8.7* Hct-27.7* MCV-104* MCH-32.9* MCHC-31.5 RDW-18.7* Plt Ct-383 [**2158-11-1**] 06:08AM BLOOD WBC-5.4 RBC-2.58* Hgb-8.4* Hct-27.3* MCV-106* MCH-32.5* MCHC-30.7* RDW-19.0* Plt Ct-377 [**2158-10-31**] 05:21AM BLOOD WBC-6.2 RBC-2.61* Hgb-8.6* Hct-28.1* MCV-108* MCH-32.8* MCHC-30.5* RDW-18.8* Plt Ct-429 [**2158-10-30**] 05:25AM BLOOD WBC-6.3 RBC-2.78* Hgb-9.1* Hct-28.8* MCV-104* MCH-32.9* MCHC-31.6 RDW-18.4* Plt Ct-418 [**2158-10-29**] 05:09AM BLOOD WBC-5.8 RBC-2.60* Hgb-8.5* Hct-26.5* MCV-102* MCH-32.6* MCHC-32.0 RDW-18.7* Plt Ct-423 [**2158-10-28**] 06:40AM BLOOD WBC-7.2 RBC-2.94* Hgb-9.5* Hct-29.9* MCV-102* MCH-32.2* MCHC-31.6 RDW-18.7* Plt Ct-447* [**2158-10-27**] 07:00AM BLOOD WBC-6.9 RBC-2.97* Hgb-9.8* Hct-30.2* MCV-102* MCH-33.2* MCHC-32.6 RDW-18.8* Plt Ct-496* [**2158-10-26**] 06:45AM BLOOD WBC-7.1 RBC-2.99* Hgb-9.6* Hct-30.4* MCV-102* MCH-32.1* MCHC-31.5 RDW-19.0* Plt Ct-550* [**2158-10-25**] 10:25AM BLOOD WBC-12.4* RBC-2.95* Hgb-9.5* Hct-29.9* MCV-101* MCH-32.3* MCHC-31.8 RDW-18.9* Plt Ct-542* [**2158-10-25**] 07:20AM BLOOD WBC-10.1 RBC-2.84* Hgb-9.7* Hct-29.0* MCV-102* MCH-34.2* MCHC-33.5 RDW-19.0* Plt Ct-540* [**2158-10-24**] 07:15AM BLOOD WBC-12.9* RBC-3.04* Hgb-10.2* Hct-30.6* MCV-101* MCH-33.4* MCHC-33.1 RDW-19.0* Plt Ct-581* [**2158-10-23**] 07:20AM BLOOD WBC-12.0* RBC-2.98* Hgb-9.4* Hct-30.3* MCV-102* MCH-31.6 MCHC-31.0 RDW-19.1* Plt Ct-649* [**2158-10-22**] 05:10AM BLOOD WBC-9.6 RBC-2.70* Hgb-8.9* Hct-27.5* MCV-102* MCH-33.1* MCHC-32.4 RDW-19.7* Plt Ct-618* [**2158-10-21**] 04:12AM BLOOD WBC-11.1* RBC-2.71* Hgb-8.9* Hct-27.7* MCV-102* MCH-32.8* MCHC-32.1 RDW-19.5* Plt Ct-626* [**2158-10-20**] 10:41PM BLOOD WBC-12.0* RBC-2.88* Hgb-9.1* Hct-29.2* MCV-101* MCH-31.4 MCHC-31.0 RDW-19.2* Plt Ct-644* [**2158-10-20**] 02:25PM BLOOD WBC-14.0* RBC-3.72* Hgb-12.0* Hct-38.1* MCV-103* MCH-32.2* MCHC-31.4 RDW-18.8* Plt Ct-758* [**2158-10-24**] 07:15AM BLOOD Neuts-96* Bands-0 Lymphs-3* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* [**2158-10-28**] 07:34PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+ Macrocy-2+ Microcy-1+ Polychr-NORMAL Spheroc-1+ Ovalocy-1+ Target-OCCASIONAL Schisto-OCCASIONAL [**2158-11-2**] 11:30AM BLOOD PT-20.9* PTT-30.6 INR(PT)-1.9* [**2158-11-2**] 09:35AM BLOOD PT-21.4* PTT-31.3 INR(PT)-2.0* [**2158-11-1**] 10:45AM BLOOD PT-23.7* PTT-32.5 INR(PT)-2.2* [**2158-10-31**] 05:21AM BLOOD PT-33.0* PTT-35.2* INR(PT)-3.3* [**2158-10-30**] 10:40AM BLOOD PT-43.7* PTT-42.4* INR(PT)-4.5* [**2158-10-30**] 05:25AM BLOOD PT-41.7* PTT-39.1* INR(PT)-4.3* [**2158-10-29**] 05:09AM BLOOD PT-28.1* PTT-41.2* INR(PT)-2.7* [**2158-10-28**] 06:40AM BLOOD PT-29.9* PTT-42.2* INR(PT)-2.9* [**2158-10-27**] 07:00AM BLOOD PT-24.9* PTT-32.2 INR(PT)-2.4* [**2158-10-26**] 06:45AM BLOOD PT-24.0* PTT-31.5 INR(PT)-2.3* [**2158-10-30**] 05:25AM BLOOD Parst S-NEGATIVE [**2158-10-28**] 06:40AM BLOOD ESR-59* [**2158-11-2**] 07:52AM BLOOD Glucose-127* UreaN-26* Creat-1.8* Na-139 K-4.3 Cl-104 HCO3-25 AnGap-14 [**2158-11-1**] 06:08AM BLOOD Glucose-56* UreaN-26* Creat-1.9* Na-136 K-4.2 Cl-100 HCO3-26 AnGap-14 [**2158-10-31**] 05:21AM BLOOD Glucose-87 UreaN-26* Creat-2.0* Na-137 K-4.5 Cl-104 HCO3-26 AnGap-12 [**2158-10-30**] 05:25AM BLOOD Glucose-96 UreaN-21* Creat-1.9* Na-138 K-4.7 Cl-101 HCO3-25 AnGap-17 [**2158-10-29**] 05:09AM BLOOD Glucose-137* UreaN-22* Creat-1.9* Na-137 K-4.4 Cl-103 HCO3-27 AnGap-11 [**2158-10-28**] 06:40AM BLOOD Glucose-86 UreaN-23* Creat-2.0* Na-135 K-4.7 Cl-98 HCO3-27 AnGap-15 [**2158-10-27**] 07:00AM BLOOD Glucose-86 UreaN-24* Creat-2.0* Na-135 K-4.6 Cl-97 HCO3-28 AnGap-15 [**2158-10-25**] 07:20AM BLOOD Glucose-84 UreaN-24* Creat-1.8* Na-135 K-5.0 Cl-96 HCO3-30 AnGap-14 [**2158-10-24**] 07:15AM BLOOD Glucose-70 UreaN-25* Creat-1.9* Na-134 K-4.9 Cl-99 HCO3-26 AnGap-14 [**2158-10-23**] 07:20AM BLOOD Glucose-59* UreaN-29* Creat-1.9* Na-136 K-4.5 Cl-106 HCO3-21* AnGap-14 [**2158-10-22**] 05:10AM BLOOD Glucose-91 UreaN-41* Creat-1.8* Na-141 K-4.3 Cl-110* HCO3-21* AnGap-14 [**2158-10-21**] 01:45PM BLOOD Glucose-180* UreaN-45* Creat-2.0* Na-139 K-4.5 Cl-110* HCO3-21* AnGap-13 [**2158-10-21**] 04:12AM BLOOD Glucose-227* UreaN-51* Creat-2.2* Na-147* K-5.2* Cl-118* HCO3-19* AnGap-15 [**2158-10-20**] 02:25PM BLOOD Glucose-98 UreaN-69* Creat-3.1* Na-134 K-8.3* Cl-99 HCO3-21* AnGap-22* [**2158-11-2**] 07:52AM BLOOD ALT-21 AST-14 AlkPhos-127 TotBili-0.2 [**2158-10-31**] 05:21AM BLOOD ALT-28 AST-16 LD(LDH)-180 AlkPhos-130 TotBili-0.2 [**2158-10-29**] 05:09AM BLOOD ALT-20 AST-15 AlkPhos-119 TotBili-0.2 [**2158-10-21**] 04:12AM BLOOD ALT-27 AST-18 LD(LDH)-194 CK(CPK)-36* AlkPhos-126 TotBili-0.2 [**2158-10-20**] 10:41PM BLOOD ALT-26 AST-21 LD(LDH)-206 CK(CPK)-33* AlkPhos-134* TotBili-0.2 [**2158-10-20**] 02:25PM BLOOD ALT-43* AST-90* LD(LDH)-1235* AlkPhos-197* TotBili-0.4 [**2158-10-20**] 10:41PM BLOOD Lipase-24 [**2158-10-21**] 04:12AM BLOOD CK-MB-3 cTropnT-<0.01 [**2158-10-20**] 10:41PM BLOOD CK-MB-2 cTropnT-0.02* [**2158-10-20**] 02:25PM BLOOD cTropnT-0.05* [**2158-10-28**] 06:40AM BLOOD Ferritn-508* [**2158-10-28**] 06:40AM BLOOD TSH-2.2 [**2158-10-28**] 06:40AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE [**2158-10-26**] 06:45AM BLOOD ANCA-NEGATIVE B [**2158-10-28**] 06:40AM BLOOD RheuFac-16* CRP-82.7* [**2158-10-26**] 06:45AM BLOOD [**Doctor First Name **]-NEGATIVE [**2158-10-28**] 06:40AM BLOOD PEP-NO SPECIFI [**2158-10-28**] 06:40AM BLOOD HCV Ab-NEGATIVE [**2158-10-30**] 10:40AM BLOOD QUANTIFERON-TB GOLD-PND [**2158-10-28**] 07:34PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD- [**2158-10-27**] 12:25PM BLOOD HISTOPLASMA ANTIBODY (BY CF AND ID)-Test [**2158-10-26**] 06:45AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test [**2158-10-26**] 06:45AM BLOOD COCCIDIOIDES ANTIBODY, IMMUNODIFFUSION-Test [**2158-10-26**] 06:45AM BLOOD HISTOPLASMA ANTIGEN- [**2158-10-26**] 06:45AM BLOOD B-GLUCAN-Test Brief Hospital Course: 58M with a complicated past medical including a history of complicated abdominal abcesses and presumed sarcoidosis presenting with fever, hypotension and leukocytosis. . #Fever with hypotension - In a gentleman with a history of immunocompromise and a complex history of intrabdominal infections and a fever, concern for sepsis was high. Systolic BPs at lowest were in the 80s. He responded to IV fluid boluses and received a total of 7L during his ED and ICU stay. BPs thereafter remained stable. He did not require pressors. Per ID recommendations, he was started on linezolid and meropenem in the ICU. He did receive a dose of dexamethasone in the ED and a few dose of hydrocortisone for stress dose steroids in the ICU. All blood cultures have been negative to date as well as urine and stool. Lyme serologies negative. Crytococcus antigen, legionella antigen were negative. Beta-glucan, galactomannan, Cocci Ab, Histo Ab/antigen were negative. EBV/CMV VL were undetected. Blood smear was not suggestive of blast cells. ESR/CRP were elevated, but [**Doctor First Name **] and ANCA were negative. Hepatitis serologies were negative. Pt did not meet criteria for adult Stills disease. In addition, his background was not suggestive of heritage to strongly support FMF. There were obvious signs of malignancy other than (Thyroid nodule-see below). Imaging studies including echocardiogram, 2 CT scans, and MRI of the c-spine, and CXR have been unrevealing. Therefore, it was decided that patient would be treated with IV meropenem and PO linezolid for a 14 day course of therapy to treated suspected bacteremia from an intraabdominal source given his prior complicated abdominal anatomy and history of abdominal abscesses/infection with MDR organisms. PET scan was performed as well showing FDG avidity in the thyroid nodule as well as some areas of musculature (rectus, serratus, gluteus). However, corresponding imaging of these areas did not suggest abscess/infection. ID, rheumatology, and radiology discussed extensively these radiographic findings and decided that that areas of avidity were unlikely to be infectious and have unclear if any clinical significance. Quantiferon gold is still PENDING at the time of discharge. Pt will be discharged home to complete his course of Linezolid and meropenem, 1 day of therapy left at time of discharge. In addition, he will follow up with rheumatology to continue evaluation for his underlying granulomatous disease ?sarcoid and to continue to consider whether this process is involved in current presentation. In addition, he will follow up in [**Hospital **] clinic to continue his infectious w/u and in hematology/oncology clinic. He carries a diagnosis of PCV, however there was no evidence of leukemia on peripheral smear. Flow was considered, but pathology felt that this was not indicated given lack of apparent blasts cells, but this can be considered in the outpatient setting as well as a bone marrow biopsy. . #Acute on chronic renal failure. Urine lytes c/w Pre-Renal etiology. FeNa of 0.5. Creatinine returned to baseline. Currently CKD III. Did receive IV contrast for CT scan on this admission and was given pre- and post-hydration with sodium bicarbonate. Creatinine has remained stable and was 1.8 on discharge. . #PCV - Platelets chronically elevated. HCT goal is less than 45 which the patient is currently at. He was continued on his hydrea . #GERD - continued on PPI. . #Radiculopathy - continued GABAPENTIN renally adjusted and decreased to 300mg [**Hospital1 **]. . #Granulomatous dz/Sarcoid - He was continued on his hydroxychloroquine. He received stress dose steroids initially and was transitioned back to home dose prednisone. He was seen by Rheumatology Consult, and in reviewing his case, they suggested to consider a pulmonary or renal biopsy to attempt to confirm his diagnosis of sarcoidosis. His diagnosis had previously been based on the constellation of uveitis and granulomas seen on prostate biopsy from his radical prostatectomy. [**Doctor First Name **] and ANCA were negative. Pt did not appear interested in this at this time. In addition, see above for PET results. There were some superficial appearing areas of muscular avidity which may be associated with ???sarcoid. Biopsy can be considered in the outpatient setting. . #Portal vein thrombosis - INR was 4.0 upon admission. Coumadin was held initially then resumed. He became supratherapeutic again and coumadin was held on [**2158-10-30**]. INR returned to 2.0, coumadin was resumed on [**11-1**]. Currently he is therapeutic on his home regimen of Coumadin 7.5mg and 10mg alternating daily. Pt was instructed to continue this regimen upon discharge. INR monitoring as previously schedule. . #L.shoulder tendonitis-Pt reported history of L.arm weakness since a recent rehab stay. He developed pain in the last few weeks. Outpt MRI suggested tendinopathy. Given that this was patient's only localizing symptom, considered infection. However, outpt MRI did not suggest infection and PET did not suggest infection of this area. Pt did not have erythema or other suggestion that this was an infected joint. Pt was started on oxycodone and a lidocaine patch for pain. Pt should f/u in rheumatology clinic as well as consideration of ortho clinic to consider need for local injection, physical therapy and/or need for surgical intervention. . #THYROID NODULE-SUSPICIOUS FOR MALIGNANCY. TSH WAS NORMAL. REVEALED ON PET IMAGING. PT IS AWARE THAT HE WILL NEED OUTPT THYROID U/S AND BIOPSY OF THIS AREA TO R/O MALIGNANCY. HOWEVER, CT OF THE CHEST REMARKED THAT THE THYROID WAS NORMAL APPEARING. . #macrocytic anemia-baseline appears to be 26-30. last b12 and folate were normal. Currently at baseline. No signs of active bleeding. Hct on discharge 27.7 . #thrombocytosis-likely due to prior splenectomy. Could also be reactive. Resolved. plt count 383 on discharge. . #DM-continue HISS +10units lantus. DM diet. FS QId. . FEN - diabetic diet . Prophylaxis - INR > 2 . Precautions - prior hx of VRE . Code - full code . Transitional Issues: 1. He will need repeat chest imaging to monitor the CENTRILOBULAR RML OPACITY seen on CT scan (seen on prior imaging as well). . Medications on Admission: ESOMEPRAZOLE MAGNESIUM [NEXIUM] - (Prescribed by Other Provider) - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once daily GABAPENTIN - 400 mg Capsule - 1 Capsule(s) by mouth three times a day HYDROXYCHLOROQUINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day HYDROXYUREA - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 500 mg Capsule - 1 Capsule(s) by mouth daily. INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Cartridge - 10 units once daily at bedtime INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100 unit/mL Cartridge - Administer per sliding scale PREDNISONE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once daily PREDNISONE - 1 mg Tablet - 4 Tablet(s) by mouth once a day w/food WARFARIN - 2.5 mg Tablet - Take up to 3 tablets by mouth once a day at 4pm or as directed by [**Hospital 191**] [**Hospital 197**] Clinic Medications - OTC ASCORBIC ACID - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 500 mg Tablet - 1 Tablet(s) by mouth twice daily CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 WITH D] - 500 mg (1,250 mg)-400 unit Tablet - 1 Tablet(s) by mouth twice a day CHOLECALCIFEROL (VITAMIN D3) - 400 unit Capsule - 2 Capsule(s) by mouth once a day LOPERAMIDE [LO-PERAMIDE] - (Prescribed by Other Provider) - 2 mg Tablet - 2 Tablet(s) by mouth twice a day MULTIVITAMIN,TX-MINERALS [VITAMINS & MINERALS] - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once daily PSYLLIUM - (Prescribed by Other Provider) - Packet - 1 Packet(s) by mouth twice a day Discharge Medications: 1. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*0* 8. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): alternate with the 10mg dose. 10. warfarin 5 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day): alternate with the 7.5mg dose. 11. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. insulin glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 13. Humalog 100 unit/mL Solution Sig: per sliding scale Subcutaneous QIDACHS. 14. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 doses. Disp:*3 Tablet(s)* Refills:*0* 15. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 16. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 5 doses. Disp:*5 Recon Soln(s)* Refills:*0* 17. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: DO NOT DRIVE WHEN TAKING THIS MEDICATION. Take only as directed. Disp:*10 Tablet(s)* Refills:*0* 18. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 19. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: Home solutions Discharge Diagnosis: acute: FUO/sepsis presumed due to intraabdominal source fever hypotension chronic: presumed sarcoidosis polycythemia [**Doctor First Name **] chronic kidney disease III diabetes mellitus diverticulitis s/p resection and ostomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with fever and low blood pressure, and initially you required admission to the ICU given your severe hypotension requiring aggressive IV fluids. You were placed on broad spectrum antibiotics, although the work-up has been negative for a specific infectious source at this time. You were seen by the Infectious Disease consultants and the Rheumatology consultants during this admission. You underwent multiple imaging studies, including CT scanx2, echocardiogram, and PET scan during this admission as well as multiple laboratory studies searching for infection. The PET scan, lit up a thyroid nodule that will require to to follow up with your PCP for [**Name Initial (PRE) **] thyroid biospy. In addition, the PET scan lit up some small non-specific areas of muscle that neither ID, rheumatology, or radiology feel strongly are consistent with infection. . Please resume your coumadin schedule as prior to admission. . Your medication changes: 1.Start linezolid and continue through friday 2.start meropenem and continue through friday 3.your neurontin was changed to 300mg twice a day due to your chronic kidney disease. 4.You were started on a lidocaine patch for pain 5.you were given a limited supply of oxycodone for pain. Please take only as directed. DO NOT DRIVE when taking this medication. This medication may cause constipation. Please purchase senna and colace over the counter to prevent constipation. . Please continue medications and keep the medical appointments as listed below. . Followup Instructions: Name: NP [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 10564**] Location: [**Hospital6 5242**] CENTER Internal Medicine Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 798**] Appointment: Monday [**2158-11-6**] 9:50am *This is a follow up appointment for your hospitalization. You will be reconnected with your primary care physician after this visit. Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 18**]-DIVISION OF RHEUMATOLOGY Address: [**Doctor First Name **], STE 4B, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2226**] *Dr. [**Last Name (STitle) **] is going to call you at home to discuss your follow up care. If you have any questions or concerns please call the office. Department: INFECTIOUS DISEASE When: WEDNESDAY [**2158-11-8**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2158-12-7**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD,PHD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2158-12-7**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "38.93", "00.11" ]

icd9pcs

[ [ [] ] ]

33968, 34013

24122, 30204

350, 428

34285, 34285

5704, 24099

35996, 37833

4688, 4742

32007, 33945

34034, 34264

30382, 31984

34436, 35398

4757, 5685

30225, 30356

35418, 35973

288, 312

456, 2500

34300, 34412

2522, 4523

4539, 4672

82,685

110,953

48014

Discharge summary

report

Admission Date: [**2142-7-23**] Discharge Date: [**2142-8-3**] Date of Birth: [**2079-5-4**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 922**] Chief Complaint: Left sided chest pain/back pain Major Surgical or Invasive Procedure: [**2142-7-23**] 1. Replacement of ascending aorta and hemiarch with a 32-mm Dacron Vascutek Gelweave graft using deep hypothermic circulatory arrest. 2. Coronary artery bypass grafting x1 with left internal mammary artery to left anterior descending coronary artery. History of Present Illness: 62 year old gentleman with a history of a type B aortic dissection in [**2141-6-9**] and ascending aortic aneurysm discovered at that time which has been managed medically with blood pressure control. Given the significance of his aneurysm along with possiblity of a connective tissue disorder, it was planned to proceed with surgery. He underwent a cardiac catheterization which revealed left anterior descending artery disease Past Medical History: Hypertension Type B Aortic Dissection Abdominal aortic aneurysm Ascending aortic aneurysm Chronic obstructive pulmonary disease Depression Gastroesophageal reflux disease Osteoarthritis Anemia Chronic Kidney Disease Stage 4 - Due to dissection of the renal artery Past Surgical History: Teeth Extraction Tonsillectomy Social History: Occupation: retired Last Dental Exam: many yrs ago, edentulous Lives with: roommate Race: Caucasian Tobacco: quit 1 yr ago after 2ppd x 40 yrs ETOH: rare Family History: Family History: non-contributory, father died of cirrhosis Occupation: retired Lives with: roommate Race: Caucasian Tobacco: quit 1 yr ago after 2ppd x 40 yrs ETOH: rare Physical Exam: Pulse: 57 Resp: 20 O2 sat: 98% B/P Left: 137/88 Height: 6'2" Weight: 215 lb General: well-developed male in no acute distress Skin: Dry [x] intact [x] lipoma on upper back HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally []expiratory wheezes throughout Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: alert and oriented to person and place, non focal Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: no bruit Left: no bruit Pertinent Results: [**2142-7-31**] 10:05AM BLOOD WBC-10.9 RBC-3.26* Hgb-9.6* Hct-28.5* MCV-88 MCH-29.4 MCHC-33.6 RDW-15.3 Plt Ct-291 [**2142-7-30**] 02:01AM BLOOD WBC-10.9 RBC-3.31* Hgb-9.7* Hct-28.8* MCV-87 MCH-29.3 MCHC-33.7 RDW-15.5 Plt Ct-254 [**2142-7-31**] 10:05AM BLOOD Glucose-112* UreaN-58* Creat-3.0* Na-134 K-5.1 Cl-100 HCO3-24 AnGap-15 [**2142-7-30**] 02:01AM BLOOD Glucose-103* UreaN-53* Creat-3.0* Na-134 K-4.8 Cl-99 HCO3-25 AnGap-15 TTE [**2142-7-23**]: Pre-bypass: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is markedly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The abdominal aorta is moderately dilated. A mobile density is seen in the descending aorta consistent with an intimal flap/aortic dissection. The aortic wall is thickened consistent with an intramural hematoma. There is flow in the false lumen. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post-bypass: There is a well-seated aortic graft above the level of the aortic annulus that measures 32 mm in diameter. Biventricular systolic function is unchanged. The aortic contour is unchanged post decannulation. [**2142-8-1**] 05:58AM BLOOD WBC-11.8* RBC-3.16* Hgb-9.0* Hct-27.5* MCV-87 MCH-28.6 MCHC-32.8 RDW-15.5 Plt Ct-293 [**2142-8-1**] 05:58AM BLOOD PT-21.9* PTT-31.8 INR(PT)-2.0* [**2142-8-1**] 05:58AM BLOOD Glucose-87 UreaN-61* Creat-3.1* Na-131* K-5.0 Cl-97 HCO3-25 AnGap-14 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2142-7-23**] where he underwent replacement of ascending aorta and hemiarch with a 32-mm Dacron Vascutek Gelweave graft using deep hypothermic circulatory arrest and coronary artery bypass grafting x1 with left internal mammary artery to left anterior descending coronary artery. See operative note for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and some breathing difficulty requiring BIPAP. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. He was started on Vancomycin and Cefepime for a presumed left sided pneumonia for a 10 day course. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He was in and out of rate controlled atrial fibrillation throughout his hospital course and started on Amiodarone and Coumadin with an INR goal 2-2.5. He will be followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and the [**Hospital 756**] [**Hospital3 **] for his Coumadin dosing. The patient was transferred to the telemetry floor for further recovery on post operative day 5. On post operative day 6 the patient was swallowing a medication, started choking and had a vagal episode losing consciousness for a few seconds. The patient was hemodynamically stable after the episode with no events on the monitor throughout the episode. He was transferred to the CVICU for further monitoring. He remained hemodynamically stable and was transferred back to the telemetry floor in stable condition. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. The patient was ambulating with oxygenation desaturation. Reassessment of his pulmonary status proved further pulmonary rehabilitation was required prior to discharge home. The wound was healing and pain was controlled with oral analgesics. He was transfused 2units of PRBC for a hematocrit of 25.6% on [**2142-8-2**]. Hematocrit rose appropriately. The patient was discharged to rehab in good condition with appropriate follow up instructions. Medications on Admission: Albuterol INH PRN Norvasc 10 mg daily Famotidine 20 mg daily Lisinopril 5 mg daily Metoprolol 12.5 mg [**Hospital1 **] Omeprazole 20 mg daily Zoloft 100 mg daily Simvastatin 40 mg daily Aspirin 325mg daily Allergies: SULFA DRUGS Discharge Medications: 1. Outpatient Lab Work Labs Chem 7 on [**8-9**] with results to Dr [**Last Name (STitle) **] fax ([**Telephone/Fax (1) 11957**] 2. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication Atrial fibrilation Goal INR 2.0-2.5 First draw [**8-6**] for further dosing 3. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 3 days: for treatment of pneumonia . 4. Cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q24H (every 24 hours) for 3 days: for treatment of pneumonia . 5. Chest PT Chest PT q6h to LLL 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. PICC line Per PICC line protocol 10. Warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 2 days: please give sat and sun - lab draw monday for further dosing . 11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for prior to walking . 13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 15. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 16. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 18. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours. 19. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 21. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q6H (every 6 hours) as needed for dyspnea. 22. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 23. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 86**] Center for Rehab & Sub-Acute Care - [**Location (un) 2312**] Discharge Diagnosis: 1. Ascending aortic aneurysm. 2. Chronic type B aortic dissection involving the descending thoracic aorta and abdominal aorta. 3. Single-vessel coronary disease.s/p Replacement of ascending aorta and hemiarch with a 32-mm Dacron Vascutek Gelweave graft using deep hypothermic circulatory arrest/Coronary artery bypass grafting x1 with left internal mammary artery to left anterior descending coronary artery 4. Chronic obstructive pulmonary disease. 5. Chronic renal failure. Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) 914**] on [**2142-8-28**] at 2:15 PM [**Telephone/Fax (1) 170**] Nephrology: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2142-8-14**] 2:00 [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2142-8-9**] 9:00 Labs Chem 7 on [**8-9**] with results to Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 11957**] Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-10**] weeks Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-10**] weeks ([**Telephone/Fax (1) 101276**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication Atrial fibrilation Goal INR 2.0-2.5 First draw [**8-6**] for further dosing Completed by:[**2142-8-3**]

[ "403.90", "784.99", "486", "285.21", "427.31", "530.81", "788.20", "311", "585.4", "441.2", "414.01", "276.1", "496", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "39.61", "38.45", "36.15", "38.93" ]

icd9pcs

[ [ [] ] ]

9793, 9903

4739, 7149

327, 614

10428, 10596

2558, 4716

11435, 12597

1618, 1775

7431, 9770

9924, 10407

7175, 7408

10620, 11412

1381, 1414

1790, 2539

256, 289

642, 1072

1094, 1358

1430, 1586

60,118

130,975

42038

Discharge summary

report

Admission Date: [**2127-8-2**] Discharge Date: [**2127-8-18**] Date of Birth: [**2050-12-30**] Sex: F Service: NEUROLOGY Allergies: morphine Attending:[**Last Name (NamePattern1) 11784**] Chief Complaint: AMS Major Surgical or Invasive Procedure: Endotracheal intubation [**2127-8-10**] History of Present Illness: This is a 75yo F PMHx L MCA stroke with residual dysarthria / aphasia / partial R hemiplegia, AF on coumadin, DM, HTN, HLD, who initally presented with lethargy to an OSH. Per patient's family, they had found her increasingly lethargic that AM, and "looked sweaty". At OSH, there was concern for whether or not neurologic exam findings were acute or chronic (family was not there to clarify), so patient was transferred to [**Hospital1 18**] for further management. . At [**Hospital1 18**], intial vital signs were 97.2 70 159/93 18 99%NRB. Exam was significant for alterred mental status, neuro exam significant for dysarthria, partial R hemiplegia (family arrived at this point and reported these were ALL CHRONIC, no new deficits). NCHCT did not demonstrate any acute changes. EKG w/o prior for comparison, demonstrating qwaves. Labs were significant for WBC 9.5, Hct 38.1, Cr 0.7, Trop 7.66, UA w 1WBC, no bacteria. CXR w/o acute process. Patient denied CP, SOB, cough, fever. . Given AMS and initial concern for CVA, patient was evaluated by neurology who felt that given lack of new findings on exam and imaging, it was unlikely that patient was having a stroke, but that close neuro monitoring in an ICU was recommended. . Given elevated troponin, cardiology was consulted, who felt that cause of troponin elevation was unclear given ECG without signs of acute ischemia/infarct in a patient without chest pain; they felt that potential causes could include demand ischemia [**1-22**] afib vs neurogenic myocardial mediated by catecholamines. Patient was admitted to MICU for further monitoring Vital signs prior to transfer were 96.5 110 114/81 2L98%3LNC. Patient was comfortable, and on ROS had back pain but no chest pain, dyspnea, headache, fever, abdominal pain, or extremity pain. This was limited by her dysarthria and expressive aphasia. Past Medical History: - [**2-/2127**] - L MCA stroke with residual dysarthria / aphasia / partial R hemiplegia - AF on coumadin - DM - HTN - HLD - GERD Social History: Not tobacco, ETOH, or illicits. Currently residing in a nursing home s/p L MCA stroke. Mobilizes with wheelchair, needs assistance for transfers and ADLs. Family History: Strokes (mother, multiple), HTN (multiple family members) Physical Exam: Admission Exam: Vitals: T: 36.2 BP: 116/78 (symmetric bilaterally) P: 100 R: 18 O2: 94% General: Somnolent but rouses to voice, oriented x1, dysarthric, no acute distress HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irrregular rate and tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: 1+ pulses, no clubbing, cyanosis or edema Neuro: CN: II - L hemianopia, PERRLA 5->3 mm III, VI, VI - EOMI V - sensation intact to light touch VII - R facial weakness VIII - hearing intact bilaterally IX, X - palate elevates symmetrically [**Doctor First Name 81**] - [**4-24**] SCM strength XII - tongue midline Strength - L normal strength throughout, R significantly reduced Sensation - L normal throughout, R diminished Guaic Negative Discharge Exam: ******************* Patient afebrile, RR at 14. Did not complete full exam as pt was CMO at discharge. Pertinent Results: Admission Labs: [**2127-8-2**] 04:42PM BLOOD WBC-9.5 RBC-4.53 Hgb-12.6 Hct-38.1 MCV-84 MCH-27.9 MCHC-33.1 RDW-16.2* Plt Ct-264 [**2127-8-2**] 04:42PM BLOOD Neuts-88.9* Lymphs-7.1* Monos-2.9 Eos-0.6 Baso-0.5 [**2127-8-2**] 04:42PM BLOOD PT-19.4* PTT-26.0 INR(PT)-1.8* [**2127-8-2**] 04:42PM BLOOD Glucose-201* UreaN-31* Creat-0.7 Na-139 K-4.6 Cl-105 HCO3-24 AnGap-15 [**2127-8-2**] 04:42PM BLOOD CK(CPK)-1095* [**2127-8-2**] 04:42PM BLOOD Lipase-35 [**2127-8-2**] 04:42PM BLOOD CK-MB-64* MB Indx-5.8 cTropnT-7.66* [**2127-8-3**] 05:00AM BLOOD Calcium-10.2 Phos-2.6* Mg-1.8 Cholest-137 [**2127-8-3**] 05:00AM BLOOD %HbA1c-6.5* eAG-140* [**2127-8-3**] 05:00AM BLOOD Triglyc-60 HDL-60 CHOL/HD-2.3 LDLcalc-65 [**2127-8-3**] 04:50PM BLOOD Cortsol-28.8* [**2127-8-2**] 11:07PM BLOOD Type-[**Last Name (un) **] Temp-36.2 pO2-18* pCO2-56* pH-7.35 calTCO2-32* Base XS-2 [**2127-8-2**] 11:07PM BLOOD Lactate-2.2* CE Trend: [**2127-8-2**] 04:42PM BLOOD CK-MB-64* MB Indx-5.8 cTropnT-7.66* [**2127-8-2**] 10:45PM BLOOD CK-MB-36* cTropnT-3.29* [**2127-8-3**] 05:00AM BLOOD CK-MB-20* MB Indx-4.2 cTropnT-3.42* [**2127-8-3**] 11:05AM BLOOD CK-MB-13* MB Indx-3.8 cTropnT-2.94* [**2127-8-3**] 04:50PM BLOOD CK-MB-10 MB Indx-3.5 cTropnT-2.66* [**2127-8-4**] 03:37AM BLOOD CK-MB-8 cTropnT-1.72* Discharge Labs: We did not do labs on discharge as pt was made CMO. Imaging: [**8-2**] CXR: Mild CHF [**8-3**] CT Head: There is a moderate sized hypodense area in the right occipital lobe parasagittal in location, ( se 2, im 15-18) involving the cortex and adjacent white matter with effacement/ indistinct appearance of the right occipital [**Doctor Last Name 534**], representing an acute infarct in the right PCA territory. D/w Dr.[**Last Name (NamePattern4) 91264**] by Dr.[**Last Name (STitle) **] on [**2127-8-3**] at 2.35pm. Cllinical team is aware of the findings earlier. [**8-4**] CTA Head and Neck: HEAD AND NECK CTA: Occlusion of the distal right posterior cerebral artery, compatible with distribution of infarction. Otherwise, the remaining arteries are patent with no evidence of stenosis. No evidence of aneurysm formation. IMPRESSION: 1. Extension of the previously described right posterior cerebellar artery infarction now including the right occipital and right temporal lobe. 2. New area of infarction involving the right cerebellar hemisphere. 3. Occlusion of the distal right posterior cerebellar artery compatible with the distribution of infarction. 4. No evidence of herniation or midline shift. [**8-4**] EEG IMPRESSION: This is a markedly abnormal record. It shows significant loss of background frequencies suggestive of either multifocal disease or significant encephalopathic component. There are paroxysmal epileptiform features seen independently in the left central and over the right central temporal region. The activity in the right is occasionally very rhythmic suggesting a brief electrographic seizure. These occurred perhaps 30-40 times during the course of the record and usually lasted 10-20 seconds in duration. There is no clinical accompaniment with these events. The cardiac monitor, in addition, is abnormal. [**8-5**] NCHCT IMPRESSION: 1. Technically limited study due to artifacts from monitoring devices on the scalp. Evaluation of inferior cerebellar hemispheres is particularly limited. 2. Evolving infarcts in the right PCA and SCA territories. No evidence of new intracranial abnormalities. [**8-5**] EEG IMPRESSION: This 24-hour recording is most compatible with a moderately severe to severe diffuse encephalopathy with multifocal features suggesting both an encephalopathy and underlying structural pathology. The left frontal central region seems to be one area of independent abnormality, as well as the more posterior aspects of the right hemisphere. There were no sustained events that appear to be compatible with electrographic seizures and it should be noted that the record does wax and wane throughout the course of the 24-hour recording session. [**8-6**] EEG IMPRESSION: This EEG gives evidence for marked encephalopathic disorder manifest by marked suppression of normal background rhythms, suppressive bursts with periods of one to four seconds of flatline EEG, and high voltage triphasic waves that are seen synchronously. Additionally, at least two areas appear abnormal independently in that there is delta and sharp slow activity in the left frontal region and independently seen over the right hemisphere with some excessive delta noted over the right posterior quadrant. In comparison to the prior day, the EEG appears to be slightly worse in terms of the degree of encephalopathy. [**8-7**] EEG IMPRESSION: This EEG continues to give evidence for a moderately severe to severe encephalopathic disorder likely metabolic in origin. There are also superimposed some structural features in the left frontal and the posterior quadrant on the right. In addition, the heart rhythm is abnormal and seemed, for some reason, to show a change in the QRS appearance at about 00:12 in the morning. [**8-8**] CT Abd/Pelv w/o contrast IMPRESSION: 1. Large hematoma within the right thigh, which is not completely visualized on this scan. 2. Right renal calculi. 3. Diverticula without evidence of diverticulitis. 4. Calcified fibroids within the uterus. CXR [**2127-8-13**]: IMPRESSION: No change from prior. Brief Hospital Course: 76 yo W h/o past L MCA stroke (residual R hemiplegia, nonfluent aphasia, dysarthria), AF on anticoagulation, DM2, likely prior MI p/w lethargy and nausea/vomiting/abdominal pain and found to have a R PCA and R cerebellar acute infarction accompanied by cardiac ischemia (trop 7.6) and subsequent generalized seizure activity. Hospitalization c/b UTI and acute anemia. [] Acute Cerebral Infarction - Her initial presentation was with lethargy in the setting of nausea, diaphoresis, vomiting, abdominal pain and left arm/back pain with high troponins suggestive of acute cardiac ischemia; when examined at the bedside with the family, they felt that she did not have new neurologic deficits, and the patient denied new neurologic symptoms initially. However, over the span of an hour she was noted to have a left homonymous hemianopia and poorer command following and sensory neglect. Given her INR of 1.8 and unclear deficits, she was not a candidate for intravenous tPA and was not clinically stable enough for a CTA Head/Neck or CTP Head (vomited in the CT scanner). The next day as she continued to be lethargic, she was found to have a R PCA stroke and R cerebellar hemisphere stroke. This stroke had a small amount of hemorrhagic conversion. She was rescanned multiple times in subsequent days during periods of waxing and [**Doctor Last Name 688**] mental status. Her blood pressure was maintained with an SBP > 120, sometimes requiring fluid boluses. Her infarction size did not appear to change, but she developed several other medical complications. An MRI could not be obtained due to her pacemaker. [] Seizure - The patient on [**8-4**] showed periods of broad, generalized waves suggestive of seizure activity for which she was started on Levetiracetam 1000 [**Hospital1 **], but on subsequent consultation Epilepsy felt that this activity might represent primarily encephalopathy with triphasic waves rather than seizures. There were multifocal discharges, but these did not propagate. A repeat EEG on [**8-13**] revealed diffuse encephalopathy without seizures. [] NSTEMI vs. Stress/Takutsubo Cardiomyopathy - The patient had nausea, diaphoresis, vomiting, and abdominal pain with left arm/back pain consistent with cardiac ischemia, likely NSTEMI versus stress cardiomyopathy. Cardiology was consulted and suspected that the troponin leak, which downtrended since admission, was likely due to demand ischemia from AF with RVR versus Takutsubo cardiomyopathy for which she has a depressed EF of 20-25%. She treated with aspirin, heparin infusion, metoprolol, and amiodarone. [] Atrial fibrillation - The patient has a history of persistent AF and reportedly was on propafenone. She was transitioned to amiodarone as an alternative. Her HR occasionally would rise to the 120s-130s and required further beta blockade with metoprolol. [] Urinary Tract Infection - The patient on [**8-5**] was found to have >100,000 GNR in her foul-smelling urine with low-grade fevers, a suggestive UA, and worsening mental status suggestive of a UTI. The urine culture was later resulted as contaminated, but treatment was continued due to high clinical suspicion for UTI. [] Respiratory Failure/Pneumonia - On [**2127-8-10**], the patient's respiratory status decompensated such that she required intubation. She had a high fever of 105.6 at the time, raising suspicion for a pulmonary infection. Her prior antibiotic treatment for UTI was extended to Vancomycin and Piperacillin-Tazobactam. She was continued on broad spectrum antibiotics but required pressors and continuous IVF to maintain her BP and warming blankets as her temperature dropped. No organism was identified and the family declined bronchoscopy. [] Goals of Care - Multiple discussions took place with the patient's children (two daughters, [**Name (NI) 2048**] and [**Name (NI) **], and one son, [**Doctor Last Name **] wherein they decided to make the patient DNR but not DNI given her worsening clinical status and diminishing chances of meaningful recovery. On [**8-14**], given the patient's multisystem dysfunction and lack of significant interactivity, the family decided to make the patient CMO. Palliative Care was consulted for assistance with counseling and offering hospice services. She was extubated at approximately 7:30 PM on [**8-14**]. She remained comfortable throughout the rest of her stay and was discharged to hospice on [**8-18**]. Medications on Admission: - Senna - miralax - Propafenone 150mg TID - omeprazole 20mg daily - metformin 500mg [**Hospital1 **] - colace - biscodyl - ASA 81mg daily - milk of magnesia - cholecalciferol 800 units daily - sertraline 50mg daily - simvastatin 10mg daily - cranberry extract - gabapentin 600mg qhs - vitmain b12 1000mcg daily - coumadin 5mg Discharge Medications: 1. hydromorphone 3 mg Suppository Sig: [**12-22**] Suppositorys Rectal Q3H (every 3 hours) as needed for agitation. 2. acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for standing. 3. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Five (5) mg PO Q4H (every 4 hours). Discharge Disposition: Extended Care Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Primary: Right PCA and R Cerebellar infarct Secondary: Atrial fibrillation, past L MCA stroke, DM, hx of MI Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to the hospital because you had a stroke and heart damage. Your course was complicated by a UTI and persistently depressed level of consciousness. While here, your family decided to make you Comfort Measures Only, which was done in an effort to make you comfortable. You were then able to be sent to hospice. We stopped all of your home medications and started you on the following medications: 1) Dilaudid 3-6mg per rectum as needed for agitation. 2) Tylenol 650mg every 6 hours. 3) Morphine concentrated oral solution 5mg every 4 hours. If you have any questions about your care please consult your hospice doctor. It was a pleasure taking care of you on this hospitalization. Followup Instructions: You will be followed by your hospice team at your hospice facility.

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icd9cm

[ [ [] ] ]

[ "96.72", "33.29", "96.6" ]

icd9pcs

[ [ [] ] ]

14311, 14400

9156, 13584

283, 324

14552, 14552

3770, 3770

15448, 15519

2555, 2615

13961, 14288

14421, 14531

13610, 13938

14688, 15425

5063, 5161

2630, 3630

3646, 3751

240, 245

352, 2214

5170, 9133

3786, 5047

14567, 14664

2236, 2367

2383, 2539

68,336

150,140

38275

Discharge summary

report

Admission Date: [**2120-8-11**] Discharge Date: [**2120-8-16**] Date of Birth: [**2084-12-12**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 16613**] Chief Complaint: Motorcycle collision Major Surgical or Invasive Procedure: [**2120-8-11**]: s/p open reduction internal fixation left distal fibula and right tibia. History of Present Illness: 35 yo Male s/p [**Hospital **] transferred from [**Hospital 189**] Hospital for open Right tibia fracture and closed Left ankle lateral malleolus fracture. Past Medical History: h/o machete attack missing 3rd and 4th fingers of L hand distal to PIP joint, GSW Social History: unemployed on disability, five children, parallel history notes he drinks 5-15 beers a day Family History: n/a Pertinent Results: [**2120-8-11**] 07:05AM FIBRINOGE-272 [**2120-8-11**] 07:05AM PT-11.3 PTT-23.2 INR(PT)-0.9 [**2120-8-11**] 07:05AM PLT COUNT-331 [**2120-8-11**] 07:05AM WBC-14.6* RBC-4.42* HGB-13.9* HCT-40.9 MCV-93 MCH-31.4 MCHC-33.9 RDW-13.8 [**2120-8-11**] 07:05AM ASA-NEG ETHANOL-148* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2120-8-11**] 07:05AM LIPASE-22 [**2120-8-11**] 07:05AM estGFR-Using this [**2120-8-11**] 07:05AM UREA N-12 CREAT-1.1 [**2120-8-11**] 07:18AM HGB-14.9 calcHCT-45 O2 SAT-65 CARBOXYHB-4 MET HGB-0 [**2120-8-11**] 07:18AM GLUCOSE-103 LACTATE-2.3* NA+-146 K+-4.1 CL--106 TCO2-25 [**2120-8-11**] 07:18AM PH-7.28* Brief Hospital Course: Mr [**Known lastname 85299**] was admitted to the ICU on [**2120-8-11**] after being involved in a motorcycle collision. On the day of admission he underwent Irrigation and debridement right open tibial fracture with Open reduction and internal fixation of the right tibia and open reduction and internal fixation left ankle fracture without complication. On [**2120-8-12**] he was transferred out of the ICU onto the Orthopedic service. The remainder of his hospitalization was unremarkable. He made steady progress with PT, tolerated a diet and his pain was controlled with PO medications. He will be discharge home WBAT on RLE, NWB LLE and will continue Lovenox for 4 weeks for DVT prophylaxis after being cleared for discharge by the physical therapy service. Medications on Admission: Ativan Discharge Disposition: Home Discharge Diagnosis: 1. Right open tibia fracture. 2. Left distal fibula fracture. 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: Wound Care: -Keep Incision dry. -Do not soak the incision in a bath or pool. -Staples will be removed at your first post-operative visit. Activity: -Continue to be non weight bearing on your left leg. -Continue to be full weight bearing on your right leg. -Do not remove cast. Keep cast dry. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so 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 narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. If you have questions, concerns or experience any of the below danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go to your local emergency room. Followup Instructions: 2 weeks in the [**Hospital **] clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. Please call [**Telephone/Fax (1) 1228**] to make this appointment. [**Name6 (MD) 13978**] [**Name8 (MD) **] MD [**MD Number(2) 16614**] Completed by:[**2120-8-15**]

[ "309.81", "305.20", "305.60", "E812.2", "824.2", "V62.84", "823.30" ]

icd9cm

[ [ [] ] ]

[ "79.66", "79.36" ]

icd9pcs

[ [ [] ] ]

2382, 2388

1554, 2325

342, 434

2494, 2494

873, 1531

4122, 4432

849, 854

2409, 2473

2351, 2359

2677, 2677

282, 304

2689, 4099

462, 619

2509, 2653

642, 725

741, 833

3,815

111,697

5478

Discharge summary

report

Admission Date: [**2168-9-28**] Discharge Date: [**2168-10-3**] Service: NEUROLOGY Allergies: Trileptal Attending:[**First Name3 (LF) 5831**] Chief Complaint: Decreased Responsiveness Major Surgical or Invasive Procedure: Video EEG monitoring History of Present Illness: [**Age over 90 **]y right handed F with a h/o progressive dementia, generalized seizure disorder, hypothyroidism and colon cancer admitted to Neuro-ICU for seizure, non-convulsive status epilepticus (NCSE). She was p/w an episode of unresponsiveness, sleepiness and less talkative, found by the staff at her [**Hospital3 **] facility. Patient was brought in to [**Hospital1 18**] ED accompanied with her daughter, who was called from facility suspected for seizure. Patient showed above symptoms and also presistent shiverring like movements, which was recognized 4mo ago when she was brought into ED for seizure. At ED, patient was hypertensive (SBP226) and had UTI. She had continued on shivering like movement throughout. She received Nitropaste, labetalol iv, Cipro 250mg, home dose of Keppra (500mg), Ativan 2mg. Patient was admitted to medical service in the beginning to control confusion, UTI, seizure. After the admission, patient stayed still unclear, less talkative and occasionally starring. Bedside EEG reveiled NCSE, and patient was transferred to Neurology ICU service. At ICU, she was loaded with Dilantin and has been doing better, less confusive, no seizure episodes. The shiverring movements were also disappeared. Follow up EEG study showed resolution of electrical status. After the stabilization, patient was transferred to Neurology service. She has a history of "[**Doctor Last Name 11332**] mal" seizures, which she suddenly stared and got uncouscious when she was younger, treated with Dilantin -> Tegretol ->Keppra. Recently in [**2168-5-23**] she had an episode, but since then no witnessed seizures. She denies recent illnesses, fever, cough, cold sx, HA, chest pain, abdominal pain, diarrhea, change in appetite, sleep. At transfer, she was more awake, alert, attentive compare to the time of admission. Has had stable VS. Past Medical History: 1. Hypothyroidism 2. Generalized Seizure D/O - Followed by Dr. [**Last Name (STitle) **]. Her seizures are "blackouts", no described tonic-clonic activity. 3. Colon Cancer - s/p right hemicolectomy [**2166-8-12**] - pt does not know about diagnosis 4. Dementia 5. Hypertension 6. h/o chronic Anemia - on B12 7. h/o falls Allergies: Trileptal (rash?) Social History: The patient lives at [**Hospital3 **]. She has been having intermittent falls [**2-25**] vertigo. She is able to dress/bath/toilet herself. Family History: Noncontributory Physical Exam: (At admission): Vitals: T: 98F P: 70 R: 16 BP: 130/70 SaO2: 98% RA General: Lying in bed with eyes closed. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: supple, no JVD or carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs with transmitted upper airway sounds bilaterally Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -mental status: Opens eyes transiently to voice. Intermittently and inconsistently follows commands. Can count fingers, but cannot state her name. -cranial nerves: PERRL 2.5 to 2mm and brisk. Visual fields full to threat. EOMI. No facial asymmetry. -motor: Normal bulk throughout. Tone mildly increased in lower extremities. Withdraws briskly to noxious stimuli in all four extremities. No adventitious movements noted. No asterixis noted. No myoclonus noted. -sensory: Grimaces to noxious stimuli in all four extremities. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was extensor bilaterally. (At Transfer to Neurology Floor - after seizure was controlled): Gen: Awake, alert, no distress HEENT: clear ears, conjunctivas, oral membrane, no neck bruit, no goiter Chest: vesicular sound, symmetrical, symmetrical chest Heart: S1, S2 nl, no murmur Abd: soft nt/nd no hepatosplenomegaly Skin: no lesions, skin stigmata, moist, turgor nl Exts: edematous legs with swollen, with increased tone NEURO MS Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Inattentive, says 4 digits backwards, foreward of 7. Speech is fluent with slightly moderately comprehension and repetition. Difficult to understand instruction and following commands. No dysarthria. [**Location (un) **] intact. Registers 0/3, recalls 0/3 in 5 minutes. No right left confusion. No evidence of apraxia or neglect. CN Fundus bil clear/sharp margin. VF full (both at biocular test), Pupils round, equal, Pupils reactive to light, right 5mm to 2mm and left 5mm to 2mm. EOMI with 2-3beats of nystagmus at bil extreme lateral gaze. Symmetrical facial sense, appearance, NLF, WFH, uvla midline, tongue full, SCM normal Motor Full throughout, normal tone Reflex DTR brisk throughout, symmetrical at UEs. LEs, absent patellar and ankle reflexes. planters going down Sensory normal and symmetrical touch/temp/vibration throughout. Coordination nl FNF. HS could not be peformed due to limitation of knees. No DDK. Gait: Unable to exam. Pertinent Results: ([**2168-9-27**]) At admission CBC: 5.9>12.8/35.7<157 diff. N:75.7 L:20.0 M:3.4 E:0.5 Bas:0.3 138 101 15 118 AGap=14 4.4 27 0.6 9.0 Mg: 2.2 P: 3.4 CK: 49 MB: Notdone Trop-*T*: <0.01 TSH:0.033 U/A: straw color/1.012/7.0/Nitrite small/LE neg/WBC6-10/RBC0-2/Bac many/yeast none/Epi3-5 Urine Cx: mixed flora, most likely fecal contamination CT w/o contrast: No intracranial hemorrhage. See above report. EEG ([**2168-9-29**]): Markedly abnormal EEG due to the generalized rhythmic [**2-26**] Hz high amplitude polyspike and wave or spike and wave discharges, which had a decreased frequency after ativan. This EEG is consistent with nonconvulsive status epilepticus, as the patient clinically was responsive without any abnormal motor activity, but was confused during the recording. LTM-EEG ([**2168-9-30**]):This 24 hour video EEG telemetry captured sustained rhythmic [**2-26**] Hz polyspike and wave, spike and wave discharges consistent with status epilepticus. The activity resolved with apparent treatment. Automated and routine sampling demonstrated isolated transient discharges more prominantly seen over the right hemispheric leads. Brief Hospital Course: The pt is a [**Age over 90 **] year-old woman with a history of seizure disorder and dimentia (considered as Alzheimer disease) who presented with encephalopathy and was found to be in non-convulsive status epilepticus (less responsiveness, shiverring movement). On examination at transfer, patient was much clearer, showed significant improvement in mental status except persistent working [**Last Name **] problem (remote memory was preserved well). Head CT did not show any intracranial lesions. After dilantin loading, no seizure episodes were observed and EEG was improved (less frequent spikes). After improvement in seizure with Dilantin and once Keppra reached at target dose (750/500/750mg; 2g/day), Dilantin was tapered from 100mg tid to 100mg [**Hospital1 **] (for 5days) without any recurrence of seizure. It will be tapered further to 100mg daily x5days and off. The epilepsy will be managed with Keppra 750/500/750mg and be followed by Dr. [**Last Name (STitle) **] (Neurologist). Regarding to her dementia, with history and examination, Alzheimer Disease will be most likely diagnosis. By reviewing history, Memantine was not tried so far for her dementia, which might be benefitial for the symptom especially for memory impairment. For UTI, patient was treated with Cipro initially, then changed to Levofloxacin and also again switched to Ceftriaxone (given total of 3 days) after tranferred to Neurology service, considering epileptogenic effect of both Cipro and Levofloxacin. The UTI could be the exacerbation factor of seizure and mental status. Culture grew mixed pathogen (fecal contamination?). The [**Last Name 22147**] problem has been followed by Dr. [**Last Name (STitle) **] as well and will be followed at f/u visit. Medications on Admission: Cipro 250mg po qd Aricept 10mg qd Keppra 500mg TID (last adjustment; increased on [**2168-5-26**]) Zoloft 25mg [**Hospital1 **] Levothyroxine 125mcg qd folate 1mg qd metoprolol 25mg [**Hospital1 **] cyanocobalamin injection q month senna, colace, heparin sc Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 3. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:*30 Tablet(s)* Refills:*2* 10. Keppra 750 mg Tablet Sig: One (1) Tablet PO once a day: in the morning. Disp:*30 Tablet(s)* Refills:*2* 11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY AT 2PM (). Disp:*30 Tablet(s)* Refills:*2* 12. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 4 days: After 4days then switched to 100mg once daily for 5days and stop. Disp:*13 Capsule(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: Status epilepticus (non convulsive status epilepticus) Dimentia Discharge Condition: Stable/Improved Discharge Instructions: Please continue on her regular medication and seizure medication (see below). Dilantin 100mg po bid will be decreased in 4days to 100mg daily for 5days and then completed. Keppra 750mg in am, 500mg in noon, 750mg bedtime will be continued as regular medicine. Followup Instructions: Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2168-11-17**] 4:00 (Also on cancelling list for earlier visit). **Dear Administrative office at facility** Please call above number to provide the contact number to [**Hospital 878**] clinic and for possible earlier appointment. Completed by:[**2168-10-3**]

[ "244.9", "V10.05", "345.3", "294.8", "599.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10080, 10157

6629, 8379

243, 265

10265, 10283

5440, 6606

10592, 10984

2699, 2716

8687, 10057

10178, 10244

8405, 8664

10307, 10569

3460, 5421

2731, 3295

179, 205

293, 2151

3310, 3442

2173, 2525

2541, 2683

21,706

117,351

29353

Discharge summary

report

Admission Date: [**2115-12-25**] Discharge Date: [**2115-12-29**] Date of Birth: [**2047-11-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 18369**] Chief Complaint: Transfer from outside hospital with Cerebellar mass Major Surgical or Invasive Procedure: Lumbar Puncture History of Present Illness: Mr. [**Known lastname 70518**] is a 68M with DM and esophageal CA who presented to an OSH for evaluation of recent increased gait unsteadiness. Per report from the outside hospital MRI, the patient had a 3-4cm left cerebellar mass on MRI with evidence of mass effect (effacing the 4th ventricle), vasogenic edema Past Medical History: Stage III esophageal cancer R eye prosthesis HTN DOE BPH chronic foley Diabetes h/o trach/PEG in [**11/2113**] h/o anemia in [**12/2113**] s/p cholecystectomy cognitive impairment s/p MVC Social History: A 40-60 pack year smoker, discontinued 30 years ago. Occupation former machine operator, lives alone in senior housing, does not drink, and has no exposure history. Family History: Remarkable for mother with diabetes and a brother with diabetes and prostate cancer. Physical Exam: Vitals 97.8 91 151/73 17 99% on RA General Pleasant man in no distress HEENT PEARL, EOMI, dry MM, NC/AT Pulm Lungs clear bilaterally CV Regular S1 S2 no m/r/g Chest left portacath, no erythema or purulence Abd Soft nontender +bowel sounds Extrem Warm no edema full distal pulses Neuro Alert and awake, oreitned x 3. answering appropriately. CN2-12 intact aside from diminished vision right eye. Full strength in bilateral upper and lower extremities. +imprecision on finger-nose-finger left upper extremity. +resting tremor of arms. Pertinent Results: [**2115-12-28**] 07:35AM BLOOD WBC-5.1 RBC-4.52* Hgb-14.2 Hct-42.1 MCV-93 MCH-31.5 MCHC-33.8 RDW-14.2 Plt Ct-137* [**2115-12-25**] 08:00PM BLOOD WBC-7.7 RBC-4.35* Hgb-13.7* Hct-40.0 MCV-92 MCH-31.6 MCHC-34.4 RDW-14.9 Plt Ct-132* [**2115-12-25**] 08:00PM BLOOD Neuts-92.2* Lymphs-5.4* Monos-2.1 Eos-0.2 Baso-0.1 [**2115-12-28**] 07:35AM BLOOD PT-14.3* PTT-26.2 INR(PT)-1.2* [**2115-12-28**] 07:35AM BLOOD Plt Ct-137* [**2115-12-25**] 08:00PM BLOOD Plt Ct-132* [**2115-12-25**] 08:00PM BLOOD Glucose-125* UreaN-18 Creat-0.9 Na-142 K-4.2 Cl-105 HCO3-27 AnGap-14 [**2115-12-27**] 06:30AM BLOOD Glucose-89 UreaN-26* Creat-0.9 Na-142 K-3.9 Cl-104 HCO3-31 AnGap-11 [**2115-12-28**] 07:35AM BLOOD Glucose-99 UreaN-27* Creat-1.0 Na-142 K-4.0 Cl-104 HCO3-32 AnGap-10 [**2115-12-28**] 07:35AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8 [**2115-12-27**] 06:30AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.8 [**2115-12-28**] CT Head IMPRESSION: Hyperdense 3-cm focus in the left cerebellum with surrounding compatible with edema. Mild effacement of the fourth ventricle, but no herniation or hydrocephalus. MRI is recommended for further evaluation, to determine whether this represents hemorrhage, hyperdense mass, or hemorrhage within an underlying mass/vascular malformation. CSF: Total Protein, CSF 94* mg/dL Glucose, CSF 67 mg/dL Lactate Dehydrogenase, CSF 43 IU/L PEP, CSF Pending WBC, CSF 1 #/uL RBC, CSF 1* #/uL Polys 3 % Lymphs 51 % Monocytes 0 % Macrophage 46 % Brief Hospital Course: #. Cerebellar mass: In the ED, vitals were 96.9 71 172/88 20 99 on RA. The patient was seen by neurosurgery saw the patient and recommended no steroids as the 4th ventricle was widely patent, doubted esopageal CA as it rarely metastasizes to the brain. They also recommended close BP control (SBP <140) so the patient was transferred to the MICU for monitoring. His BP remained stable overnight. On evaluation in the MICU, patient denied any headache, diplopia, weakness, numbness. He did have gait unsteadiness (a chronic issue) but no fevers, chills, sweats, cough. He was transfered to the oncology service for further evaluation. Neuro-oncology consult felt his outside hospital MRI was consistent with leptomeningeal disease so LP was performed for diagnostic purposes. CSF had increased protein, normal glucose, lyphocyte predominant cells with few WBCs per HPF. The patient remained stable so it was felt he could go home and await final pathology with close follow up in the [**Hospital **] clinic. He was seen by physical therapy for his gait instability and they recommended home physical therapy. . #. Diabetes type 2: Patient was maintained on isulin sliding scale. . #. BPH: Patient continued home continue home flomax and finasteride . # Depression: Patient continued on home celexa. . # History of traumatic brain injury: With residual gain instability, right eye blindness and tremor. Patient continued on home Amantadine. . #GERD: Patient continued on PPI. . Medications on Admission: Celexa 10mg daily Protonix 40mg daily Amantadine 100mg [**Hospital1 **] Flomax 0.4mg daily Finasteride 5mg daily INSULIN sliding scale AMLODIPINE 10mg daily VITAMIN D 1000u daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Citalopram 20 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 3. Amantadine 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: 2.5 Tablets PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a day as needed for constipation. 9. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: One (1) unit Subcutaneous ASDIR (AS DIRECTED): Please follow your sliding scale insulin as prior to hospitalization. 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr [**Hospital1 **]: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Vna of [**Last Name (un) **] Discharge Diagnosis: Primaru Diagnosis: Cerebellar Mass Esophageal Cancer Diabetes Type 2 Hypertension BPH Traumatic Brain injury s/p MVA Discharge Condition: Stable Discharge Instructions: You were transferred to our hospital with increasing difficulty walking and a new mass in your brain. We controlled your blood pressure and did a lumbar puncture to try to diagnose the mass. The results of this are still pending, but there was no evidence for infection. You need to follow up with Dr. [**Last Name (STitle) 724**] in the [**Hospital **] clinic for further diagnosis and treatment plan. We also had physical therapy see you and they recommended home physical therapy . We did not stop any of your medications, please take all your medications as directed. We ADDED Metoprolol 50mg po Daily for your blood pressure. . If you have any headache, confusion, difficulty speaking, difficulty walking, any numbness, tingling or weakness in your extremities, any fevers, vomiting or any other symptoms that are concerning to you, please call your doctor or come to the emergency room. Followup Instructions: Please follow up in [**Hospital **] clinic with Dr. [**Last Name (STitle) 724**]. The clinic is not open on the weekend to make you an appointment, you need to call to make an appointment on Tuesday morning (monday is a holiday) [**Telephone/Fax (1) 1844**]. . You may call([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], but I would suggest doing this after seeing Dr. [**Last Name (STitle) 724**]. . Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2116-1-28**] 9:30 . Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2116-1-28**] 1:00 . Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2116-2-17**] 1:45

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icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

6148, 6207

3264, 4744

371, 389

6368, 6377

1797, 3241

7320, 8155

1142, 1228

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26,027

115,133

7490

Discharge summary

report

Admission Date: [**2205-12-6**] Discharge Date: [**2205-12-7**] Date of Birth: [**2166-7-13**] Sex: M Service: MEDICINE Allergies: Gabapentin / Trazodone / Codeine Attending:[**First Name3 (LF) 3326**] Chief Complaint: ETOH Withdrawl Major Surgical or Invasive Procedure: none Past Medical History: * Subdural hematoma ([**2204-4-12**]) from fall * Alcohol and polysubstance abuse * Hepatitis C virus infection * Mood disorder with multiple suicide attempts * ?PTSD, bipolar/anti-social personality/impulse/rage disorders * Migraines * Chronic lower back pain * MVA s/p chest tube placement in [**2200**] * Seizure disorder since [**08**] yo, alcohol withdrawal seizures (Please see note from [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] [**2205-12-7**] which calls into question the veracity of this history) * Aspiration pneumonia treated at [**Hospital1 2177**] from [**Date range (1) 27397**] Social History: Stays with his girlfriend in [**Name (NI) **]. - Tobacco: Smokes 5 cigarettes/day last 2-3 years. - Alcohol: 1/5th daily of hard liquour, has been drinking since 9 yo, has h/o DTs and alcohol withdrawal seizures, - Illicits: Past use of cocaine, heroin, opiates, benzodiazepines documented in [**Name (NI) **], but patient currently denying any of this. Family History: Father was an alcoholic. Physical Exam: 39M well known to [**Hospital1 18**] for multiple alcohol related admissions, BIBA for [**Last Name (un) 10737**] unresponsive on a park bench. The patient states that today he got back together with his long-term girlfriend/wife who brought him a family sized bottle of Listerine in the mall and then layed on bench and became unresponsive. He states that they began to fight and then she beat him about the head and chest with his own cane. She left and at a time distant to the assault he passed out on a park bench. He states that he drank more of the listerine, "being the bigger man." EMS arrived and finger stick was found to be in the 150's. In the ER he opened his eyes and was able to communicate appropriately despite slurred speech. He adamantly claimed that he only drank listerine, and no other drugs. Initial vitals were 99.1 100 144/78 20 100%. . Plan was for CIWA and observation until sober re-evaluation. However after several hours in observation he began to withdraw and score on CIWA for tremulousness and tachycardia. Given his seizure history and requirement of 6mg Ativan over an hour he was transferred to the [**Hospital Unit Name **]. . On arrival here, he is alert, interactive and asking for pain meds . Of note Mr [**Known lastname 27389**] has had multiple recent admissions as follows: - [**Hospital1 18**] ICU w/ d/c AMA on [**11-14**] for presumed isopropyl alcohol intoxication and admission from [**Date range (1) 27400**] to [**Hospital1 2177**] for presumed aspiration pneumonia on cefpodoxime/azithromycin - [**Hospital1 18**] [**11-28**] for fevers, CP, and productive cough cough. . - [**Hospital1 18**] ICU from [**11-13**] to [**11-14**]. Patient was visiting his wife [**Name (NI) **] in the ICU when he was noted to become unresponsive. - Durring his hospitalization [**11-28**] he called his [**Company 191**] PCP and complained of not getting enough pain meds, he then told his PCP [**Name Initial (PRE) **] "if he didnt give him more pain meds he would put him in as much pain as he ([**Known firstname **]) was already in." This resulted in the patient being banned from [**Hospital 191**] clinic, patient relations involvement and an agreement by which Mr. [**Known lastname 27389**] is not allowed to get any outpatient prescriptions from [**Hospital1 **]. Pertinent Results: [**2205-12-6**] 09:21PM URINE HOURS-RANDOM [**2205-12-6**] 06:40PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2205-12-6**] 10:31PM BLOOD ASA-NEG Ethanol-82* [**2205-12-6**] 10:31PM BLOOD Osmolal-314* [**2205-12-7**] 06:15AM BLOOD Osmolal-290 Brief Hospital Course: 39M with complicated social situation and multiple [**Hospital1 18**] admission for ingestions of alcohol and its related denatured counterparts. . Listerine Ingestion: Per the ingredient list Listerine is 40% etoh and also includes a salicylate. Mr [**Known lastname 27401**] ETOH level on admission to the ICU was 85 while his salicylate level was negative. It is likely that ETOH was driving all of his assorted issues. This likely explained his lowish anion gap metabolic acidosis on admission. Using the formula that ETOH is corrected for in the osmolar gap by dividing by 3.8, his osmolar gap is accounted for by his ETOH level, making coingestion with isopropanol or ethylene glycol much less likely. He scored only once on CIWA, over 18 hours ago, and currently has normal vital signs. We will plan for discharge. - Per prior agreement he will not be discharged with prescriptions for any medications . Hypoxia: Suspect medication induced hypoventilion c/b splinting leading to increased CO2 and thus increased CO2 admixture via the alveolar gas equation, stably in the low 90's overnight while asleep. Resolved morning of discharge. . Pain control: This patient is a terrible candidate for opiates, and refuses nsaids, we used low dose tylenol and would not give opiates in any situation if possible. Despite sleeping easily, he continued to request fioricet/fioranol for his migraines when he awakened, but this medication was not in his medication discarge list. He was given tylenol. . Rib Pain: No hct drop to raise c/f splenic rupture, no fractured ribs, no ptx . Multiple Psychiatric diagnoses: Patient was continued on his home regimen, he should continue with his home supply at home. . ?Seizure d/o history: . [**First Name8 (NamePattern2) **] [**Doctor Last Name **] recent note calls into question his seizure history; however, the patient comes in with a positive barbiturate level. Given his lack of seizure disorders and previous plans, we will discharge him without a prescription for phenobarb. . Dicharge planning: Please refer to the below note from Chief Resident [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] regarding his rules for discharge. . " After discussion with the patient and his consulting services, we will not provide prescriptions for any of his reported home medication including clonazepam, carbamazepine, amitriptyline, olanzapine or mirtazapine. At this time, the risk of significant toxicity including death, in the setting of his [**Last Name (NamePattern1) 17577**] substance abuse is greater the risk of any potential withdrawal symptoms. . After discussion with neurology we will provide the patient with a short duration of phenobarbital with planned Neurology Access Clinic follow up." Medications on Admission: Meds he should be on that are no longer prescribed by [**Hospital1 18**]: . thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY cholecalciferol (vitamin D3) 1,000 unit DAILY (Daily). folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). multivitamin Tablet Sig: One (1) Tablet PO once a day. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for Pain. amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). olanzapine 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). Discharge Medications: Meds he should be on that are no longer prescribed by [**Hospital1 18**]: . thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY cholecalciferol (vitamin D3) 1,000 unit DAILY (Daily). folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). multivitamin Tablet Sig: One (1) Tablet PO once a day. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for Pain. amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). olanzapine 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: ETOH withdrawl Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [**Known lastname 27389**] you were admitted to the [**Hospital1 **] with alcohol withdrawl from drinking listerine. As you know your previous actions at [**Hospital1 **] have resulted in our inability to provide you with any outpatient medications. You must establish follow-up with health care for the homeless as soon as possible. You also should follow up with neuro as soon as possible. . Please call [**Hospital 86**] Healthcare for the Homeless at ([**Telephone/Fax (1) 27399**] to schedule an appointment for PCP [**Name Initial (PRE) **]. If you are feeling concerned about your mental health, you can contact the [**Name (NI) 86**] Psychiatry Urgent Care Service at 1-[**Telephone/Fax (1) 20233**]. Please call neurology at [**Telephone/Fax (1) 44**] to schedule an appointment to be seen as soon as possible in the [**Hospital 878**] Clinic. Followup Instructions: see above, remember you are no longer able to follow-up at [**Company 191**] Completed by:[**2205-12-7**]

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icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

8062, 8068

4042, 6820

308, 315

8127, 8127

3750, 4019

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254, 270

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1,372

183,402

16157

Discharge summary

report

Admission Date: [**2167-3-3**] Discharge Date: [**2167-3-4**] Date of Birth: [**2107-2-21**] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: This is a 60-year-old male with a history of alcohol abuse transferred here from [**Hospital 1459**] Hospital for persistent GI bleeding. The patient was in his usual state of health until the night of admission at 6:30 p.m. He drank half a beer at a bar and then began to feel lightheaded and hot. He had some episodes of vomiting coffee grounds. He briefly syncopized after standing up, but was witnessed to have fallen flat on his backside with no head trauma. He was taken to [**Hospital 46152**] Hospital where his vital signs on arrival were a systolic blood pressure 90/palpable. This improved to 116/79 with a pulse of 95. He had orthostasis. A NG tube lavage was performed which drained bright red blood that would not clear. He received IV fluid boluses but no blood as his hematocrit was 38. He was also started on Protonix 40 mg IV and Ativan 1 mg IV. The patient states that he has a significant alcohol and tobacco history. The patient was brought to the [**Hospital1 18**] for endoscopy. In the ED, the patient had another NG tube lavage that did not clear. REVIEW OF SYSTEMS: Positive for black stools in the past, hemorrhoids, bloody stool recently, NSAID use at a rate of about two tablets a day, vague abdominal pain over the past month, but no jaundice, icterus, nausea, diarrhea, GU symptoms, fever, chills, weight loss, stool changes other than those described above. He says that his last bowel movement was about two days ago. PAST MEDICAL HISTORY: 1. Foot operation. 2. Basal cell carcinoma excision of the left ear. 3. Status post appendectomy. 4. Osteoarthritis. 5. Hemorrhoids. FAMILY HISTORY: The patient's mother has arthritis and is alive. The father died at the age of 76 for unknown reasons. The patient has a half brother who is healthy and a daughter with scoliosis. SOCIAL HISTORY: The patient lives in [**Location 1459**]. He works as a courier driver. He lives with his wife. [**Name (NI) **] uses no drugs. He drinks about five drinks a day. He has a 40 pack year history of smoking. He is a former Navy soldier. SCREENING: The patient has had a colonoscopy some time within the last five to ten years at [**Location (un) **] [**Location (un) 1459**] and it was essentially negative. The patient has had positive fecal occult blood test prior to this colonoscopy which prompted performance of this procedure. PHYSICAL EXAMINATION ON ADMISSION: The patient's physical examination was significant for stable vital signs but with orthostatic findings. His NG tube was in place and draining blood. HEENT examination: No icterus. Poor dentition. His conjunctivae were pink. Lungs: Clear. Cardiovascular: Regular rate and rhythm. No murmurs. Abdomen: Benign. Rectal: Negative for Guaiac. Extremities: No clubbing, cyanosis or edema. Neurologic: He had no asterixis. LABORATORY DATA/DIAGNOSTICS: Hematocrit 34.8, normal electrolytes, normal coagulations. ASSESSMENT/PLAN: This is a 56-year-old man with a presumed new GI bleed secondary to ulcer versus gastritis versus varices. He was admitted for control of his bleeding and subsequent EGD. IV access was maintained throughout the [**Hospital 228**] hospital stay with two IVs. He was continued on Protonix. He was typed and cross-matched and received 2 units of packed red blood cells. His hematocrit was checked q. four hours. He was placed on a CIWA scale to guard against alcohol withdrawal. His LFTs were checked and were within normal range. On hospital day number two, the patient underwent an EGD which revealed Barrett's esophagus, ulcers in the prepyloric region, an ulcer in the stomach body, and erosion and erythema in the bulb compatible with duodenitis. He was continued on his proton pump inhibitor. H. pylori serology was checked. Given the low chance of re-bleeding as per GI and the fact that the patient's hematocrit was stable for 24 hours, and the fact that he was tolerating p.o. intake, the decision was made to discharge the patient home on hospital day number two. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. FOLLOW-UP: In six weeks with GI. DISCHARGE MEDICATIONS: Protonix 40 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: The patient is to abstain from alcohol, cigarettes, and NSAIDs. He will receive a Nutrition consult and Social Work consults before leaving the hospital in order to help him abstain from these. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Last Name (NamePattern1) 1595**] MEDQUIST36 D: [**2167-3-4**] 12:39 T: [**2167-3-6**] 12:08 JOB#: [**Job Number 77**]

[ "530.2", "531.00", "305.1", "535.60", "E935.9", "V10.82", "303.90", "291.81" ]

icd9cm

[ [ [] ] ]

[ "96.34", "45.13" ]

icd9pcs

[ [ [] ] ]

1803, 1985

4321, 4349

4374, 4835

1264, 1625

2577, 4201

1647, 1786

2002, 2562

4226, 4297

54,197

154,990

47676+58990

Discharge summary

report+addendum

Admission Date: [**2140-7-16**] Discharge Date: [**2140-8-19**] Date of Birth: [**2076-2-1**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 2763**] Chief Complaint: Chief Complaint: UGIB . Reason for MICU transfer: post-arrest, intubated, on Levophed Major Surgical or Invasive Procedure: PEG tube, tracheostomy History of Present Illness: This is a 62yo M with h/o CHF, DM and peptic ulcer who now presents with black, tarry stools all day and three episodes of coffee ground emesis. A neighbor called EMS who brought the pt into the ED. . In ED, initial VS were HR 68, RR 21, BP 92/53 and O2Sat 98% Pt denied CP, but had ST elevations w/ reciprocal changes on EMS strip. ST elevation 1 mm in III and depressions in aVL on initial EKG here. Pt had coffee ground emesis, and an NGT placed with return of same. Pt then became hypotensive to 78 systolic, and a R IJ cordis was placed due to lack of other access. Hct was 29 (baseline of 47 in [**4-/2139**]), wnl plts, INR 1.5. Also, Cr is 1.8 (baseline 1.2 in [**2139**]). Pt was then getting blood with plans to be admitted to the [**Hospital Unit Name 153**] when the pt had a brady/PEA arrest. CPR was performed for 5 min, during which time he received Epi, Ca and additional blood. Pt then got pulses back. During the code, pt was intubated, sedated. GI plans to perform an emergent scope tonight to investigate the etiology of his UGIB. Pt has been given 2-3L NS and 6U pRBCs total. Also, started on Protonix bolus and gtt. Currently, also on Levophed gtt to support his pressures. ED plan to give pt [**Name (NI) **]/Zosyn to cover for possible aspiration pneumonia, given the code. Repeat EKG shows that ST elevations have resolved, but still 1 mm depression aVL remains. It is thought to be [**3-17**] demand ischemia, with TnT of 0.04. The post-arrest team evaluated pt and is considering cooling the pt after GI performs EGD. After intubation, pt desatted briefly to low 80s, PEEP was incr PEEP to 12 and pt is now satting 100%. Pt has a cordis and two PIVs (18g and 20g) for access. Also, pt had an elev K (6.5) which improved to 4.8 after insulin/glucose. Pt also received Ca during the code. Of note, lactate was 6.3, then 8.7 after code. On transfer, VS were HR 105, BP 106/78, 100% on vent. . On arrival to the MICU, pt is sedated, intubated. On minimal sedation (Versed 1mg/hr), pt is not responsive to voice, sternal rub. Pt is responsive to painful stimuli in upper ext, not lower. Is not following commands. Past Medical History: CAD s/p MI (5 yrs ago), CHF, DMII Social History: unable to obtain Family History: unable to obtain Physical Exam: On admission Vitals: per Metavision General: sedated, gagging on ETT, appears uncomfortable HEENT: pale conjunctivae, dry mucous membranes, ETT in place, OGT in place Neck: supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally in anterior [**Last Name (un) 8434**], no wheezes, rales, ronchi Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no organomegaly Ext: cool clammy ext, faint pulses, 1+ [**Last Name (un) 6191**] Neuro: sedated, pupils 2mm minimally reactive, moves all ext On discharge Vitals: T37.3 BP 117/59-131/70 HR80 RR24 O2 100% General: trach in place, opens eyes to voice, shakes head yes/no to questions, will move extremities on command HEENT: dry MM, sclera less icteric, PERRL-sluggish reaction Cardiac: RRR, normal S1 + S2, 2/6 systolic murmur at lsb Abdomen: BS+, NTND, soft Ext: 2+ pitting edema b/l in dependent areas Skin: Large unstageable sacral decub ulcer black eschar, erythematous borders now s/p debridement and dressed; maculopapular rash on torso/extremities improving Neuro: opens eyes to voice, shakes head yes/no to questions, will move extremities on command GU: foley and flexiseal in place Pertinent Results: Admission labs: [**2140-7-16**] 10:00PM BLOOD Neuts-73.5* Lymphs-18.0 Monos-6.8 Eos-1.2 Baso-0.5 [**2140-7-16**] 10:00PM BLOOD WBC-8.1 RBC-3.52* Hgb-8.8* Hct-29.0* MCV-82 MCH-25.0* MCHC-30.4* RDW-17.0* Plt Ct-246 [**2140-7-16**] 10:00PM BLOOD cTropnT-0.04* [**2140-7-17**] 03:15AM BLOOD CK-MB-12* MB Indx-7.3* cTropnT-0.25* [**2140-7-17**] 08:31PM BLOOD CK-MB-23* MB Indx-22.3* cTropnT-0.96* [**2140-8-5**] 03:55AM BLOOD TSH-0.77 [**2140-8-14**] 01:00PM BLOOD HBsAg-NEGATIVE [**2140-8-14**] 01:00PM BLOOD HIV Ab-NEGATIVE Discharge Labs: [**2140-8-19**] 04:32AM BLOOD WBC-6.6 RBC-3.32* Hgb-9.4* Hct-30.7* MCV-93 MCH-28.5 MCHC-30.8* RDW-22.4* Plt Ct-241 [**2140-8-17**] 10:46AM BLOOD PT-12.5 PTT-29.7 INR(PT)-1.2* [**2140-8-19**] 04:32AM BLOOD Glucose-125* UreaN-73* Creat-1.2 Na-150* K-4.3 Cl-111* HCO3-31 AnGap-12 [**2140-8-19**] 04:32AM BLOOD ALT-82* AST-157* LD(LDH)-324* AlkPhos-636* TotBili-2.6* [**2140-8-19**] 04:32AM BLOOD Albumin-2.6* Calcium-7.8* Phos-3.4 Mg-2.2 [**2140-8-19**] 04:32AM BLOOD Vanco-31.1* [**2140-8-15**] 06:00PM URINE Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.016 [**2140-8-15**] 06:00PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.5 Leuks-LG [**2140-8-15**] 06:00PM URINE RBC-30* WBC->182* Bacteri-MOD Yeast-MANY Epi-1 [**2140-8-15**] 06:00PM URINE CastHy-17* [**2140-8-15**] 06:00PM URINE AmorphX-RARE [**2140-8-19**] 02:39PM BLOOD Glucose-156* Creat-1.2 Na-148* K-3.9 Cl-110* HCO3-30 AnGap-12 Micro: [**2140-8-18**] 4:27 am CATHETER TIP-IV Source: right picc. WOUND CULTURE (Preliminary): No significant growth. [**2140-8-18**] 2:06 am BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): [**2140-8-18**] 2:06 am BLOOD CULTURE Source: Line-Right PICC. Blood Culture, Routine (Pending): [**2140-8-15**] 5:22 pm URINE Source: Catheter. **FINAL REPORT [**2140-8-16**]** URINE CULTURE (Final [**2140-8-16**]): YEAST. >100,000 ORGANISMS/ML.. [**2140-8-13**] 8:23 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2140-8-19**]** Blood Culture, Routine (Final [**2140-8-19**]): NO GROWTH. [**2140-8-13**] 6:43 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2140-8-15**]** GRAM STAIN (Final [**2140-8-13**]): [**12-8**] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): YEAST(S). RESPIRATORY CULTURE (Final [**2140-8-15**]): SPARSE GROWTH Commensal Respiratory Flora. YEAST. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. IMAGING: MR HEAD W/O CONTRAST Study Date of [**2140-8-16**] 10:47 AM FINDINGS: The study is significantly limited by motion artifact. However, the diffusion weighted images are diagnostic, demonstrating no diffusion abnormality to suggest an acute infarction. The gradient echo images are nondiagnostic, limiting evaluation for hemorrhage. An area of encephalomalacia in the left frontal lobe is unchanged from [**2140-8-10**], compatible with a prior MCA territory infarct. Prominent ventricles and sulci are unchanged and compatible with global age-related volume loss. Principal vascular flow voids are preserved. The mastoid air cells are opacified bilaterally. IMPRESSION: No evidence of acute infarction. Otherwise, a motion-limited study. CHEST (PORTABLE AP) Study Date of [**2140-8-15**] 4:48 PM FINDINGS: As compared to the previous radiograph, the monitoring and support devices are constant in position. The pre-existing right basal opacity, with maximum in the infrahilar area, is not substantially changed. On the left, there is decreased visibility of the left hemidiaphragm, suggesting the appearance of either atelectasis or small left pleural effusion. Unchanged moderate cardiomegaly. The right costophrenic sinus is unremarkable. CT HEAD W/O CONTRAST Study Date of [**2140-8-10**] 8:27 AM FINDINGS: In the left frontal lobe, there is a region of established encephalomalacia. The adjacent sulci are not effaced and there is mild ex vacuo ventricular dilatation, confirming that this relates to an old infarction. There is no evidence acute vascular territoral infarction. There is no hemorrhage, edema, mass, or positive mass effect. The ventricles and sulci are prominent, consistent with age-related atrophy. The basal cisterns are patent. Periventricular confluent white matter hypodensities are consistent with sequelae of chronic small vessel ischemic disease. Vascular calcifications are noted within the vertebral and internal carotid arteries. No fracture is identified. The visualized paranasal sinuses are clear. The bilateral mastoid air cells are opacified, with a small amount of fluid within the left middle ear, findings likely related to prolonged intubation. The extracalvarial soft tissues are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. Established encephalomalacia in the left frontal lobe, consistent with remote infarction. LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Study Date of [**2140-8-9**] 11:10 AM FINDINGS: The hepatic architecture is normal in appearance with no concerning liver lesion identified. No biliary dilatation is seen and the common duct measures 0.3 cm. The portal vein is patent with hepatopetal flow. The gallbladder is distended and contains sludge and there are two large conglomerations of [**Doctor Last Name 5691**] material within the neck. The gallbladder wall is slightly edematous; however, the patient is known to have a low albumin and this edema is likely due to third spacing. There is a moderate amount of ascites seen in the right upper quadrant. IMPRESSION: 1. No focal liver lesion and no biliary dilatation. 2. Distended gallbladder with sludge and two conglomerations of [**Doctor Last Name 5691**]-like material. Gallbladder wall edema is likely related to third spacing. 3. Moderate ascites in the right upper quadrant. CT ABD & PELVIS W/O CONTRAST Study Date of [**2140-8-6**] 2:55 PM CT OF THE ABDOMEN: Limited images of the lung bases demonstrate consolidation in the left lower lobe (2:9) with some associated atelectasis. There is extensive coronary artery calcification and aortic calcifications throughout the visualized course of the aorta. No pericardial effusion. Increase in the contrast between the cardiac [**Doctor Last Name 1754**] and the myocardium suggests anemia. An NG tube is in situ with its tip in the distal stomach. Assessment of the liver parenchyma is limited by the lack of intravenous contrast; however, the liver appears grossly normal. There is a moderate amount of free fluid in the abdomen. The spleen is enlarged measuring 14 cm in craniocaudal distance. Both adrenal glands are unremarkable in appearance. The left kidney is noted to be mildly malrotated, but otherwise, non-contrast examination of both kidneys is unremarkable. The pancreas appears normal. There is diffuse anasarca of the subcutaneous tissues with involvement of the intra-abdominal fat also. The small and large bowel is normal in caliber and unremarkable in appearance. There is no biliary duct dilatation. There is high-attenuation material within the gallbladder, it is not clear whether this represents very markedly high attenuation, biliary sludge or if there might have been reflux of oral contrast into the gallbladder. The gallbladder wall is not thickened. CT OF THE PELVIS: There is a moderate amount of free fluid in the pelvis. There are bilateral inguinal hernias, the left inguinal hernia contains fat and a small amount of fluid. The right inguinal hernia contains a relatively large amount of small bowel, but no evidence of obstruction. The urinary bladder contains a Foley catheter and some air, but is otherwise unremarkable. The rectum is distended by a rectal tube. No pelvic lymphadenopathy. OSSEOUS STRUCTURES: There are multilevel anterior osteophytes seen throughout the lumber spine. In addition, there is an abnormality of the T10 vertebral body. The appearances suggest a partial malunion and possible congenital abnormality rather than a fracture. There is no retropulsion evident on this study. Multilevel facet joint degenerative changes. IMPRESSION: 1. Left lower lobe consolidation. 2. Moderate ascites. 3. Right inguinal hernia containing small bowel loops. Left inguinal hernia containing fat only. No obstruction. 4. Diffuse anasarca. 5. Unusually high-attenuation material within the gallbladder could reflect vicarious excretion of IV contrast if the patient has previously received IV contrast, alternatively this could reflect reflux of oral contrast or hyperdense sludge. 6. Abnormal configuration of T10 appears chronic, possibly a congenital abnormality. Extensive degenerative changes throughout the lumbar spine. Portable TTE (Complete) Done [**2140-8-4**] at 3:41:44 PM FINAL The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mildly dilated severely hypokinetic left ventricle. Increased left ventricular filling pressure. Dilated, hypocontractile right ventricle. Mildly dilated ascending aorta. At least mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. Left pleural effusion. Compared with the prior study (images reviewed) of [**2140-7-23**], the findings are similar. EGD: [**Last Name (LF) 1017**], [**2140-7-17**] Indications: Upper GI bleed. History of large gastric ulcer in [**2124**]. Procedure: The procedure, indications, preparation and potential complications were explained to the patient's mother and close friend, who indicated their understanding and signed the corresponding consent forms over phone. The consent was witnessed by the nurse. A physical exam was performed. The patient was already intubated and was on Fentanyl and Versed drips. The patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the third part of the duodenum was reached. Careful visualization of the upper GI tract was performed. The procedure was not difficult. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Contents: Old blood was seen in the distal esophagus. Mucosa: Normal mucosa was noted. Stomach: Contents: A lot of old blood was seen in the stomach. There was a large blood clot in fundus which could not be removed despite multiple attempts. Excavated Lesions A single 1 cm ulcer with overlying exudate was found in the stomach body. Initially 4 two cc.Epinephrine 1/[**Numeric Identifier 961**] injections were applied. The ulcer started oozing. Five endoclips were successfully applied for the purpose of hemostasis. This was followed by 3 two cc.Epinephrine 1/[**Numeric Identifier 961**] injections for hemostasis with success. Duodenum: Contents: Old blood was seen in the duodenum. Mucosa: Diffuse friability, erythema and congestion of the mucosa with no bleeding were noted in the duodenal bulb compatible with Moderate duodenitis. Impression: Normal mucosa in the esophagus Blood in the esophagus, stomach and duodenum. Big clot in stomach fundusm which could not be removed. Ulcer in the stomach body (endoclip, injection) Moderate duodenitis Otherwise normal EGD to third part of the duodenum Recommendations: The ulcer is the likely source of bleeding. Continue PPI drip. Check H. Pylori Ab in serum and treat if positive. Serial Hct. Transfuse prn to keep Hct above 30. NPO No NG tube till [**Numeric Identifier 1017**] mid-day Patient may need repeat EGD on Monday to evaluate the fundus. Repeat EGD in 8 weeks to document gastric ulcer healing given high risk of malignancy with gastric ulcers. Patient has history of large gastric ulcer in [**2124**] which was not followed up with repeat EGD, it seems like. High suspicion for this current ulcer to be malignant. No NSAIDs. Patient should follow-up with GI as an outpatient closely. ECG Study Date of [**2140-8-16**] 12:39:26 PM Sinus rhythm. Possible left atrial enlargement. Possible old inferior myocardial infarction. Poor R wave progression in leads V1-V4, raising the possibility of old anteroseptal myocardial infarction. Q-T interval is prolonged for rate. Compared to the previous tracing of [**2140-4-10**] R waves have appeared in lead V5 and V6, the Q-T interval has further prolonged. Brief Hospital Course: 64yo M with h/o CHF, DMII, peptic ulcer now admitted with UGIB, s/p brady-PEA arrest . # Post-arrest: During hospitalization, patient experienced multiple episodes of cardiac arrest. First brady PEA arrest in the setting of bradycardia and hypotension following massive GI bleed. On [**2140-7-23**], the patient went into AFib with RVR leading to another brady PEA arrest, with ROSC with epi + HCO3. The patient immediately experienced another episode of brady PEA arrest. The patient was loaded with amiodarone and then dosed PO. The patient also received an 48 hr EEG which showed no malignant activity. On [**2140-7-27**], the patient went into AFib with RVR with aberrancy with rates up to the 190s with hypotension following a trial of metoprolol. The patient received epi and an amiodarone load. The patient then went into V tach arrest, was shocked, and following more epi and bicarb, experienced ROSC. Since then, the patient has been in sinus rhythm with heart rates in the 70s and BPs running 130s/70s. The patient was transferred to the CCU given the complexity of this case. During this hospitalization, he required BP aumentation with pressors, but has not required this intervention for several weeks prior to discharge. . # Repiratory failure after multiple arrests. Patient was on mechanical ventiliation after PEA arrest, multiple attempts were made to wean from the ventilator and eventually the deicison was made to preform a tracheostomy which was performed on [**8-12**]. Currently patient is able to breath on own with trach mask, but at times requires pressure support. . # Atrial fibrillation: CHADS 2 score of 5. currently in NSR. Currently off coumadin given recent GIB which ended patient in the unit. Currently would suggest that risk of bleeding outweighs daily risk of stroke. Patient had episode of afib with RVR and bradycardic arrests while in house. He was amiodarone loaded and we will continue Amiodarone 400mg daily and will continue aspirin for anticoagulation. . # Coronary artery disease: The patient presented to the ED with changes on his EKG despite denying any chest pain at admission. According to the patient's home cardiologist, Dr. [**Last Name (STitle) 11378**] [**Telephone/Fax (1) 34506**] in [**Location (un) **], the patient had an inferior MI 5 years ago. He should f/u with his outpatient cardiologist after discharge. . # HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC: At admission, patient had an EF of 25%. Following patient's 2nd and 3rd cardiac arrests, the echocardiography showed a further diminished EF of 15%. The patient likely has had multiple ischemic insults over course of this hospitalization, also likely tachycardic cardiomyopathy. Volume status has been difficult to manage in setting of mixed cardiogenic and distributive shock picture. Given his labile BPs previously, future diuresis will be avoided unless the patient's respiratory status worsens. He will be followed as an outpatient for consideration of further management. For now, Plan to continue rhythm/rate control with amiodarone. . # FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN): The patient was febrile since [**7-23**] following his episodes of PEA arrest. Etiologies include drug fever, VAP, UTI, response to ischemic injury, acalculous cholecystitis, catheter infection, and skin infection (given that patient developed a 7 x 10 cm deep tissue ulcer over his coccyx). While on antibiotics, the patient continued to be febrile, spiking at 104.4 degrees though his fever was never associated with leukocytosis. The patient's antibiotics were discontinued to r/o drug fever, and his fever curve trended down with additional use of a cooling blanket. However, stopping his antibiotics resulted in a white count jump to 17.6 on [**2140-7-28**]. There continues to be an unclear source of infection, considering VAP but no growth on cultures to date. Sputum cultures currently growing yeast, no speciation. Cefepime d/c??????ed [**8-12**] after adequate coverage. BCx only showed 2 bottles with Staph epi from [**7-29**] and [**8-2**]. Finished a course of abx for VAP with cefepime [**8-10**] and vancomycin [**8-12**]. . # Pneumonia: Patient with complicated course and periodic fevers as above, at one point attributed to hospital acquired pneumonia given LLL infiltrate on CT. Less likely related to line infection (line removed [**8-7**] and again on [**8-18**]) or gall bladder/abdomen (elevated tbili and AP w/ prior e/o gallbladder edema). His fever seems to precipitate afib with RVR leading to cardiac events. s/p cefepime and vancomycin on and off for over 20 days. . # Altered mental status attributed to seizures and history of old stroke in the setting of critical illness. Following the PEA arrest in the ED s/p cooling and three further PEA arrests in the setting of atrial fibrillation with subsequent worsening after cardioversion and hypotension was accompanied by decreased responsiveness and CT head showed an old left frontal encephalomalacia. EEG initially showed frequent electroclinical seizures correlated with head turning to left. He was initially trialled on keppra and this was changed to lacosamide after developing a rash on keppra. His EEG improved after institution of AED therapy showing encephalopathy but no seizures and last day of LTM EEG was [**8-13**]. MRI of the head demonstrated an age indeterminate infarct with encephalomalacia. At discharge, patient is intermittently following commands, with level of alertness improving each day. . # ACUTE KIDNEY INJURY: The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] in the setting of multiple cardiac arrests was most likely [**3-17**] ischemia. His Cre at discharge had returned to a baseline of 1.2. . # UGIB: The patient initially presented with hematemesis and melena. The patient had a EGD which showed a 2 cm gastric ulcer which GI found to be stable and would not require follow-up for another 8 weeks. The patient was treated with pantoprazole and his Hct was monitored daily. The patient has planned f/u with GI for repeat endoscopy. . # Acalculous Cholecystitis: Alk Phos and T. bili remain elevated in the setting of recent abd CT on [**8-6**] with contast in gall bladder, possibly gall bladder sludge. RUQ U/S ?????? no biliary duct dilation, gallbladder sludge, moderate ruq acites . # DECUBITUS ULCER: The patient developed an ulcer over coccyx and was evaluated and followed by the wound consult team. His ulcer was Debrided by surgery on [**2140-8-19**]. He should follow up in surgery clinic 2 weeks from discharge. Please refer to page 2 for specific wound care recommendations. . # DMII: The patient was placed on an insulin sliding scale. Fingersticks were checked QID. . # PSYCHOSOCIAL: The patient is the primary caretaker for his mother, [**Name (NI) **]. The MICU team updated his mother and family each day regarding changes in his clinical care. . # NUTRITION: PEG placement/nutrition:PEG placed [**2140-8-17**] Flexseal in place, last changed [**2140-8-11**] Foley catheter in place . . TRANSITIONAL ISSUES: # Concern for Line infection: The patient had a Picc line in place, which was discontinued on [**2140-8-17**]. Vancomycin was given at that time, but blood and picc line cultures did not show any growth and the picc line site showed only some mild contact dermatitis (likely from adhesive tape), so vanco was discontinued prior to discharge. Please call [**Hospital1 18**] to ensure that blood cultures from [**2140-8-18**] become finalized with no growth. No growth at time of discharge. . # hypernatremia: Patient with new hypernatremia to 151 on morning of discharge. Improved to 148 at 3pm after giving 500 cc free water through PEG. He was also ordered for free water flushes at 100ml q6 hours. Chem 7 including Na should be checked on [**8-20**], and flushed adjusted accordingly. - Patient is full code Medications on Admission: (confirmed with patient's cardiologist) Aspirin 81 mg qday Crestor 10 mg 5 days/wk Glipizide 5 mg qday Lasix 40 mg qday Amlodipine 10 mg qday Spironolactone 12.5 mg qday Metoprolol Succinate 100 mg qday Discharge Medications: 1. Lacosamide 100 mg PO BID 2. Senna 1 TAB PO BID:PRN constipation 3. Clobetasol Propionate 0.05% Cream 1 Appl TP [**Hospital1 **] drug rash Please apply to affected areas of skin. Thank you. 4. Artificial Tear Ointment 1 Appl BOTH EYES [**Hospital1 **]:PRN intubated 5. Amiodarone 400 mg PO DAILY 6. Acetaminophen IV 1000 mg IV Q6H:PRN pain/fever 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Glargine 10 Units Bedtime Insulin SC Sliding Scale using REG Insulin 9. Pantoprazole 40 mg IV Q12H 10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 12. Aspirin 81 mg PO DAILY 13. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: GastroIntestinal bleed Cardiopulmonary arrest: pulseless electrical activity Coronary artery disease HEART FAILURE (congestive), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC pneumonia altered mental status Shock liver acute kidney injury Decubitus ulcer Secondary: Diabetes Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname 1728**], It was our pleasure to care for you at [**Hospital1 18**]. You were admitted for a GI bleed and had an extended hospital course including cardiopulmonary arrests, requiring placement of a tube in your neck to help you breathe, and a tube in your stomach to help you get nutrition. We made the following changes to your medications. Please STOP all the following medications: Crestor 10 mg 5 days/wk Glipizide 5 mg qday Lasix 40 mg qday Amlodipine 10 mg qday Spironolactone 12.5 mg qday Metoprolol Succinate 100 mg qday Please CONTINUE aspirin Please START Amiodarone Please START Tylenol PRN Please START senna PRN Please START polyethylene glycol PRN Please START lacosamide Please START glargine Please START clobetasol cream Please START artificial tear ointment Please START oxycodone as needed for pain Followup Instructions: Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Name: [**Last Name (LF) **],[**First Name3 (LF) 132**] C. Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 133**] Name: [**Last Name (LF) 11378**], [**Name8 (MD) 41172**] MD When: Thursday [**9-15**] at 12:30 Address: LOWN CARDIOLOGY,[**Hospital1 72615**], [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 34506**] Department: Neurology Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] When: Dr. [**Last Name (STitle) 10865**] office is working on a follow up appointment for you in 16-30 days after your hospital discharge. You will be called by the office with your appointment date and time. If you have not heard from the office or have questions please call the number listed below. Location: [**Hospital1 **] Address: [**Location (un) **], KS 457, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2928**] Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2140-8-30**] at 10:30 AM With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Please make an appointment to be seen in surgery clinic for follow-up of your sacral decubitus ulcer approximately 2 weeks from the date of discharge. Acute Care Surgery Clinic, call ([**Telephone/Fax (1) 2537**] to schedule appt. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 16058**] Admission Date: [**2140-7-16**] Discharge Date: [**2140-8-19**] Date of Birth: [**2076-2-1**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 13451**] Addendum: On [**8-19**], the patient underwent an excisional debridement of a sacral decubitus ulcer by the surgical service. The ulcer was sharply debrided. Major Surgical or Invasive Procedure: PEG placed [**2140-8-17**] tracheostomy performed on [**8-12**] PICC line placed and removed Sacral decubitus ulcer excisional debridement [**8-19**] Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 13452**] Completed by:[**2140-9-1**]

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icd9cm

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icd9pcs

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30182, 30334

26812, 26812

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27825, 30144

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2718, 3945

5791, 17463

24627, 25445

253, 325

5556, 5649

415, 2575

3980, 4486

26827, 26927

2597, 2633

2649, 2668

24,129

136,897

10070+56101

Discharge summary

report+addendum

Admission Date: [**2113-8-19**] Discharge Date: [**2113-8-22**] Date of Birth: [**2063-4-17**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Zithromax / Floxin / Penicillins / Demerol / Morphine Sulfate / Dilaudid / Bactrim Attending:[**First Name3 (LF) 905**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Tracheal intubation EEG History of Present Illness: HPI: Pt is a 50 y/o female with multiple medical problems including orthostatic hypotension, adrenal insufficiency, h/o DVT/PE s/p filter, s/p gastric bypass with chronic malnutrition, ICH s/p fall [**1-25**] who was sent to the ED from her nursing home to have her G-tube evaluated [**2-22**] reports of clotting. On arrival to the ED, she was noted to be unresponsive (clearly a change from how she left the NH). Per report obtained by Dr. [**Last Name (STitle) 575**], she was given her usual dose of methadone (15mg) prior to leaving in the ambulance at which time she was alert and oriented x 3. Per EMS reports, the pt became progressively more somnolent en route to [**Hospital1 18**]. At the time of arrival, she was minimally responsive to sternal rub per the ED staff. After discovering that the pt had received methadone, the ED staff administered Narcan at which point the pt began to become somewhat more responsive (although minimally per ED staff). Shortly thereafter, the pt experienced a 10 second episode of rigid extension of both legs with shivering movements of her upper extremities. There was no history of clonic movements after this episode of rigidity. There was discrepancy between some members of the ED team as to whether this event could have been seizure activity. She was given intravenous lorazepam. She was subsequently intubated for airway protection. . Per the notes, there is no history of antecedant fever, chills, or focal complaints prior to transfer from the [**Hospital1 1501**] to the [**Hospital1 18**]. . Past Medical History: 1. S/p gastric bypass in [**2099**] for weight loss, very complicated course including chronic malnutrition s/p J-tube 2. DVT/PE [**10-23**] IVC filter placed on [**2111-11-23**]. 3. SLE with dermatologic involvement, treated with low dose chronic prednisone for several yrs. s/p biopsy. 4. Hypothyroidism, treated with levothyroxine. 5. Hypoventilation syndrome with CO2 in 60s. 6. Osteoporosis 7. Barretts esophagus and esophageal stricture. 8. Peripheral neuropathy. 9. H/O tachycardia, ? MAT 10. Anxiety and depression. 11. Chronic malnutrition s/p J- tube 12. h/o thigh hematomas while on coumadin therapy X 2 occassions (right and left) 13. orthostatic hypotension 14. Migraine headache 15. Asthma 16. Adrenal Insufficiency 17. Small left frontal cortical bleed and frontal scalp hematoma s/p [**2111**]8. Status post cholecystectomy [**27**]. History of seizures Social History: 75 pack year smoking history and quit few months ago. She denies any alcohol consumption. She lives in a nursing home at the [**Location (un) 29393**] in [**Location (un) 2251**]. Family History: Father died on MI, had diabetes; mother died of MI Physical Exam: PE: VS: T 99.5, HR 81, BP 154/90, RR 16, O2 sats 99% on AC 450x16, 0.5, 5. Gen: Sedated, intubated. HEENT: NCAT. No signs of external injury to head. PERRL (2-3mm bilaterally). MM dry. CV: RR, normal S1, S2. Dynamic precordium. No m/r/g. Lungs: Coarse breath sounds throughout. No crackles or wheezes. Abd: Bony prominence protruding at level of xiphoid. Large, well healed scar runs vertically up the midline of her abdomen. Multiple healing excoriations and lesions are scattered across her abdomen. G tube site is erythematous with yellowish drainage (? TF or pus). Abdominal wall appears thin as bowel peristalsis is visible through the skin of the abdomen. Soft, NTND. + BS. No organomegaly appreciated. Ext: No c/c/e. [**4-25**] inch wound on lateral aspect R shin is erythematous, warm, almost flocculent. Stitches are still in place, skin is peeling around it. Neuro: With propofol on, does not wake to sternal rub, does not withdraw to noxious stimuli. With propofol off, could answer questions by shaking head yes or no. Was able to squeeze her hands bilaterally and wiggle her feet bilaterally. . Pertinent Results: [**2113-8-19**] 11:52PM TYPE-ART TEMP-36.6 RATES-/40 PO2-263* PCO2-28* PH-7.47* TOTAL CO2-21 BASE XS--1 -ASSIST/CON INTUBATED-INTUBATED [**2113-8-19**] 11:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2113-8-19**] 11:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2113-8-19**] 11:40PM URINE RBC-[**6-30**]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-1 [**2113-8-19**] 09:45PM GLUCOSE-94 UREA N-10 CREAT-0.6 SODIUM-127* POTASSIUM-5.2* CHLORIDE-90* TOTAL CO2-30 ANION GAP-12 [**2113-8-19**] 09:45PM CORTISOL-4.2 [**2113-8-19**] 09:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2113-8-19**] 09:45PM WBC-6.4 RBC-4.23 HGB-14.1 HCT-44.2 MCV-104* MCH-33.5* MCHC-32.0 RDW-13.0 [**2113-8-19**] 09:45PM PT-11.3 PTT-31.3 INR(PT)-0.8 [**2113-8-21**] 04:31AM BLOOD WBC-7.3 RBC-3.87* Hgb-12.9 Hct-40.2 MCV-104* MCH-33.4* MCHC-32.1 RDW-13.1 Plt Ct-213 [**2113-8-21**] 04:31AM BLOOD Plt Ct-213 [**2113-8-21**] 04:31AM BLOOD Glucose-82 UreaN-10 Creat-0.4 Na-133 K-4.5 Cl-95* HCO3-30 AnGap-13 [**2113-8-21**] 04:31AM BLOOD Albumin-3.4 Calcium-8.6 Phos-2.7 Mg-2.1 ------- Urine Cx prelim: + for enterococcus, speciation pending CT Head: No evidence of intracranial hemorrhage or edema. CXR: 1) Placement of nasogastric and endotracheal tubes as described above. 2) The shoulders are incompletely included on this view. However, there is an atypical appearance to both shoulder. Correlation with physical exam to exclude shoulder dislocation or fracture is requested. EEG: Brief Hospital Course: A/P: 50yo female with an extensive PMH who presented to the ED for G-tube clotting, but then developed ? seizure-like activity resulting in intubation for protection of her airways. . 1. ? Seizure activity/unresponsiveness: Possible etiologies for her unresponsiveness included toxic/metabolic derangements (uremia, hypoglycemia, hyponatremia, medication overdose, etc), seizure activity, infection, or an intracranial event. CT of her head was normal. An EEG was performed, and a preliminary read showed bifronal delta frequency slowing with sharp features (however, no clear epileptiform features, no current seizure activity). LFTs, BUN, and glucose were normal. She was hyponatremic with Na of 127, but that did not seem like enough of a shift in Na to cause unresponsiveness. Glu was 94, so hypoglycemia was not an issue. Despite a normal WBC and afebrile condition, the patient did have a urine culture positive for enterococcus. Blood cultures were negative. Given that she was loaded with methadone just prior to leaving in the ambulance, which is when she became somnolent, perhaps she received too much methadone and became overly sedated and unresponsive. Tox screen (serum and urine) were both negative, even for methadone. The most likely explanation is a combination of factors, including the UTI, hypovolemia from dumping syndrome, and narcotic use, leading to an altered mental status/state of unresponsiveness. . 2. UTI: Pt found to have urine cultures positive for enterococcus, sensitivities pending. In the past ([**5-25**]), she had a similar urine culture, which was sensitive to vancomycin and nitrofurantoin. She was given one dose of vancomycin and switched to nitrofurantoin upon discharge. . 3. Respiratory status: Pt was intubated and extubated uneventfully. No further respiratory distress during admission. . 4. Metabolic alkalosis on admission: Likely due to dumping syndrome after her gastric bypass procedure, as she is hypochloremic and hyponatremic in the setting of an elevated bicarb. . 5. Hyponatremia: Resolved with NS. Most likely due to hypovolemia in addition to her adrenal insufficiency. . 6. Glycemic control: Pt was initially hyperglycemic in the ICU. This was controlled with SSI and resolved. . 7. FEN: G-tube had been clogged on arrival, was made patent again in the ICU. She can be restarted on the tube feeds that she was on prior to admission (Jevity at 50cc/hr). . Medications on Admission: methadone 15mg po bid prednisone 7.5mg alternating with 9.5mg po qd seroquel 100/50/200mg po qd klonopin 0.5mg po bid, 1mg po qhs plaquenil 200mg po bid gabapentin 600mg po tid levothyroxine 75mcg po qd paroxetine 40mg po qd pantoprazole 40mg po qd thiamine Discharge Medications: 1. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO QMOWEFR (Monday -Wednesday-Friday). Tablet(s) 2. Prednisone 2.5 mg Tablet Sig: 9.5mg mg PO QTUTHSA ([**Doctor First Name **],TU,TH,SA). 3. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 4. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Quetiapine Fumarate 200 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 10. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Nitrofurantoin 100 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 10 days. Discharge Disposition: Extended Care Facility: [**Location (un) 29393**] - [**Location (un) 2251**] Discharge Diagnosis: Primary diagnosis: 1. Altered mental state secondary to medications and narcotics Secondary diagnoses: 1. Hypertension 2. Adrenal insufficiency 3. Hyponatremia Discharge Condition: Stable Discharge Instructions: Continue all your medications as prescribed below. Your methadone dose has been changed to 5mg by mouth twice daily. Call your doctor if you have any uncontrolled movements, weakness, difficulty moving extremities, an episode with loss of consciousness, difficulty breathing, nausea/vomiting, dizziness, or lightheadedness. Followup Instructions: You have a follow-up appointment with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 33650**] Monday, [**2113-8-28**] at 2:15pm. . You have these appointments previously scheduled: Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2113-8-25**] 10:00 Provider: [**First Name4 (NamePattern1) 8990**] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2113-9-1**] 1:00 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 8673**] [**Name (STitle) **] Where: FD [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) PAIN MANAGEMENT CENTER Phone:[**Telephone/Fax (1) 1091**] Date/Time:[**2113-9-19**] 9:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Name: [**Known lastname 5875**],[**Known firstname 194**] Unit No: [**Numeric Identifier 5876**] Admission Date: [**2113-8-19**] Discharge Date: [**2113-8-22**] Date of Birth: [**2063-4-17**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Zithromax / Floxin / Penicillins / Demerol / Morphine Sulfate / Dilaudid / Bactrim Attending:[**First Name3 (LF) 391**] Addendum: Ms. [**Known lastname **] was discharged on methadone 5mg [**Hospital1 **], a much lower dose than her outpatient regimen. She was discharged on the lower dose because the exact etiology of her altered mental status was never determined, and may have been a result of the interaction between her urinary tract infection and methadone use. Given that she had only been started on antibiotics for her UTI the day prior to discharge, we were not comfortable sending her out on her normal methadone dose and risking a repeat of her altered mental status. Her methadone should be titrated as appropriate as an outpatient, depending on her infection and mental status. Discharge Disposition: Extended Care Facility: [**Location (un) 5155**] - [**Location (un) **] [**Name6 (MD) 116**] [**Name8 (MD) 117**] MD [**MD Number(1) 392**] Completed by:[**2113-8-22**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "89.14" ]

icd9pcs

[ [ [] ] ]

12719, 12919

5923, 7785

379, 404

10224, 10233

4290, 5555

10605, 12696

3094, 3146

8650, 9918

10041, 10041

8368, 8627

10257, 10582

3161, 4271

10144, 10203

318, 341

432, 1986

5564, 5900

10060, 10123

7799, 8342

2008, 2880

2896, 3078

31,239

121,924

33402

Discharge summary

report

Admission Date: [**2199-5-7**] Discharge Date: [**2199-5-9**] Date of Birth: [**2133-2-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Elective admission for carotid stent Major Surgical or Invasive Procedure: Carotid angiography with stent placement History of Present Illness: 66 yom with h/o history of a right carotid endarterectomy done in [**2194**] and has since been followed with serial ultrasounds. He now has been found to have an asymptomatic, high grade stenosis involving the left internal carotid. Past Medical History: CAD s/p 3V CABG in [**2179**] S/p PCI [**2194**] [**9-27**] stent to vg to RCA s/p NSTEMI [**11-27**], s/p 2.5mm DES to VG to RCA Hypertension Borderline diabetes, diet controlled Hyperlipidemia Right carpal tunnel syndrome Two basal cell cancers removed In situ bladder cancer s/p ablation Obstructive sleep apnea-does not use cpap Dyslipidemia Tonsillectomy Glaucoma Social History: married and lives with his wife. Retired firefighter. . Has 2 children. Has alcohol 3 times per week. Family History: N/A Physical Exam: Gen: Elderly male lying in bed in nad HEENT: PERRL, EOMi, MMM Neck: supple Chest: CTAb, no crackles CVR: RRR, nl s1, s2, no r/m/g Abd: soft, nt, nd Ext: no edema Neuro: A&O X3, PERRL (4->3mm), EOMI, strength 5/5 upper and lower extremities. sensation intact throughout. Pertinent Results: [**2199-5-7**] 03:51PM GLUCOSE-93 UREA N-17 CREAT-1.0 SODIUM-141 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-27 ANION GAP-12 [**2199-5-7**] 03:51PM estGFR-Using this [**2199-5-7**] 03:51PM CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-2.2 [**2199-5-7**] 03:51PM PT-12.8 PTT-27.9 INR(PT)-1.1 C.CATH COMMENTS: 1. Access: Retro RFA with catheter to selective RCCA, RSCA nad LCCA. Selective injections were taken in the RCCA and LCCA. 2. Hemodynamics: 148/64/89. HR 73 3. Thoracic aorta: Type 2 arch noted following supravaular aortagraphy. 4. Subclavian artery. The RSCA is without significant disease. 5. Carotid arteries: The RCCA is normal. The [**Country **] is without critical lesions. The [**Country **] fills the ipsilateral MCA and fetal origin PCA though no filling is noted in the RACA. The LCCA is normal. the [**Doctor First Name 3098**] has a tubular 80% lesion. The ICA fills the ipsilateral MCA and noted filling of the ipsilateral and contralateral ACA. 6. Successful PTA/stent to [**Doctor First Name 3098**] with a 6-8x30mm Protege stent posted with a 4.5mm balloon. Excellent result with normal flow down artery and 10% residual stenosis. FINAL DIAGNOSIS: 1. [**Last Name (un) 5052**] 2 aortic arch. 2. No significant disease in RCCA or [**Country **]. 3. [**Doctor First Name 3098**] supplies ipsilateral MCA and ACA as well as contralateral ACA. 4. Successful PTA/stent to [**Doctor First Name 3098**] with a 6-8x30mm Protege stent. Brief Hospital Course: Patient was admitted to the cath lab and underwent angiography with a right femoral access. [**Country **] was without disease, [**Doctor First Name 3098**] with 80% stenosis. Vagal episode (HR down to 30s, RR 18, O2 97%) with ballon dilation, given atropine and started on neosynephrine drip. Stent was placed. Post cath patient was transferred to the CCU for further management. In the CCU, pt was maintained on a neosynephrine gtt to maintain a SBP>100 but <160. His home blood pressure medications were held. He was subsequently weaned off the gtt and BP remained stable. His home blood pressure medications were held on discharge with plans to follow up the day after discharge wtih Dr [**Last Name (STitle) 77515**] in [**Location (un) **] for BP check and ongoing management. Medications on Admission: Lipitor 40mg daily in the am Tenormin 50mg daily in the PM Centrum ?????? tablet daily in the am Timolol eye gtts 0.5% 1 gtt each eye [**Hospital1 **] Ecasa 325mg daily Quinapril 20mg daily Plavix 75mg daily Protonix 40mg [**Hospital1 **] Imdur 60mg daily in the PM Amlodipine 10mg daily in the pm Ntg quick 0.4mg prn Tricor 48mg daily in the am Ativan 1mg qhs 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). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO daily (). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Discharge Disposition: Home Discharge Diagnosis: Carotid stenosis s/p PCI Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for an elective procedure to fix the stenosis in your carotid artery. You had a stent placed in the artery. You were monitored in the cardiac care unit after the procedure. . There were changes made to your medications. All of you blood pressure medications were stopped for now; but may be restarted once you follow up with the cardiogist, Dr [**Last Name (STitle) **] tomorrow. Tenormin 50mg daily in the PM- STOPPED Quinapril 20mg daily-STOPPED Imdur 60mg daily in the PM-STOPPED Amlodipine 10mg daily in the pm-STOPPED . If you have any lightheadness, change in vision, facial weakness or numbness, chest pain, shortness of breath, palpitations or other concerning symptoms, please return to the emergency room or call your doctor. . In addition, you were felt to have some evidence of sleep apnea. You have had a study in the past that you did not complete, but please discuss this with your primary care doctor and consider another sleep study. Followup Instructions: Please follow up with Dr [**Last Name (STitle) **] in [**Location (un) **] tomorrow [**5-10**] at 10:45AM. [**Location (un) **], [**Apartment Address(1) 32773**], [**Location (un) **], MA. ([**Telephone/Fax (1) 77516**] . Please call your PCP Dr [**Last Name (STitle) **] and make a follow up appointment in the next 3-4 weeks. Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2199-6-10**] 11:00

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icd9cm

[ [ [] ] ]

[ "00.40", "00.61", "00.63", "00.45", "99.19" ]

icd9pcs

[ [ [] ] ]

4764, 4770

2967, 3752

350, 392

4838, 4846

1496, 2646

5881, 6320

1185, 1190

4164, 4741

4791, 4817

3778, 4141

2663, 2944

4870, 5858

1205, 1477

274, 312

420, 656

678, 1049

1065, 1169

27,650

105,704

483

Discharge summary

report

Admission Date: [**2156-8-1**] Discharge Date: [**2156-8-12**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 358**] Chief Complaint: epigastric/chest pain Major Surgical or Invasive Procedure: ERCP with stent placement, no sphincterotomy seconary to supratheraputic INR History of Present Illness: HPI: 87yo man with h/o CAD s/p CABG [**2141**], mult PCI since, ischemic CMY with LVEF 35%, Afib on coumadin, possible AS and/or MR, diet controlled DM2, ?CRI, gout, who presented to [**Hospital **] Hospital at 4am on [**2156-8-1**] with pain in his epigastrium and chest, and was transferred here out of concern for cholangitis. The patient reports intermittent discomfort in his chest and epigastrium which began 1-2 weeks ago, with no precipitating factors such as exertion or food. He describes it as a cramping pain, with radiation to his R shoulder, but not to his back or arms. He did say that it felt worse at night while lying down. The pain felt different than his prior angina, and he treated it with Tylenol with some relief. However, on the night PTA, the pain recurred and he was unable to get back to sleep. His wife called EMS, and he was [**Name (NI) 4045**] to [**Hospital **] Hospital. ROS is notable for: chronic DOE, prehaps with some increase over baseline; increase in his RLE swelling (has chronic L>R edema from prior surgeries; denies F/C/V, diarrhea, constipation, changes in stool or urine color or frequency. He does have some erythema and swelling of his left 5th digit, which started 3 weeks ago, and which he thinks may have been from a bug bite. At [**Hospital **] Hospital, he was found to have EKG without change and normal cardiac enzymes. CXR showed bilateral pleural effusions, L>R. He was felt to be in CHF on exam, given Lasix for diuresis. His labs came back with WBC 12.4 with 88% PMNs, 8% bands, and abnl LFTs (AST 122, ALT 54, AP 307, TBili 3.3, DBili 2.5, TProt 7.3, Alb 3.5). His lipase was elevated at 2214, and his BUN and Cr were elevated at 36/1.4, unclear if chronic or acute. An abd u/s revealed several small gallstones in the gallbladder, without thickening of his GB walls, and with no biliary dilatation. He received Levaquin + CTX, vomited once and received Zofran. His INR was 2.8, and he was given 5mg Vit K sq once (no FFP). After discussion with the ERCP fellow at [**Hospital1 18**], the patient was transferred here for further care and plan for ERCP. Past Medical History: CAD s/p CABG [**2141**], mult PCI since ischemic cardiomyopathy with LVEF 35% cardiac murmur consistent with MR Afib on coumadin DM2, diet controlled CKD (?) gout Social History: SH: lives at home with his wife on the [**Location (un) 1121**]; previously smoked pipes and cigars, quit several years ago and then restarted, quit again 2 weeks ago. Rare etoh use. No illicits. Worked as a Master Craftsman for GTE until 21y ago, since retired. Still crafts things for enjoyment. Does not have a garden or work outside often. . Family History: noncontributory Physical Exam: Afebrile, mild hypertension to 140/100, sats >90% on room air Gen -- pleasant, cooperative HEENT -- poor dentition, op clear, anicteric sclera, conjunctiva nonerythematous, neck supple, no carotid bruit. Heart -- regular, holosystolic murmur at apex not radiating to carotids Lungs -- clear bilaterally Abd -- soft, nontender, mildly distended, appropriate bowel sounds Ext -- no edema, rash or lesion Gait -- unsteady Pertinent Results: [**2156-8-1**] 07:20PM GLUCOSE-69* UREA N-36* CREAT-1.6* SODIUM-139 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-28 ANION GAP-14 [**2156-8-1**] 07:20PM ALT(SGPT)-64* AST(SGOT)-141* ALK PHOS-309* AMYLASE-901* [**2156-8-1**] 07:20PM DIGOXIN-0.8* [**2156-8-1**] 07:20PM WBC-16.6* RBC-3.54* HGB-13.0* HCT-38.9* MCV-110* MCH-36.6* MCHC-33.4 RDW-15.4 [**2156-8-1**] 07:20PM NEUTS-74* BANDS-20* LYMPHS-2* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* NUC RBCS-1* Brief Hospital Course: Mr. [**Known lastname **] is an 87 year old male admitted [**2156-8-4**] as a trasfer from [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 4046**] to the [**Hospital Unit Name 153**] for sepsis/pancreatitis. 1. pancreatitis/E.coli septicemia -- ERCP revealed obstructive gallstone, and a stent was placed. Outside blood cultures positive for pan sensitive E. coli. He received antibiotics, including initially rocephin at outside hospital, ampicillin on transfer, then ciprofloxacin since [**8-5**], with a stop date planned for [**2156-8-16**]. A follow up appointment as an outpatient for repeat ERCP and stent removal should be planned for [**4-12**] weeks post discharge (initial ERCP date [**2156-8-4**]). He improved dramatically after ERCP, with no abdominal pain and tolerating a full diet on discharge. 2. acute renal failure -- improved to baseline with Lasix and supportive care of sepsis. ACE inhibitor and digoxin held. 3. CAD/ischemic cardiomyopathy -- some question of ACS on admission, however no ECG changes and symptoms consistent with pancreatitis. His antiplatelet medications were held due to interventions, and should be held 10 days post ERCP. His beta blocker was restarted when he improved from his inital presentation. A statin was added during his hospitalization as well, and should be followed up with liver enzymes and lipid profile in 5 weeks after discharge. His home dose Lasix was restarted as well, three days prior to discharge. 4. atrial fibrillation/coumadin -- Mr. [**Known lastname **] received FFP on presentation in order to perform ERCP. After the procedure, it was restarted at his home dose of 4 mg po qhs. However, his INR was affected by the simulateous administration of ciprofloxacin, and was supratheraputic to 3.6 on [**2155-8-12**]. It was held the night prior to discharge, with instructions for the rehab facility to follow INR closely, and adjust coumadin appropriately. He was rate controlled appropriately throughout his hospitalization, although his digoxin was held secondary to renal insufficiency. It can be restarted at the discretion of his primary physician. 5. hypertension -- mildly elevated blood pressures in the latter part of his hospitalization, controlled with Lasix and metoprolol. ACE inhibitor held initially because of renal insufficiency. Restarted day prior to discharge. He should have Crt/potassium checked one week after restarting ace (instructions given to rehab facility). Medications on Admission: unknown Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. lisinopril 5 mg po qday Discharge Disposition: Extended Care Facility: [**Location (un) 4047**] Nursing & Rehabilitation Center - [**Location (un) 4047**] Discharge Diagnosis: 1. gallstone pancreatitis s/p ERCP with stent placement 2. E.coli sepsis, resolved 3. acute renal failure, resolved Discharge Condition: stable Discharge Instructions: You were hospitalized with gallstone pancreatitis in the ICU. You had acute renal failure, which recovered to your normal kidney function. You will be discharged to a rehabilitation facility in order to gain strength and continue to receive help with your medications. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 3278**] in one week. You should be evaluated as an outpatient for obstructive sleep apnea. The gastroenterology outpatient clinic will call you with a follow up appointment for ERCP and common bile duct stent removal.

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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139,237

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Discharge summary

report+addendum

Admission Date: [**2189-12-27**] Discharge Date: [**2190-1-5**] Date of Birth: [**2113-5-6**] Sex: F Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 76 year old woman who was transferred from an outside hospital with complaints of right sided headache times one month and gait instability times two to three weeks. She initially presented to an outside hospital on [**11-12**] status post a fall secondary to a syncopal episode. Head CT performed at that time was negative. She has complained of constant headache daily since fall with a new onset of gait instability starting one to two weeks the fall. Both have progressively worsened with no photophobia, nausea or vomiting. Today again she presented to an outside hospital with the above complaints. Head CT showed bilateral subdural hematomas, acute and chronic with midline shift to the left. Patient was transferred to [**Hospital1 69**] for further management. PAST MEDICAL HISTORY: Coronary artery disease, angina, irritable bowel syndrome, gastroesophageal reflux disease. PAST SURGICAL HISTORY: Patient has allergy to codeine. PHYSICAL EXAMINATION: She was in no acute distress. Pleasant, conversant, awake and alert and oriented times three. Head, eyes, ears, nose and throat nonicteric, extraocular movements full. Pupils equal, round and reactive to light. Chest clear to auscultation, no murmur, rub or gallop cardiac-wise. Abdomen was soft, nontender, nondistended. Neurologic: Nonfocal examination. Sensation: Intact to light touch throughout. Strength is 5 out of 5 in all muscle groups. Her reflexes were 2 plus symmetric throughout. Her toes were downgoing. She had no clonus. Head CT with contrast again showed the same as the outside CT. Mixed attenuation bilateral subdural hematomas with 1 to 1.5 cm of midline shift to the left. The patient was admitted to the Intensive Care Unit for close neurologic observation. She was seen by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] and was taken to the operating room on [**12-28**] for burr hole evacuation of a left sided subacute subdural hematoma. There were no intraoperative complications. Postoperative vital signs were stable. She was afebrile. She was awake, alert and oriented times three in all extremities with good strength on the right side. On the left her biceps was 4, triceps 4 plus and lower extremity strength was 5 out of 5. Her sensation was intact. She had a drain in place that was left in until [**2189-12-31**] when it was discontinued. Head CT remained stable postoperatively with evacuation. She was started on lisinopril and then it was discontinued due to hypotension. Electrocardiogram showed normal sinus rhythm without ischemia. She was transferred to the step down unit on [**2189-12-31**]. She remained neurologically stable. On [**2190-1-2**] she complained of abdominal pain with distention and diarrhea and vomiting. She had a KUB which showed partial bowel obstruction and a CT of her abdomen which showed mildly dilated loops of small bowel without a clear transition point. The colon is to be decompressed. This likely represents partial small bowel obstruction. There is no evidence of complete obstruction as air and contrast are seen throughout the colon down to the rectum. She also has bibasilar pleural effusions and associated atelectasis. The patient was kept NPO She did have diarrhea which resolved on its own and a C difficile toxin which came back negative. She was therefore not started on antibiotics for C difficile at this point. Her vital signs remained stable. She has been afebrile. She tolerated a full liquid diet this afternoon and is being advanced to a regular diet this evening. She will be discharged to rehabilitation with follow up with [**Doctor Last Name 1132**] in two weeks with a repeat head CT. Medications include Bactrim Double Strength 1 tablet P.O. B.I.D for ten days, Dilantin 100 mg P.O. t.i.d., heparin 5,000 units subcutaneous t.i.d., sodium chloride 2 grams P.O. t.i.d., atorvastatin 20 P.O. q day, atenolol 25 P.O. q day, lansoprazole 30 P.O. q day. Patient's condition was stable at the time of discharge. She will follow up with Dr. [**Last Name (STitle) 1132**] in two weeks for a repeat head CT. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern1) 6583**] MEDQUIST36 D: [**2190-1-4**] 16:24:59 T: [**2190-1-4**] 17:21:19 Job#: [**Job Number 59765**] Name: [**Known lastname 3567**], [**Known firstname 2770**] C Unit No: [**Numeric Identifier 10944**] Admission Date: [**2189-12-27**] Discharge Date: [**2190-1-10**] Date of Birth: [**2113-5-6**] Sex: F Service: NSU ADDENDUM: Addendum from the dates of [**2190-1-5**] until [**2190-1-10**]. The patient had no complications or further events while in house. On Thursday - [**2190-1-7**] - the patient did have two episodes of chest discomfort; for which he was given nitroglycerin and those resolved. The patient did have an evaluation of electrocardiogram done by Cardiology which was negative and had laboratory results for rule out myocardial infarction which were also negative. Cardiology was aware of the patient. The patient had no further episodes of chest discomfort and remained afebrile while in house. Per Infectious Disease, okay for the patient to be discharged in stable condition to [**Hospital3 **] facility. [**Name6 (MD) **] [**Last Name (NamePattern4) 2483**], [**MD Number(1) 2484**] Dictated By:[**Last Name (NamePattern1) 10945**] MEDQUIST36 D: [**2190-1-10**] 11:17:25 T: [**2190-1-10**] 17:20:17 Job#: [**Job Number 10946**]

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icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

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140,416

52697

Discharge summary

report

Admission Date: [**2103-2-22**] Discharge Date: [**2103-2-28**] Date of Birth: [**2039-2-13**] Sex: F Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 30**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: colonoscopy central venous line placement and removal History of Present Illness: This is a 64 year-old F with Crohn's disease (intact anatomy, maintained on Asacol and Ciprofloxacin), alcoholic cirrhosis, PUD, pancreatic insufficiency, CAD on aspirin 325mg and plavix, and CHF who presents with BRBPR since Tuesday AM. She awoke on Tuesday morning with a large, non-painful, bloody bowel movement (stool mixed with blood as well as blood pouring from her rectum, no clots). She stayed at home because she thought it would resolve spontaneously, but over the course of Tuesday ([**2-20**]) she had 9 more bowel movements. She presented to the ED yesterday (Wed, [**2-21**]) where her Hct was 27.0 down from 34.8 2 days prior, and proceded to have around [**8-19**] more bloody bowel movements. She received 1U pRBCs with no increase in her Hct, so received 1 additional unit with last Hct of 30.8. She has had 4 large bloody BMs already today. Both the patient and nurse say there was hardly any stool, but mostly blood and blood clots. The medical team has held her plavix (still on full-dose ASAS) and initially stopped her BB, but she has been tachycardic to 140's and light-headed with movement so they resumed the BB just this afternoon. She also reported dizziness and nausea with this. She denies any hematemesis, chest pain, and altered mental status. She only has 1 PIV due to body habitus. . Ms. [**Known lastname 108723**] was diagnosed with Crohn's disease at age 39 when she presented with abdominal pain, weight loss, and bloody diarrhea. She has been maintained since this time on Asacol (and recently Ciprofloxacin + Asacol) with very few flares and no surgery. She has baseline [**8-18**] BM's per day (thought to be due to pancreatic insufficiency) with no systemic symptoms (including fevers, arthralgias, rash, abdominal pain) and had a normal colonscopy in 8/[**2102**]. She did have an episode of GI bleeding [**2102-2-5**] similar to this, but lasting only 24 hours. She was not scoped because the bleeding coincided with initiation of aspirin/plavix; bleeding resolved spontaneously. . ROS: Pt denies fever or chills. No recent weight loss or gain. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. No orthopnea. Denied nausea, vomiting, diarrhea, or constipation. No dysuria. No sick contacts, no undercooked meat or pets (other than a house cat). Past Medical History: 1. CAD s/p RCA w/BMS on [**2102-2-2**] 2. Diastolic CHF (Recent EF~55%) 3. Crohn's Disease: h/o pancolitis w/o small bowel involvement; colonoscopy [**10-15**] showed no active disease 4. Chronic Renal Failure (Cr~1.4 at baseline). 5. DM Type II 6. Hypertension 7. h/o idiopathic dilated CMP now resolved 8. Peptic ulcer disease. 9. Alcoholic cirrhosis. 10. GERD. 11. Rheumatoid arthritis. 12. Pulmonary embolus in [**2098**]. 13. Total right knee replacement with subsequent chronic pain. 14. [**Doctor Last Name **] mal seizure in childhood. 15. Cervical disc disease. 16. L5/S1 radiculopathy with anterolisthesis of L4 on L5 on X- Ray with EMG consistent with mild radiculopathy. Social History: Patient lives with a disabled son in [**Name (NI) 669**]. She has one other son who is currently incarcerated. She was married but divorced a long time ago. 4 pack year smoking history, quit 6 years ago. Drank ~1 pint alcohol/day x 10 years, quit 6 years ago. Family History: Mom died of colon cancer. Father with DM requiring bilateral below the knee amputation. One sister has had cervical cancer(cured) and rheumatoid arthritis. Most members of her family have trouble with hypertension. No one else with IBD. Physical Exam: Vitals: T: 98.3 BP: 100/60-120/86 P: 90-108 at rest RR: 20 SpO2: 98% RA wt 192 lbs General: cheerful, well-appearing, bed in NAD. HEENT: EOMI, sclera anicteric. MMM, OP without lesions Neck: supple, unable to assess JVD. Pulm: crackles to b/t bases Cardiac: RRR, nl S1/S2, no murmurs appreciated Abdomen: soft, diffusely tender, mild distention. + BS. no rebound or guarding. Rectal: BRBPR, glove with maroon blood coating glove Ext: No edema b/t Pertinent Results: Colonoscopy: Internal hemorrhoids, Diverticulum in the sigmoid colon Additional notes: Bleeding likely hemorrhoidal in origin. No blood seen in colon. Normal mucosa . CT ABD [**2-21**] - Distended gallbladder. If clinically indicated, this could be further evaluated by ultrasound. Nonspecific small amount of free fluid within the pelvis . ECHO [**12-16**] - The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >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. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal RV size and function. The pulmonary artery systolic pressures could not be determined as a tricuspid regurgitant jet was not well seen. If clinically indicated, focused views after the injection of agitated saline could help to estimate PA pressures. Compared with the prior study (images reviewed) of [**2100-11-11**], the findings are similar. . PERTINENT LABS: Hct remained stable and greater than 27. creatinine remained at baseline. Brief Hospital Course: 64yoF with stable Crohn's disease, PUD, CAD, and pancreatic insuffiency presented with BRBPR, . # BRBPR - Patient has known Crohn's disease and intermittent RLQ pain at baseline. She had >5 episodes of bloody diarrhea upon admission to hospital and HCT did not increase appropriately to 3 units of PRBCs. Nasogastric lavage was negative. At that point, the medical team was unable to get adequate venous access and she was transferred to ICU for access and closer monitoring. In the MICU, she had a R IJ CVL placed and remained hemodynamically stable with no frther bloody stools or transfusion needs. She underwent colonocopsy which revealed internal hemorrhoids and diverticuli, but otherwise normal appear colonic mucosa and no obvious source of bleed. She was transferred back to the medical floor and continued to do well. Her aspirin, plavix (BMS in [**1-15**]), Toprol, Diovan, lasix were stopped initially in the setting of bleed and for colonoscopy. She was restarted on her aspirin and 2 days later developed one more episode of BRBPR. Aspirin was [**Last Name (un) 7162**] held. GI was reconsulted. She then underwent capsule endoscopy study to evaluate for upper GI source of bleed. She tolerated this well and had no further bloody bowel movements. Her Hct remained stable in the 24-25 range; however, given her CAD hisotry, she was transfused one more unit at discharge. By discharge, she was feeling well. -- She was told to stop her aspirin, plavix until she sees Dr. [**Last Name (STitle) 2161**] in follow-up on [**2-/2024**] -- She was told to stop her diovan and take a decreased dose of Toprol (25 mg instead of 100mg) until she sees Dr. [**Last Name (STitle) **] in [**Company 191**] on Friday [**3-2**]. If at that time, BP is higher, she can restart these BP meds. The lasix she only takes when she is above her dry weight. . # Crohn's disease - Stable disease state as per primary Dr. [**Last Name (STitle) **]. She continued home regimen of asacol, cipro, and creon. . # CAD - She had no chest pain or coronary complaints. Her cardiac medications were adjusted as above. . # CHF - ECHOs from past showed compromised EF, but has resolved EF in [**12-16**]. She was at her goal weight of 192 lbs. She only takes lasix if weight greater than 195 pounds, and she did not receive any while in house. . # DM - insulin-dependant. Goal for blood glucoses 80% <150. During bleed, she was NPO and lantus was decreased to 30 units with blood sugars in the 130-160 range. By discharge, she had gradually increased her diet, and was instructed to contact her PCP regarding increasing the lantus back to her home regiman of 68 units at night. . # Chronic renal failure - at baseline, will trend given fluid changes. . # Chronic pain. She continued lidocaine patch, neurontin, and topamax. . # Prophylaxis - pneumoboots, no indication for GI prophylaxis . # access - 1pIV, RIJ placed and removed on discharge day # Code - full Medications on Admission: -ASACOL 1600MG TID -ASPIRIN 325 mg QDay -TOPROL XL 100 mg QDay -CALCIUM 500 mg TID with meals -CIPRO 250 mg PO BID -CYMBALTA 60 mg QDay -DIOVAN 80 mg QDay -FOLIC ACID 1 MG Qam -HYDROXYZINE HCL 25 mg [**Hospital1 **] prn itching -LANTUS 68u at bedtime -LASIX 20 mg PO QOD prn weight >195 lbs. -LIDODERM 5%--Place patch on affected region for 12 hours at a time -LOMOTIL 2.5 mg-0.025 mg/5 mL--[**5-19**] ml PO QID prn diarrhea -NEURONTIN 1600 mg TID -NYSTATIN 100,000 unit/mL--10 ml suspension(s) PO QID -OXYCODONE 2.5 mg PO Q4-6h prn pain -OXYCONTIN 40 mg PO TID -PLAVIX 75 mg PO QDay -SIMVASTATIN 20 mg PO QDay -TOPAMAX 100 mg QDay -VITAMIN D 800 UNIT QDay -Creon 4 capsules TIDac Discharge Medications: 1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Topiramate 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: Four (4) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime: This dose is less than your usual home dose. As you eat more, please discuss with your PCP to adjust back to original home dose of 68 units at bedtime. 12. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 16. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Lasix 20 mg Tablet Sig: One (1) Tablet PO as directed: Please take one if your weight is greater than 195 pounds. 18. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 19. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Lower GI bleed Crohn's disease Peptic ulcer disease . Secondary: CAD Hypertension Chronic renal insufficiency Discharge Condition: stable, pain free, HCT stable Discharge Instructions: You had a GI bleed, but the source in unclear. Your colonoscopy did not show any source of bleed. You had a capsule study to evaluate your upper GI tract. Your blood counts have stabilized. Please stop taking your aspirin, plavix, and diovan until you see Dr. [**Last Name (STitle) 2161**] and Dr. [**First Name (STitle) 437**]. You should take a lower dose of your Toprol at 25 mg daily until you see Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 2161**]. You have also been taking lower doses of your Lantus. You should slowly go back to your home dose once you start to eat normally. Please call you doctor if you have any shortness of breath, bloody stools, black tarry stools, chest pain, palpitations, shortness of breath or any other concerning symptoms. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 2161**] regarding your recent hospitalization. You have an appointment on [**2-10**] at 11AM [**Hospital Ward Name 516**] [**Hospital Unit Name **]. Please see on Friday [**3-2**] to have your blood count and blood pressure checked. You will see Dr. [**Last Name (STitle) **] at Friday [**3-2**] at 3:30PM. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2103-3-5**] 2:00 Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2103-3-6**] 11:30 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2103-3-12**] 2:00

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icd9cm

[ [ [] ] ]

[ "38.93", "45.23", "99.04", "45.19" ]

icd9pcs

[ [ [] ] ]

11450, 11456

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5063

Discharge summary

report

Admission Date: [**2127-8-30**] Discharge Date: [**2127-9-1**] Date of Birth: [**2071-6-27**] Sex: M Service: MEDICINE Allergies: Tapazole Attending:[**First Name3 (LF) 30**] Chief Complaint: found unresponsive after not showing up for HD Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 56 yoM with brittle Type I DM c/b insulin antibodies, retinopathy & nephropathy, who was found at home unresponsive with core body temperature of 32 degrees celsius and a fingerstick glucose of 33 (his home [**Hospital **] clinic called EMS when he did not show up for his scheduled HD session). There was also concern upon arrival he was having a tonic seizure. Unclear course in the field. Of note, he has had multiple episodes of severe hypoglycemia complicated by prfoundly altered mental status. During the most recent of these episodes in [**6-/2127**] he was found to be bacteremic and was treated with two weeks of vancomycin (last dose to be given [**2127-7-24**] per DCS). A diagnosis of "bacteremia" was listed on discharge paperwork; [**Month/Day/Year **] cultures from [**2127-8-18**] grew Staph epi; subsequent cultures were negative. He was discharged to rehab. In the ED, he was groggy but arousable initially and then had a tonic clonic seizure. He was given ativan 1 mg x 2 with seizure termination, but he was intubated (with rocuronium + etomidate) for concern for airway protection. He received an amp of D50 as well as IV thiamine. This raised his fingerstick glucose to 175 mg/dl. Past Medical History: -- Type 1 DM: complicated by labile [**Month/Day/Year **] glucose readings and frequent admissions for hypoglycemia; diabetes is complicated by retinopathy and nephropathy -- End Stage Renal Disease on HD -- Has anti-insulin antibody; on prednisone 15 mg QD -- Chronic diastolic CHF -- PVD -- Hypertension -- Hyperlipidemia -- Hypothyroidism with a history of Grave's Disease -- h/o anemia, though currently does not appear to have low Hct; not on Epo or iron -- ? gout (per med list) -- ? BPH (per med list) Social History: Lives with parents; not currently working Denies EtOH, tobacco, drugs Family History: Mother has DM2 and RA. Maternal Aunt also with DM2. Nephew with DM1. Physical Exam: VS on arrival for ICU: T 97.1, BP 106/57, HR 90, 97% Vent: AC 500x16(23), PEEP 8, FiO2 50% (on propofol) General: intuabted, sedated, not repsonding to voice or rub HEENT: soft tissue swelling above right eye (above browline); not ecchymotic; no lacerations; right scleral edema; pupils equal and reactive Lungs: crackles at bases anteriorly; otherwise clear Cardio: rate regular, no MRG appreciated Abd: somewhat distended though soft, does not ellicit movement on palpation, no HSM, + BS Extremities: no edema Neuro: reflexes symmetric 2+ throughout; sedated & not able to do ful command Pertinent Results: LABORATORY RESULTS =================== Admission Labs: Glucose-160* UreaN-48* Creat-5.7* Na-143 K-4.5 Cl-100 HCO3-27 WBC-8.7 RBC-4.45* Hgb-13.1* Hct-40.1 MCV-90 RDW-15.1 Plt Ct-156 ----Neuts-91* Bands-0 Lymphs-3* Monos-5 Eos-1 (Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL) Fibrino-491* Calcium-10.2 Phos-5.1* Mg-2.2 Tox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG OTHER STUDIES ============== Admission EKG: sinus; no evidence of ST wave changes, non-specific T wave inversion in V5-6 (not seen on priors) Admission CXR: ET tube in place; no evidence of infiltrates or effusions on our read (official read pending). [**8-30**] N/C Head CT: Probable swelling along the right frontal scalp. Otherwise, no evidence of skull fracture or acute intracranial pathology on non-contrast CT. If there is concern for more subtle intracranial process, [**Month/Day (4) 4338**] would be recommended. Brief Hospital Course: 56 yoM with brittle T1DM, admitted with hypoglycemia, hypothermia and seizure. . # Altered Mental Status: A head CT on admission showed swelling along the right frontal scalp (chronic based on head CT from [**7-6**]) w/o evidence of skull fracture or acute intracranial pathology on non-contrast CT. Patient was intubated in the ED and on [**8-30**] patient was extubated when mental status improved. He was calm at first, but shortly thereafter wanted to leave AMA and became aggressive towards staff. A code purple called. Pt was given 5mg IV haldol. Patient refused all medications while in the ICU. Upon transfer to the floor patient was A&Ox3 and had no further episodes of AMS. Patient unable to confirm his home medications, was maintained on meds per OMR notes and records. . #. Hypoglycemia: Patient has had similar episodes in the past without clear mechanism found. Infectious work up initially negative but given concomitant hypothermia patient was placed on cefepime/vancomycin then switched to levofloxacin/vanc. Cardiac enzymes were negative. [**Last Name (un) **] team consulted and initially patient kept on lantus 3 units [**Hospital1 **] and D5 drip. Subsequently patient maintained on lantus 3U w/ conservative ISS. Upon transfer to the floor, antibiotics were discontinued and patient was maintained on conservative ISS. Fingersticks remained in 200s and patient was discharged on lantus 4U QHS. . #. Seizure: in setting of hypoglycemia; no structural abnormalities on head CT. Patient had right forehead swelling but this was also noted on last admission; no evidence of facial fx on CT. Patient was monitored and had no further seizure activity after being admitted to the ICU. . #. Diabetes Mellitus: Very brittle at baseline. While on the floor patient maintained on lantus 3U w/ conservative ISS and discharged on lantus 4U QHS (see above). Patient unable to confirm his home medications, but was continued on prednisone (per OMR recs) for insulin antibodies was continued. . #. ESRD: Patient got one round of HD in ICU [**8-30**]. Remained hemodynamically stable while on the floors and was continued on nephrocaps, sevelamer. . #. HTN: Patient's home meds were initially held except for clonidine patch. BP remained stable 120s. Home antihypertensives were restarted. . #. Hyperlipidemia: Patient was continued on home rosuvastatin. #. PVD: Patient was continued on home aspirin Medications on Admission: Lantus 4 units Qam, 3 units Qpm Per DCS [**2127-7-14**], sliding scale insulin with humalog (gentle dose) ASA 81 mg QD Rosuvastatin 20 mg QHS Levothyroxine 75 mg Prednisone 15 mg QD Dorzolamide-Timolol eye drops [**Hospital1 **] Nephrocaps Sevelamer TID with meals Doxzosin 4 mg QHS Diltiazem 180 mg SR [**Hospital1 **] Pantoprazole 40 mg QD Mioxidil 5 mg [**Hospital1 **] Lasix 80 mg [**Hospital1 **] Allopurinol 100 mg QD Clonidine 0.3 mcg/day patch Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 6. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 11. Catapres-TTS-2 0.2 mg/24 hr Patch Weekly Sig: One (1) Transdermal once a week. 12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 13. Epogen 4,000 unit/mL Solution Sig: One (1) mL Injection With [**Hospital1 2286**]. 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO once a day. 17. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 18. Insulin Lantus insulin: 4 units at bedtime Humalog sliding scale insulin: Please see attached insulin sliding. 19. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 20. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: - Hypoglycemia - Seizure secondary to hypoglycemia - Diabetes mellitus, type I - Anti-insulin antibody, on chronic prednisone Secondary: - ESRD, on hemodialysis - Hypertension - Hyperlipidemia Discharge Condition: Hemodynamically stable. Ambulatory. No episodes of hypoglycemia for >24 hours. Discharge Instructions: You were admited to [**Hospital1 69**] on [**2127-8-30**] after being found unconscious. Your [**Date Range **] glucose was found to be low, and you subsequently had a seizure. You spent one night in the intensive care unit, and briefly required intubation (a tube in your throat to support your breathing). You were then transferred to the medicine floor, and did well. On discharge, your [**Date Range **] glucose is >100. If you have feelings of lightheadedness, sweating, or feeling that your [**Date Range **] glucose is low, be sure to drink juice and eat something sweet. Your medication regimen has changed. Changes include: Changing your insulin dose to help prevent low [**Date Range **] glucose. Changing your allopurinol dose to that appropriate for patients on [**Date Range 2286**]. Please be sure to follow-up with your providers as listed below. Please return to the emergency department or call your provider for low or high [**Date Range **] glucose, lightheadedness, chest pain, fever, or for any other symptoms which are concerning to you. In terms of your discharge, we had extensive discussions with you, your parents, and your social worker at [**Name (NI) 20880**]. We devised a plan where your social worker will help you beginning this week to find an apartment to rent. In the meantime, you will stay with your parents. We discussed other options, such as a rehab or nursing home, and you were not interested in exploring potential options. Followup Instructions: Please be sure to resume your normal [**Name (NI) 2286**] schedule in the morning. Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2127-9-2**] 7:30 You have an appointment with your primary care provider in [**Hospital3 **] tomorrow, [**2127-9-2**] at 4:30pm. The office phone number is ([**Telephone/Fax (1) 1921**] and they are located on the [**Location (un) **] Central of the [**Hospital Ward Name 23**] Building on the [**Hospital1 18**] [**Hospital Ward Name 516**]. You have an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10088**] in [**Last Name (un) **] tomorrow, [**2127-9-2**] at 1:30pm. The office phone number is ([**Telephone/Fax (1) 20881**]. Completed by:[**2127-9-8**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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192,316

53067+59500+59495

Discharge summary

report+addendum+addendum

Admission Date: [**2113-5-8**] Discharge Date: Service: C-MED NOTE: Discharge date unknown at this point, but current date is [**2113-5-11**]. This is a Discharge Summary in preparation for discharge later on. CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: This is an 82-year-old Caucasian female with diabetes mellitus, hypertension, smoking history, and hypercholesterolemia who presented to the Emergency Department at an outside hospital two days prior to admission with complaints of nausea, vomiting, and bilateral arm pain for three to four hours. At that time, the patient was sent home with resolving discomfort. The symptoms recurred one day prior to admission for 30 minutes. She presented to her primary care physician in the early morning of admission and was noted to have electrocardiogram changes including ST depressions in V2 through V5. At this time, she was sent to the Emergency Department for further workup. Creatine kinase on admission was 601 with a troponin of 45. She was started on intravenous heparin, aspirin, Lopressor, and Integrilin in the Emergency Department. REVIEW OF SYSTEMS: Review of systems was positive for rhinitis. Negative for headache. Negative for vision or hearing changes. Positive for chest pain. Negative for shortness of breath or lightheadedness. Negative for palpitations. Positive for nausea and vomiting. Negative for diarrhea or constipation. Negative for bright red blood per rectum or melena. Negative for swelling. PAST MEDICAL HISTORY: 1. Hypertension times two days. 2. Diabetes mellitus with recent hemoglobin A1c of 7.6. 3. Hypercholesterolemia. 4. Peripheral vascular disease, status post iliac stent. 5. Bilateral heel ulcers. 6. History of breast biopsy 30 to 40 years prior. MEDICATIONS ON ADMISSION: Medications on admission included Amaryl 1 mg p.o. b.i.d., Maxzide 25 mg, Cosopt 1 drop each eye b.i.d., Lipitor 10 mg p.o. q.d. SOCIAL HISTORY: Social history was positive for a tobacco history of one pack per day for 60 years, and negative for alcohol or intravenous drug use. FAMILY HISTORY: Family history negative coronary artery disease, diabetes, or hypertension. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed vital signs with temperature of 97.9, pulse of 79, blood pressure of 155/81, respiratory rate of 16, satting 100% on room air. In general, this was a thin Caucasian female lying in bed, in no acute distress. Head, eyes, ears, nose, and throat revealed pupils were equal, round, and reactive to light. Extraocular movements were intact. The oropharynx was clear. Mucous membranes were moist. No jugular venous distention. No carotid bruits. No lymphadenopathy. Cardiovascular revealed a regular rate and rhythm. No murmurs, rubs or gallops. A nondisplaced point of maximal impulse. Lungs were clear to auscultation bilaterally; occasional inspiratory wheeze. The abdomen revealed normal active bowel sounds, nontender and nondistended, and no masses. No hepatosplenomegaly. Per Emergency Department, guaiac-negative. Extremities were clean, dry, and intact. Good dorsalis pedis and posterior tibialis pulses. Good femoral pulses. No bruits. No swelling. Healing heel ulcers bilaterally. Neurologically, alert and oriented times three, nonfocal. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission included a white blood cell count of 19.2, hematocrit of 40.6, platelets of 295. PT of 12.8, PTT of 22.3, INR of 1.1. Chem-7 showed a sodium of 129, potassium of 2.8, chloride of 96, bicarbonate of 23, blood urea nitrogen of 28, creatinine of 1.5, blood sugar of 174. Creatine kinase of 601, MB of 53, with an MB fraction of 8.8. Troponin was 45.6. Urinalysis showed moderate leukocyte esterase, 11 to 20 white blood cells, few bacteria, 3 to 5 squamous epithelial cells. RADIOLOGY/IMAGING: Electrocardiogram showed ST depressions in V2 through V5; which was improved two hours later, normal axis and intervals, normal sinus rhythm, no Q waves. Chest x-ray was negative for cardiopulmonary processes. HOSPITAL COURSE: 1. CARDIOVASCULAR: Coronary artery disease. Ms. [**Known lastname **] was admitted to the C-MED Service for further treatment of her non-ST elevation myocardial infarction. She was given aspirin, intravenous and p.o. Lopressor, heparin, and Integrilin in the Emergency Department. On the floor, she was also started on captopril 6.25 mg p.o. t.i.d. with good results. She had no further symptoms during her hospital stay. On [**2113-5-9**], she underwent cardiac catheterization which showed a right-dominant system with severe 3-vessel disease. The left main had mild disease, left anterior descending artery with 70% proximal stenosis and 60% distal stenosis after a large second diagonal. The left circumflex was diffusely diseased with a thrombotic 80% stenosis after first obtuse marginal. The second obtuse marginal with 50% stenosis with TIMI-II flow. Dominant right coronary artery was diffusely disease with 80% and 90% serial stenoses in the proximal and middle vessel. The patient underwent evaluation by Cardiothoracic Surgery and was deemed appropriate for both coronary artery bypass graft and mitral valve replacement. Of note, an echocardiogram was completed on [**2113-5-10**] showing mild regional left ventricular dysfunction with severe hypokinesis of the posterobasal wall. There was 1+ aortic regurgitation and moderate-to-severe mitral regurgitation seen. 2. ENDOCRINE: Ms. [**Known lastname **] has a history of diabetes mellitus times two years. She was initially treated only with Amaryl but continued on q.i.d. fingersticks and sliding-scale insulin. She was also placed on an American Diabetes Association cardiac diet. DISCHARGE DISPOSITION: Ms. [**Known lastname **] was to be going to coronary artery bypass graft and mitral valve replacement on [**2113-5-12**]. At that time she will be transferred to the Cardiothoracic Surgery Service. DISCHARGE DIAGNOSES: 1. Non-ST elevation myocardial infarction. 2. Hypertension. 3. Diabetes mellitus. 4. Hypercholesterolemia. 5. Peripheral vascular disease. 6. Tobacco history. CONDITION AT DISCHARGE: Condition on discharge was fair. MEDICATIONS ON DISCHARGE: Medications will be discussed in a later Discharge Summary. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Name8 (MD) 8073**] MEDQUIST36 D: [**2113-5-11**] 10:14 T: [**2113-5-11**] 13:16 JOB#: [**Job Number 109344**] Name: [**Known lastname 17925**], [**Known firstname **] Unit No: [**Numeric Identifier 17926**] Admission Date: [**2113-5-8**] Discharge Date: [**2113-5-12**] Date of Birth: [**2030-5-10**] Sex: F Service: DISCHARGE SUMMARY ADDENDUM: [**Known firstname **] [**Known lastname **] is a 83 year-old Caucasian female who came in with two episodes of nausea, vomiting and bilateral arm pain her anginal equivalent and was ruled in for myocardial infarction. EKG was notable for ST depression in leads V2 through V5. Ms. [**Known lastname **] [**Last Name (Titles) **] catheterization showing three vessel disease and was screened for CT surgery for a possible CABG and mitral valve replacement. On [**2113-5-11**] she was noted to have grossly guaiac positive stools and Integrilin and Heparin were discontinued. CT surgery was notified. Based on Ms. [**Known lastname 17937**] severe coronary artery disease and recent myocardial infarction it was decided Ms. [**Known lastname **] would proceed to CABG and MVR. She received one unit of packed red blood cells on [**2113-5-11**] with stable hematocrit in the next 12 hours. On the morning of [**2113-5-12**] her hematocrit had dropped to 31.3. At this time she was taken to CT surgery. Of note Ms. [**Known lastname **] had .................... pauses between 2.5 seconds in duration notably three times within one minute. She is asymptomatic from this and blood pressure was stable. Discharge addendum to follow from CT surgery. Dr. [**Last Name (STitle) **] Dictated By:[**Name8 (MD) 1037**] MEDQUIST36 D: [**2113-5-12**] 10:42 T: [**2113-5-12**] 11:50 JOB#: [**Job Number 17938**] Name: [**Known lastname 17925**], [**Known firstname **] Unit No: [**Numeric Identifier 17926**] Admission Date: [**2113-5-8**] Discharge Date: [**2113-5-31**] Date of Birth: [**2030-5-10**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is an 83 year-old female patient who was admitted to an outside hospital Emergency Department for chest pain approximately three days prior to admission associated with arm heaviness and nausea and vomiting. She was subsequently discharged home, but the pain recurred two days later. She presented to her primary care physician on [**2113-5-8**] and was noted to have ST changes on her electrocardiogram, which was obtained in the office and she was sent to the Emergency Department at [**Hospital1 960**]. PAST MEDICAL HISTORY: Significant for diabetes mellitus, hypercholesterolemia, hypertension, significant smoking history approximately 120 pack years. She has peripheral vascular disease and is status post right iliac stent for a nonhealing ulcer on the right heel. PREOPERATIVE MEDICATIONS: Amaryl 1 mg po b.i.d., Maxzide, Cosopt eye drops and Lipitor. ALLERGIES: No known drug allergies. LABORATORY VALUES ON ADMISSION: White blood cell count of 19.[**2111**], hematocrit 40.6, platelet count 295, sodium 129, potassium 2.8, BUN 28, creatinine 1.5 and glucose of 174. HOSPITAL COURSE: The patient was admitted to the Cardiology Medicine Service. She subsequently ruled in for myocardial infarction. She was placed on Integrilin drip. She was also treated with aspirin and heparin. She went to the Cardiac Catheterization Laboratory on [**2113-5-9**] where she was found to have three vessel coronary artery disease. An echocardiogram at that time revealed a left ventricular ejection fraction of 50%. The patient was taken to the Operating Room on [**2113-5-12**] by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] where she underwent coronary artery bypass graft times three with a mitral valve repair with a 26 mm ring. Postoperatively, the patient was on Milrinone, Amiodarone, neo-synephrine and insulin intravenous drips and was transported to the Operating Room to the Cardiac Surgery Recovery Unit. The patient had some supraventricular dysrhythmias throughout the operation and was placed on Amiodarone for that reason. The patient was extubated on postoperative day two, however, she remained very lethargic and difficult to arouse. She was noted to hve no movement of her right arm. A head CT was obtained at that time, which was essentially negative. The patient was reintubated on postoperative day three due to increase work of breathing and tachypnea and enteral tube feeds were initiated at that time. On [**5-16**], postoperative day four the patient underwent a bronchoscopy for copious secretions. She was noted to have purulent secretions and cultures of those secretions grew out Moraxella for which she was placed on Levofloxacin and has completed a ten day course of that. On the [**5-17**] a Neurology consult was obtained due to continued flaccidity of the right arm with intermittent movements of the legs noted. Neurologists initially believed this to be a central cord syndrome versus a small cerebrovascular accident. CT of the head remained essentially negative. The patient was placed in a soft cervical collar until spinal cord compression was ruled out. The patient had another bronchoscopy the following day for copious amounts of secretions and she was subsequently extubated. The following day the patient was reintubated for decreased mental status and increased respiratory distress. CT of her head was repeated on [**5-19**], which was again negative. At this point the Neurology Service strongly recommended an MRI to determine what the pathology was causing her neurological examination. MRI of the head and neck were obtained and revealed multiple small fossae posterior infarcts, basilar artery infarcts, mild basilar artery stenosis and no spinal cord compression. The patient was started the following day on a low dose heparin drip for her stroke and basilar artery stenosis. It was the Neurology Services recommendation to keep her systolic blood pressure above 120. The patient was again extubated on the [**5-22**]. At that time she was more awake and able to cough and clear her secretions. However, later in the day the patient was subsequently reintubated again for continued increased respiratory rate and work of breathing. She also had copious secretions, which she became unable to clear possibly due to fatigue. On [**5-24**] the patient was noted to have an increase in white blood cell count. She was fully cultured. Her central line was discontinued. She had a double lumen PICC line placed. Her arteriole line site was changed. She underwent a bronchoscopy again due to copious secretions and she had a percutaneous tracheostomy performed at the bedside as well as a PEG for feeding purposes. The following day the patient's white blood cell count peaked at 45,000. She had some minor abdominal tenderness and went for chest, abdomen and pelvis CT scans, which were all negative. Hematology consult was obtained at that time since there was no apparent source of infection due to increasing white blood cell count. The patient did have a remote history of lymphoma and the question was brought up as to whether the white blood cell count was in some way related to the lymphoma. The Hematology Service did not feel this was in any way related to her lymphoma and thought that we should continue to rule out an infection source. The Infectious Disease Service was consulted and they recommended discontinuing her antibiotics, because they could find no obvious source of infection. The patient has had some diarrhea and she has had two negative C-difficile examination on her stool. The patient was intermittently placed on low dose neo-synephrine around the [**5-26**] for one to two days due to some mild hypotension in the one teens in attempts to keep her systolic blood pressure higher, because of her neurologic status. Tube feed was reinitiated on [**5-26**]. She also had intermittent bouts of atrial fibrillation with controlled ventricular response. The following few days the patient became more awake and interactive with her family. She expressed significant depressive symptoms to her family. She was subsequently started on Celexa, however, this was discontinued after approximately three days due to increasing lethargy. The patient remains on a heparin drip and on the [**5-28**] was placed on a trach collar and taken off the ventilator. She appeared to be doing well from a respiratory standpoint. Her Lopressor was increased due to a heart rate in the 90s. She was begun on NPH insulin since she had been tolerating her tube feeds well at this point. Her antibiotics were discontinued. The Hematology Service had signed off since her white blood cell count had subsequently been coming down over the last few days. On the [**5-29**] the patient was noted to hve increased lethargy, decreased responsiveness and was placed back on the ventilator due to worsening work of breathing with a PACO2 of 63. This was corrected as soon as she was placed on the ventilator. The patient became more alert. On [**5-30**] the patient underwent a repeat MRI of her head and neck at the request of the Neurology Service, which showed no change from her previous study. The patient was also noted on chest x-ray after being placed back on the ventilator to have a left pleural effusion. She underwent a thoracentesis on [**5-30**] for approximately 400 cc of serosanguineous fluid. Repeat chest x-ray showed reexpansion of the lung with no pneumothorax. The patient has remained hemodynamically stable and is ready to be discharged to a rehabilitation facility for continued stroke rehabilitation, physical therapy, speech therapy and weaning from the ventilator. Most recent culture data, on [**5-22**] the patient had one positive blood culture drawn from a peripheral A line for coag negative staph. However, she subsequently had three blood cultures, which were negative and the line was discontinued upon receiving the information of the initial positive blood culture. The patient's central intravenous catheter on [**5-24**] cultured negative. The patient had a gram stain of her sputum on the 18th, which was gram positive coxae, but the culture subsequently revealed no bacteria and some sparse growth of yeast. The patient remains afebrile at this time with no antibiotics with a decreasing white count. Other recent laboratory values from [**5-29**] revealed a white blood cell count of 16.9, which has come down to 16.0 today on [**5-30**]. Hematocrit 30.2, platelet count 206,000. PTT this morning on 1100 units per hour of heparin was 116. The heparin was discontinued for one hour and resumed at 900 units per hour with a subsequent PTT pending. Her potassium this morning is 4.4, glucose 214. She remains on the ventilator in the CPAP mode at 40% FIO2 with pressure support of 10 and PEEP of 5. The patient's physical examination today, neurologically the patient is very lethargic. She had decreased movement of her right arm, otherwise has spontaneous movements of her left arm. She also has intermittent decreased movements of her right leg. Coronary examination is regular rate and rhythm. Her lungs are clear to auscultation bilaterally. Her abdomen is soft, nontender with her PEG tube in place. Her extremities are warm and well perfused. She has a small area of the saphenous vein harvest site in her right thigh area, which is nonhealing that is requiring Santal ointment to be placed to the area. DISCHARGE MEDICATIONS: Coumadin 5 mg per G tube q.d. with a target INR of 2.0. She is being anticoagulated for basilar artery stenosis per the Neurology Service. Lasix 40 mg per G tube q.d., Protonix 40 mg per G tube q.d., Colace 100 mg per G tube b.i.d. this has been held for the past day or two due to increase in stools. Cosopt eye drops to both eyes b.i.d., Lumigan 0.03% to both eyes q.h.s., aspirin 325 mg per G tube q.d., Albuterol nebulizers treatments q 4 hours and prn, Lopressor 25 mg per G tube b.i.d. to be held for a heart rate less then 60 or a systolic blood pressure less then 110. She is receiving NPH insulin 10 units subcutaneously b.i.d. This will have to be assessed on an ongoing basis due to the patient's nutritional status as she begins to take in more calories. She is also on a sliding scale regular insulin. Coverage for blood sugar of 150 to 200 she gets 3 units of regular insulin subcutaneously for, 200 to 250 she gets 6 units, 250 to 300 she [**Last Name (un) 17927**] 9 units subcutaneously. The patient as previously noted been on Celexa due to apparent clinical depression, however, this was discontinued due to decreasing level of responsiveness, increase in lethargy. This should also be readdressed as the patient recovers from her stroke and cardiac surgery to be determined whether she is appropriate to be placed on an anti-depressant. The patient is to follow up here at [**Hospital1 4242**] with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] at [**Telephone/Fax (1) 1477**] upon discharge from the rehabilitation facility or to be called for any concerns related to her surgery. The patient is being followed by the Neurology/[**Hospital 9879**] Clinic here at [**Hospital1 1294**]. She is to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] in one month from now at [**Telephone/Fax (1) 17928**]. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSES: 1. Mitral regurgitation status post mitral valve repair. 2. Coronary artery disease status post coronary artery bypass graft times three. 3. Respiratory failure/chronic obstructive pulmonary disease status post tracheostomy. 4. Cerebrovascular accident. 5. Diabetes mellitus. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**] Dictated By:[**Name8 (MD) 5563**] MEDQUIST36 D: [**2113-5-31**] 08:36 T: [**2113-5-31**] 09:17 JOB#: [**Job Number 17929**]

[ "427.31", "410.91", "496", "202.80", "997.02", "396.3", "414.01", "518.5", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "37.22", "36.13", "33.23", "31.1", "35.24", "88.56", "88.53", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

5817, 6018

2118, 4108

20092, 20621

18180, 20071

6291, 8628

1819, 1949

9769, 18156

9468, 9587

6230, 6264

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240, 253

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161,415

35024

Discharge summary

report

Admission Date: [**2120-11-7**] Discharge Date: [**2120-11-20**] Date of Birth: [**2055-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: Biliary Sepsis Major Surgical or Invasive Procedure: Intubation Mechanical Ventilation Paracentesis History of Present Illness: This is a 65 yoM w/ a PMHx of ETOH abuse and DM who is transferred from [**Hospital3 20284**] Center in [**Hospital1 189**] MA with biliary sepsis. He is transferred intubated. . In summary the patient's relatively complicated past hospital course began when he had biliary colic like symptoms and presented to an OSH roughly 10 days PTA here. On [**2120-10-28**] he underwent a CT scan which visualized a stone within the cystic duct. He then went for cholecystectomy, an inflamed gallbladder and cirrhotic liver were noted by the surgeon intraop. At that time his LFTs were elevated and his T bili was 3.0 so there was a thought of a common duct stone but there was no intraop cholangiogram performed given the inability to lift the cirrhotic liver laparascopically. He underwent a cholecystectomy and began to improve and was discharged home. He then returned to the hospital very ill. He presented with shock and a lipase of 14,000, also his transaminases were both around the 200 range, and a bili of 3.0. In hindsight it was thought that he likely had stones in his common bile duct and now was presenting with biliary sepsis. His blood cultures from this admission had grown enterobacter and from his previous admission he had a gall bladder decompression and the bile had also grown enterobacter. He was treated with IVF and antibiotics and was improving. At that time he was sent for an MRCP which he was unable to tolerate given the inability to hold his breath for 15-20 seconds. Later he began having increasing epigastric pain and confusion and was transferred to the ICU, during this time his urine output had decreased to 100cc/8hrs and his HR had increased but BP was stable, this was despite aggressive fluid repletion. There was also an increase in his intraabdominal ascites and there was a thought that he had a biliary system leak- he underwent a HIDA scan which was negative for CBD obstruction or a bile leak. He then underwent a paracentesis and had 2.5 liters of bilious fluid removed with a bili of 2.8 and a lipase of 7000, also there were 8000 WBC and 80% PMNs. The patient then had worsening hypoxia thought to be due to massive fluid resuscitation that he was requiring and he was intubated. Post intubation he became more hypotensive and required more fluid and pressors. Upon transfer he was normotensive but requiring the assistance of two pressors (dopa and neosynephrine). Past Medical History: DM II on oral agents ETOH abuse in past- per wife abstinent x few weeks PNA in past s/p decortication for empyema Biliary colic now s/p CCY Anxiety Osteoarthritis Social History: ETOH abuse, per report by wife several weeks without ETOH use. Family History: NC Physical Exam: VS: Temp:98.2 HR:86 BP:136/58 RR:21 100%RA GEN: NAD, comfortable, able to follow commands. HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea NECK: difficult to see JVP, no lymphadenopathy or thyromegaly COR: RRR, no M/G/R, normal S1 S2 PULM: CTA-b/l decreased breathe sounds and inspiratory effort R>L ABD: Distended, firm, non-tender, no rebound, + ascites. +BS, paracentesis dressing minimally saturated EXT: diffuse anasarca, livedo reticularis NEURO: AAO x 3, able to follow commands. moving all 4 extremities. DTR diminished symmetrically. Pertinent Results: [**2120-11-12**] 05:27AM BLOOD WBC-13.6* RBC-2.76* Hgb-9.7* Hct-29.0* MCV-105* MCH-35.1* MCHC-33.5 RDW-14.3 Plt Ct-247 [**2120-11-11**] 04:00AM BLOOD Neuts-92.9* Lymphs-4.1* Monos-2.3 Eos-0.6 Baso-0 [**2120-11-12**] 05:27AM BLOOD PT-14.2* PTT-27.1 INR(PT)-1.2* [**2120-11-12**] 05:27AM BLOOD Glucose-250* UreaN-26* Creat-1.3* Na-141 K-4.1 Cl-113* HCO3-24 AnGap-8 [**2120-11-12**] 05:27AM BLOOD ALT-28 AST-47* LD(LDH)-281* AlkPhos-162* TotBili-1.0 [**2120-11-12**] 05:27AM BLOOD Lipase-1311* [**2120-11-12**] 05:27AM BLOOD TotProt-4.6* Calcium-7.5* Phos-2.6* Mg-2.1 [**2120-11-9**] 04:04AM BLOOD calTIBC-107* Ferritn-564* TRF-82* [**2120-11-9**] 04:04AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM HBc-NEGATIVE [**2120-11-9**] 04:04AM BLOOD Smooth-NEGATIVE [**2120-11-9**] 04:04AM BLOOD [**Doctor First Name **]-PND [**2120-11-9**] 04:04AM BLOOD IgG-694* WBC RBC Polys Lymphs Monos [**2120-11-11**] 07:15PM 1150* 900* 75* 11* 14* [**2120-11-9**] 05:38PM 5* 821* 82* 12* 6* ASCITES CHEMISTRY TotPro Glucose LD(LDH) Amylase TotBili Albumin [**2120-11-11**] 07:15PM 1.5 [**Telephone/Fax (3) 80064**].7 LESS THAN 1 [**2120-11-9**] 05:38PM 0.4 66 LESS THAN 2 MICRO: Peritoneal Cx: PENDING [**2120-11-8**] 11:08 am URINE CULTURE (Final [**2120-11-9**]): NO GROWTH. IMAGING: TECHNIQUE: CT abdomen, pelvis w/o contrast FINDINGS: ABDOMEN: There are small bilateral pleural effusions, right greater than left, with partially imaged consolidative right basilar airspace disease, atelectasis versus pneumonia. There is ascites, with a prominent perihepatic component. The gallbladder is surgically absent. A nasogastric tube extends into the gastric lumen. There is a nodular appearance of the hepatic surface. The solid and hollow organs are otherwise within normal limits allowing for non-contrast technique. There is no free air. There are degenerative changes of the spine. PELVIS: Ascites is present. Colonic diverticulosis is noted. A Foley catheter is in place, with the balloon inflated at the low base of the bladder, near the prostatic urethra. The pelvic viscera are otherwise within normal limits, allowing for non-contrast technique. Atherosclerotic calcifications are seen within the abdominal aorta and iliac arteries. There are degenerative changes of the spine. IMPRESSION: 1. Ascites. 2. Nodular appearance of the liver surface, suggestive of cirrhosis. 3. Foley catheter balloon inflated at the base of the bladder, near the junction with the prostatic urethra, clinical correlation is recommended to exclude incorrect placement. 4. Small bilateral pleural effusions, right greater than left, with partially visualized consolidative right basilar airspace disease, atelectasis versus pneumonia. No non-contrast CT evidence of pancreatitis, as questioned. PORTABLE ABDOMINAL ULTRASOUND FINDINGS: The liver is coarse and diffusely echogenic, making the liver parenchyma difficult to penetrate and fully evaluate with ultrasound. There are no focal liver lesions identified. The main portal vein, left portal vein, right hepatic, middle hepatic, right hepatic veins are all patent. The hepatic arteries are patent. There is normal hepatopetal flow. There is a marked amount of ascites. There is no intrahepatic biliary or extrahepatic biliary dilatation. There are no stones visualized within the gallbladder. The common bile duct measures 4 mm. There is a 3 x 2.1 cm hypoechoic structure adjacent to the liver and right kidney, which could represent a focal pocket of ascites. The right kidney measures 11.8 cm and left kidney measures 11.0 cm. There are no stones, masses, or hydronephrosis. The spleen is normal in echotexture and measures 10.8 cm. The pancreas was not visualized on this study. IMPRESSION: 1. Patent hepatic vasculature. 2. Diffusely echogenic liver parenchyma without evidence for focal liver lesions. 3. Marked amount of ascites. 4. Normal appearing kidneys without evidence for hydronephrosis. 5. No gallstones. OSH RESULTS: Peritoneal Fluid: WBC 8,250. 80% PMNs. T bili 2.9. . CT scan abd / pelvis w/ PO contrast [**2120-11-5**]: increase in bilateral pleural effusions with significant RLL atelectasis at the lung bases that has significantly increased compared to prior study of [**2120-11-2**]. A significant increase in free fluid in the peritoneal cavity as well as in the pelvis, possible etiologies include ascites and bowel leak, and appear less likely to be a hemorrhage given Hounsfield unit measurements. Cholecystectomy clips and a trace amount of free air in the R side of the abdomen- assumed post surgical. No bowel obstruction. Pancreas as can be visualized without IV contrast appears unremarkable. . HIDA scan: [**2120-11-6**]: No evidence of bile leak. . CT Head w/o contrast: mild inflammatory sinus disease. No acute intracranial abnormality. . Brief Hospital Course: 65 y.o. M with history of DM and ETOH abuse transferred from an outside hospital with biliary sepsis, ascites (neutrophilic culture negative), and decompensated cirrhosis. . # Pancreatitis and Biliary Sepsis: The patient was felt to likely have had gallstone pancreatitis and ascending cholangitis in the setting of a retained CBD stone (not removed during his CCY on [**10-28**]). He was noted to have enterobacter bacteremia in his blood cultures from [**11-2**] at the OSH. He was treated at the OSH with imipenem [**Date range (1) 61726**] and zosyn from [**11-6**] on. It was later confirmed that the 2 strains of enterobacter that had been growing were sensitive to both imipenem and zosyn. Lipase on admission to the OSH had been [**Numeric Identifier 4731**]. He also had a large amount of ascites on presentation, that was felt to be due to pancreatitis vs. SBP. He had already received several days of antibiotics prior to initial paracentesis. The patient was initially hypotensive requring pressors. Pt continued zosyn & flagyl in our ICU for likely biliary sepsis. We continued fluid resuscitation, goal CVP 8-12 and goal UOP > 30cc/hr and monitored SVO2 from central venous catheter and goal of 70. On [**11-9**] paracentesis w/less than 1L taken off; transudative, cultures no growth. Abdominal ultrasound to evaluate liver, CBD, hepatic and portal flow showed no portal vein thrombosis. On [**11-11**] therapeutic paracentesis, removed 4L of fluids and given 50gm albumin. The ascitic fluid showed poly 863. Pt without abdominal pain. Continued on zosyn on which he finished a 14 day course just prior to discharge. He was started on cipro daily for SBP prophylaxis. Pt remained afebrile on the floors. He started on clear liquids and advances as tolerated. He was eating regular, low-sodium meals at time of discharge. . # Respiratory Failure/Pleural Effusions: Likely due to fluid overload and pleural effusions tracking up from ascites. Patient was intubated on transfer. On [**11-10**] patient extubated. He was started on lasix/aldactone in [**11-13**]. CXR on [**11-13**] noted a large R pleural effusion, again felt to be due to his ascites. Pt continued to have O2 sat in mid to high 90's off oxygen on the floor. He was continued on Advair, albuterol and ipratropium. He continued to diurese on the floor losing 20lbs prior to discharge with stable Cr. He was discharged on Lasix 40 QDay and Spironolactone 50 QDay. He was encouraged to continue a low sodium diet. . # Neutrophilic Culture Negative Ascites: He had a negative HIDA scan at OSH, checked to r/o biliary leak. The ascites was felt to be due to massive third spacing in the setting of liver decompensation and severe illness. The neutrophilic predominance is thought to be due to his pancreatitis, although cannot r/o infection given that he had 4 days of antibiotics prior to his initial paracentesis. Para at OSH [**11-6**] showed 8000 WBC. Para on [**11-11**] (4L off) showed 1150 WBC with 75% polys, up from the 5 WBC seen on [**11-9**]. Repeat para on [**11-13**] took off 2.5 liters and showed 235 WBC with 72% PMN. Cytology was negative for malignant cells. He was started on aldactone and lasix on [**11-13**]. Rpt HIDA [**11-19**] was negative for bile leak. . # Cirrhosis: Thought to be due to ETOH. [**Doctor First Name **] was 1:160, but unclear if this is just in setting of infection. MELD is 12. AFP 2.6. Hep B and C titers are negative. Coagulopathy resolved with INR 1.2 down from 2.4 at OSH. He will need outpatient EGD to assess for varices and possible liver biopsy. Pt to follow up with Dr. [**Last Name (STitle) 80065**] (GI) and his PCP on discharge. # DM: on oral hypoglycemics at home. Pt given Lantus and RISS here. He was taught how to give himself insulin and given visiting nurse services on discharge. He is being discharge on Lantus but will likely need short-acting insulin as well at home once he gets used to giving himself home insulin. . # ETOH abuse: Admitted to OSH on [**2120-11-2**], no withdrawal noted at OSH and or on at [**Hospital1 18**]. He was given thiamine and folate as well as counselling on abstainence from EtOH in the future. Medications on Admission: Lisinopril Zocor Zantac ASA Glucotrol Metformin Lexapro Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 6. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous once a day. Disp:*1200 units* Refills:*2* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*50 Capsule(s)* Refills:*0* 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* 12. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Greater [**Hospital1 189**] Discharge Diagnosis: Primary Diagnosis: 1. Biliary Sepsis 2. Alcoholic Cirrhosis 3. Diabetes Mellitus type II uncontrolled Secondary Diagnosis: 1. Hypertension 2. Neutrophilic, culture negative ascites 3. Acute Renal Failure 4. Pancreatitis 5. Macrocytic Anemia Discharge Condition: Stable. Ambulating with walker. Discharge Instructions: You were transferred from an outside hospital to [**Hospital1 **] Center's ICU with a severe infection of your gallbladder. You were intubated for a short while and then successfully extubated. You completed a course of IV antibiotics. You had several paracenteses for fluid in your abdomen. After you were stabilized, you were transferred to the hepatology service. During your time on the hepatology service, you were started on medications for your underlying liver disease. You must not drink alcohol as it can worsen your liver disease and lead to serious illness. . Please weigh yourself daily and call your doctor if you gain more than 3 lbs. Please keep to your low salt diet. Please take your medications as prescribed. We have added a number of medications to your regimen including insulin injections once daily. . Please keep all your medical appointments. . If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever>101, chest pain, shortness of breath, abdominal pain, bright red blood per rectum, black stools or red stools, confusion or any other concerning symptoms. Followup Instructions: You have been scheduled to see your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 7951**] [**Last Name (NamePattern1) 80066**], on Tues [**11-26**] at 3pm. He needs to address your blood pressure and your diabetes. If you cannot make this appointment, please call [**Telephone/Fax (1) 78940**]. . We are in touch with your gastroenterologist (GI) doctor, Dr. [**Last Name (STitle) 80065**]. If you do not get a call from them by Friday with an appointment, please call [**Telephone/Fax (1) 80067**] to make an appointment. Completed by:[**2120-11-25**]

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icd9cm

[ [ [] ] ]

[ "96.04", "54.91", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

14563, 14628

8610, 12792

330, 379

14914, 14949

3721, 8587

16128, 16725

3117, 3122

12899, 14540

14649, 14649

12818, 12876

14973, 16105

3137, 3702

276, 292

407, 2833

14773, 14893

14668, 14752

2855, 3020

3036, 3101

13,213

170,689

5425

Discharge summary

report

Admission Date: [**2151-7-2**] Discharge Date: [**2151-7-6**] Date of Birth: [**2086-10-29**] Sex: M Service: UROLOGY HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 64-year-old male with locally advanced distal esophageal cancer. He has recently underwent a distal esophagectomy under the care of Dr. [**Last Name (STitle) **]. In addition, he received localized external beam radial therapy and chemotherapy prior to his esophagectomy, at which time he had received a Port-A-Cath in [**2150-12-17**]. The esophagectomy was performed in [**2151-3-19**]. During his work up for esophageal cancer, an enhancing right upper pole real mass was identified. MRA showed this to be a 3x3 cm mass that enhances, therefore, had a high likelihood of renal cell carcinoma. He denied any history of hematuria, abdominal or flank pain. PAST MEDICAL HISTORY: 1. Esophageal cancer as stated above. 2. History of peptic ulcer disease. PAST SURGICAL HISTORY: 1. Distal esophagectomy occurring [**2151-3-19**] with Dr. [**Last Name (STitle) **]. 2. He has had Port-A-Cath placement and an exploratory laparotomy to rule out metastatic disease. This was performed simultaneously in [**2150-12-17**] by Dr. [**Last Name (STitle) **]. 3. Additionally, he has had a pilonidal cyst excision. SOCIAL HISTORY: He quit smoking 30 years ago. He is an engineer. He drinks one cup of coffee per day and occasional ethanol use. FAMILY HISTORY: His grandmother has diabetes, but no other genitourinary cancer history. ALLERGIES: PENICILLIN WHICH CAUSES HIVES. ADMISSION MEDICATIONS: 1. Zantac 75 mg twice day ADMISSION PHYSICAL EXAM: VITAL SIGNS: Pulse 76, blood pressure 120/70, respiratory rate 18 with 96% room air saturation. He was afebrile with a temperature of 98.7?????? orally. CHEST: Port-A-Cath in right upper chest. Incision site was well healed, no erythema. EXTREMITIES: His upper extremities were non edematous. Palpable pulses distally in the upper extremities. HEAD, EARS, EYES, NOSE AND THROAT: Unremarkable. He had no lymphadenopathy and septal neck. His trachea was midline, no jugular venous distention, no carotid bruits. CARDIAC: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, no palpable masses. No costovertebral angle tenderness. No inguinal lymphadenopathy. He does have a healed J-tube removal site. GENITOURINARY: He had a normal phallus, meatus and testis. No inguinal hernia. RECTAL: Normal tone, 30 gm prostate, no nodularity, guaiac negative. EXTREMITIES and NEUROLOGIC: He moves all four extremities without difficulty. Normal gait. Neurologically and mentally intact. SIGNIFICANT PREOPERATIVE LABS: Hematocrit 25%, BUN and creatinine of 34 and 0.7. X-RAYS: He had a CT and MRI that showed a 3 cm right upper pole mass, stable over the last seven months. He has an exophytic lesion involving the upper pole as well. HOSPITAL COURSE: Given the enhancement, likely has a round carcinoma. The patient was scheduled for an open right partial nephrectomy. Informed consent was obtained. In the presurgical clinical visit on [**2151-7-2**], the patient went to the Operating Room and underwent a partial right nephrectomy. The case was relatively uneventful. He left the Operating Room with a JP drain, chest tube and Foley catheter. At the postoperative check, he was noted to be afebrile. Vitals were otherwise stable. Chest tube is draining 130 to 150 cc of serosanguinous effluent. JP drains approximately 210 cc. Postoperative hematocrit was 25.3, white count 13.3, platelet count 300. Chemistries significant for a BUN/creatinine of 17.___. Chest x-ray postoperatively showed no evidence of pneumothorax. Chest tube in good position. He did have basilar atelectasis on the right side and a small right effusion. Otherwise, no acute cardiopulmonary disease. His epidural would be utilized for pain control. His oxygen was weaned appropriately. He was encouraged to ambulate the following day and his hematocrit was followed serially. On postoperative day #1, he had an epidural in place. Blood pressure was stable at 100 systolic. He was started on a clear liquid diet. He completed his perioperative Ancef and was ultimately transferred to the floor. By postoperative day #2, the patient was tolerating clears. He had had some flatus. No nausea or vomiting. He was out of bed ambulating. At this time, his epidural was capped and flagged and he was started on Percocet. Chest tube was removed. Follow up chest x-ray showed no evidence of pneumothorax. He was stable. Hematocrit continued to be stable. On postoperative day #3, the patient had had the epidural completely removed although it had been previously capped and flagged. Again, he was out of bed ambulating. He did not pass flatus, so he was kept on a clear liquid diet. At this point, he had developed a right upper extremity IJ clot related to his Port-A-Cath. This was discovered on the evening of postoperative day #2 into postoperative day #3. Vascular and surgical consultation had been obtained. They had recommended removal of the catheter and heparinization and Coumadinization. Total treatment length for the Coumadin therapy was to be six months. Given the fact that he had undergone recent partial nephrectomy, Dr. [**Last Name (STitle) 4229**] declined to have the patient put on heparin. He was just given arm elevation and his right subclavian Port-A-Cath was removed on postoperative day #3 by Dr.[**Name (NI) 1482**] service. This was done uneventfully and done under local anesthesia. After his conservative therapy, his right upper extremity arm edema had decreased somewhat. He was started on Coumadin on postoperative day #3, receiving an 8 mg dose. His ultimate doses for Coumadin and management for his PT/INR with a goal of 2 to 2.5 are to be managed by Dr. [**Last Name (STitle) 838**], his primary care physician. [**Name10 (NameIs) **] is a [**Hospital3 **] physician at the [**Name9 (PRE) **] office. PT/INR values will be sent to his office and they will be evaluated accordingly. His discharge INR was 1.2 with a PTT of 26 and a PT of 13. Discharge hematocrit was 28.4, platelet count 224,000. White count was 7.5000. BUN and creatinine were 14 and 0.9. DISCHARGE MEDICATIONS: 1. Percocet 5/325 1 to 2 tablets po q 4 to 6 prn 2. Colace 100 mg po bid prn 3. Zantac 150 mg po bid 4. Coumadin 4 mg per day, ultimate dosage to be titrated per patient's primary care provider. FOLLOW UP INSTRUCTIONS: See Dr. [**Last Name (STitle) 4229**] in approximately 7 to 10 days. His staples were removed on the time of discharge with Steri-Strips placed uneventfully at time of follow up. He will be reassessed to see how the progression in his right upper extremity edema had gone. This had markedly improved over 36 hours of conservative management. Additionally, the patient should follow up with his primary care physician in approximately 7 to 10 days and to have a PT/INR drawn in approximately two days from time of discharge with results being sent to the primary care physician as previously stated. DISCHARGE DIAGNOSES: 1. Status post open right partial nephrectomy for exophytic 3.3 lower pole renal mass presumed to be renal carcinoma. Final pathology is pending. Please see final path report for further detail. 2. Esophageal cancer, status post chemotherapy XRT in [**2151-1-16**], status post esophagogastrectomy Ivor-[**Doctor Last Name **] procedure with Dr. [**Last Name (STitle) **] in [**2151-3-19**]. 3. Right IJ central vein deep venous thrombosis under treatment, status post right subclavian Port-A-Cath removal during same hospitalization. DISCHARGE CONDITION: Stable DISCHARGE STATUS: Home Follow up plans as stated above. [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2151-7-6**] 06:43 T: [**2151-7-6**] 07:01 JOB#: [**Job Number 21995**]

[ "996.74", "V10.03", "458.2", "453.8", "189.0", "512.1", "150.5" ]

icd9cm

[ [ [] ] ]

[ "55.4", "86.05" ]

icd9pcs

[ [ [] ] ]

7808, 8163

1467, 1585

7246, 7786

6397, 7225

3013, 6374

1608, 1646

985, 1317

1661, 2995

168, 863

885, 962

1334, 1450

12,849

112,483

49480

Discharge summary

report

Admission Date: [**2139-5-26**] Discharge Date: [**2139-6-4**] Date of Birth: [**2090-7-7**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 48 year-old man with a history of CREST syndrome times 25 years and a more recent history of dyspnea on exertion worsening over the past several months. The patient was admitted to the hospital in late [**2139-2-21**] and diagnosed with severe pulmonary hypertension by echocardiogram and right heart catheterization, which showed a pulmonary artery pressure of 86 and a pulmonary capillary wedge pressure of 19. The patient was discharged on [**3-31**] on Bosentan 62.5 mg twice a day as well as Lasix. He took the Bosentan for a month without relief, then stopped for ten days due to loss of insurance and then restarted at 125 mg twice a day. The patient notes that he did not fill his Lasix prescription following the [**Month (only) 958**] discharge and did not check his daily weights. Over several days after restarting the Bosentan the patient noted increasing dyspnea on exertion, shortness of breath, bilateral peripheral lower extremity edema, paroxysmal nocturnal dyspnea, and increasing orthopnea. He was referred to the Emergency Department where he was admitted for the initiation of continuous infusion Flolan treatment, which had previously been planned for a week after the time of his deterioration. REVIEW OF SYSTEMS: At the time of admission revealed severe right digital pain in the right upper extremity secondary to Raynaud's. The patient denies fevers or chills, nausea and vomiting, chest pain, abdominal pain, change in bowel habits, melena or bright red blood per rectum. PAST MEDICAL HISTORY: 1. CREST syndrome diagnosed 25 years ago. The patient has a history of digital ulcers secondary to Raynaud's phenomenon and is status post right laparoscopic sympathectomy in [**2138-9-21**] without symptomatic relief. 2. Gastroesophageal reflux disease with esophageal stricture. 3. Pulmonary hypertension first noted on echocardiogram in [**2135**] and recently diagnosed as described in the history of present illness. The patient is on 4 liters of home O2. 4. Mild restrictive lung disease with a decreased DLCO. 5. History of upper gastrointestinal bleed. 6. Status post left hernia repair. ALLERGIES: The patient notes nausea and vomiting with morphine and codeine and itching with Percocet. PHYSICAL EXAMINATION ON ADMISSION TO THE FLOOR: Vital signs temperature 98.9. Pulse 73. Blood pressure 108/48. Respirations 15. O2 sat 92% on room air. The patient was alert and oriented times three and complaining of digital pain. He was in no acute distress. The pupils are equal, round and reactive to light. Extraocular movements intact. His mucous membranes are moist with telangiectasias. There was no cervical lymphadenopathy. The patient did have jugulovenous distention to about 16 cm. Lung examination revealed diffuse mild crackles throughout bilaterally with resonant percussion. Heart examination showed a regular rate and rhythm with a normal S1 and a split S2 with a loud P2. There was also a 2 out of 6 systolic ejection murmur heard best at the left upper sternal border. Extremity examination revealed no clubbing or cyanosis. The patient did have 1+ edema in the lower extremities bilaterally to the mid calf level. The calves were discolored with multiple brownish red indurated nodular lesions, which were nontender. The upper extremities had significant digital ulceration on digits one through four of the right hand. Neurological examination was notable for intact cranial nerves and intact strength and sensation in the upper and lower extremities bilaterally. LABORATORY DATA ON ADMISSION: White blood cell count 6.7, hematocrit 34.9, platelet count 211. Electrolytes sodium 139, potassium 4.0, chloride 103, bicarbonate 25, BUN 18 and creatinine 1.2 with a glucose of 94. Admission electrocardiogram showed normal sinus rhythm, T wave inversion in 1, 2, and 3 with poor R wave progression and T wave inversion in V1 through V5. There were also new T wave inversions in 2, 3 and AVF. HOSPITAL COURSE: The patient was admitted to the MICU on [**5-26**]. He was ruled out for myocardial infarction and diuresed with Lasix. A Swan-Ganz catheter was placed and the Flolan was started on [**5-27**]. A Hickman catheter was placed by general surgery on [**5-29**] and the patient was called out of the MICU to the medical floor. The Flolan was titrated to 9 nanograms per kilogram per minute with moderate flushing, headache and nausea. These side effects were treated with Compazine and Vicodin. A Flolan dose of 10 nanograms per kilogram per minute was attempted on [**6-1**], but was decreased back to 9 nanograms per kilogram per minute due to hypotension to 90/45. The patient did note improvement in his dyspnea on exertion in the days following the Flolan initiation. An outside agency provided Flolan teaching for the patient's sister who will prepare the Flolan at home. A Flolan nurse will visit the home daily in the week following discharge. Also during this admission pain service was consulted regarding the patient's digital ulcer pain. The pain was treated with Oxycontin with Vicodin for breakthrough. Oxycontin was increased from 30 b.i.d. to 30 t.i.d. on [**6-1**], but was changed to 40 b.i.d. on [**6-4**] secondary to increased sedation. In addition, on [**6-3**] the patient complained of severe throat pain and pharyngeal edema and exudate were noted on examination. A culture was sent and Amoxicillin was started for a presumed strep throat. The patient was discharged to home in stable condition. DISCHARGE STATUS: Good. DISCHARGE DIAGNOSES: 1. CREST syndrome. 2. Pulmonary hypertension. DISCHARGE MEDICATIONS: 1. Flolan 9 nanograms per kilogram per minute intravenous infusion. 2. Oxygen 4L by NC 3. Furosemide 60 mg po q.d. 4. Coumadin 1 mg po q.h.s. 5. Oxycontin 40 mg po b.i.d. 6. Vicodin one to two tablets po q 6 hours as needed for pain. 7. Lorazepam 0.5 mg po t.i.d. 8. Prazosin 1 mg po t.i.d. 9. Diltiazem SR 480 mg po q.d. 10. Compazine 10 mg po q six hours prn nausea. 11. Pantoprazole 40 mg po b.i.d. 12. Sucralfate 1 gram po q.i.d. 13. Ferrous sulfate 325 mg po q.d. FOLLOW UP PLANS: The patient is to follow up within the next two weeks with Dr. [**Last Name (STitle) **] in Pulmonology, Dr. [**Last Name (STitle) **] his primary care physician, [**Name10 (NameIs) **] Dr. [**Last Name (STitle) **] his rheumatologist. These appointments have been scheduled for him. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 103528**] Dictated By:[**First Name3 (LF) 103529**] MEDQUIST36 D: [**2139-6-4**] 03:49 T: [**2139-6-10**] 09:27 JOB#: [**Job Number 103530**]

[ "710.1", "443.0", "034.0", "428.0", "416.8", "530.81" ]

icd9cm

[ [ [] ] ]

[ "86.07" ]

icd9pcs

[ [ [] ] ]

5741, 5790

5813, 6902

4163, 5720

1417, 1681

154, 1397

3747, 4145

1703, 3732

10,718

177,406

5812

Discharge summary

report

Admission Date: [**2114-12-3**] Discharge Date: [**2114-12-26**] Date of Birth: [**2040-9-14**] Sex: F Service: MEDICINE Allergies: Codeine / Zocor Attending:[**First Name3 (LF) 2145**] Chief Complaint: CC:[**CC Contact Info 23073**] Major Surgical or Invasive Procedure: 1. ERCP 2. EGD x2 with injection of ampulla and gastric ulcer 3. IR Embolization x2 (L gastric artery) 4. Vascular surgery repair of left groin hematoma s/p JP drain placement x2 5. AV graft thrombectomy x2 6. R femoral Quinton catheter placement (and subsequent removal) 7. Tunneled HD catheter placement in R IJ History of Present Illness: HPI: 74 y/o F s/p liver tx, ESRD on HD p/w concerns for anastamotic stricture and biliary stone. Patient does not have any recent h/o icterus, abdominal pain, nausea/vomiting, yellowish discoloration of urine. Patient however complains of black colored stools for the past few months. Per patient, MRCP showed biliary dilatation w/ stones. ROS: no palpitations, chest pain, SOB, cough, fevers, change in bowel or bladder habits, weight loss or change in apetite. . [**Hospital Ward Name 516**]: She had ERCP on the [**Hospital Ward Name **] on [**12-3**] which showed Biliary tree narrowing. However procedure had to be terminated as the patient did not tolerate it (elevated HR, BP and desatting to 80's on RA). A repeat procedure to be performed under anesthesia on [**12-5**]. She was transferred to [**Hospital Ward Name 517**] for Dialysis. Past Medical History: Liver transplant in '[**92**] ESRD on HD Hypercholesterolemia Gout GERD Social History: lives with her husband, no ETOH/Tobacco Family History: Not contributory Physical Exam: Vitals: Aferbile, 136/80, 68, 93/RA (98/2L) Gen: comfortable, NAD HEENT: PERRLA, EOMI, MMM, no JVD appreciated Lungs: CTAB Heart: S1/S2, frequent ectopics, no m/r/g Abd: soft/NT/ND, BS+ Ext: no edema/erythema/rash Neuro: no focal deficits, AAOx3 Pertinent Results: [**2114-12-26**] 05:35AM BLOOD WBC-6.8 RBC-3.58* Hgb-10.7* Hct-31.4* MCV-88 MCH-30.0 MCHC-34.2 RDW-16.4* Plt Ct-261 [**2114-12-26**] 05:35AM BLOOD Plt Ct-261 [**2114-12-23**] 06:25AM BLOOD PT-11.7 PTT-31.0 INR(PT)-0.9 [**2114-12-26**] 05:35AM BLOOD Glucose-103 UreaN-54* Creat-7.2*# Na-132* K-4.7 Cl-97 HCO3-23 AnGap-17 [**2114-12-26**] 05:35AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.6 [**2114-12-11**] 12:10AM BLOOD Hapto-25* [**2114-12-10**] 04:30PM BLOOD Ferritn-400* [**2114-12-10**] 04:30PM BLOOD PTH-65 [**2114-12-13**] 01:23AM BLOOD Cortsol-25.7* [**2114-12-14**] 04:14AM BLOOD Cyclspr-107 [**2114-12-5**] 05:12AM BLOOD Cyclspr-126 . ERCP [**12-6**] IMPRESSION: No evidence of stricture or obstruction . pCXR [**12-11**] Tip of the left internal jugular introducer projects over the left margin of the mediastinum a cm above the apex of the aortic arch. Location is indeterminate from a single plain radiograph but could be in a large central vein. Slight widening of the superior mediastinum indenting the trachea to the right at the thoracic inlet is longstanding likely due to enlarged thyroid gland, not an indication of hematoma. There is no pleural effusion or pneumothorax. Moderate cardiomegaly persists, and there is mild vascular engorgement in the mediastinum consistent with volume overload explaining increased perfusion to the lungs. New irregular largely linear opacification in the right lower lung zone is probably atelectasis. There is no pneumothorax. . ECHO [**12-13**] Conclusions: 1. The left atrium is mildly dilated. 2. There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). 3. The aortic valve leaflets are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. There is severe thickening of the mitral valve chordae. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] 5. There is mild pulmonary artery systolic hypertension. 6. Compared with the findings of the prior report (tape unavailable for review) of [**2110-1-28**], there has been no significant change. . Tunneled Line [**12-25**] 1. Successful placement of a tunneled hemodialysis catheter via the right internal jugular vein with the tip in the right atrium. The catheter is ready for use. 2. Air embolism in the heart was encountered. The patient was kept in the left decubitus position and then was transported to the floor in stable condition. Brief Hospital Course: CONSULT KIDNEY/PANCREAS HD 22, POD2 Neoral 100 (cyclo-107), sulumed 125''' 74 F s/p OLT [**2092**] with UGIB from sphincterotomy ([**12-5**]) PMHx: OLT [**2092**] (PBC (?)), ESRD on HD (likely due to CsA), ^chol, GERD, PVD s/p L fem-? BPG, s/p L knee surgery [**12-3**]: ERCP unable to perform due to poor tolerance of anesthesia [**12-5**]: ERCP/sphincterotomy [**12-10**]: EGD - bleeding from eroision in proximal stomach and sphincterotomy site [**12-10**]: angio - no active bleeding [**12-11**]: angio embolized gastric a. to bleeding GU [**12-12**]: OR c Vascular to repair fem a. [**12-17**] GI says no EGD may ? get flex sig / colonoscopy [**12-21**] graft thrombectomy but reclotted Plan: IR permacath [**12-25**] and d/c home. Assessment and Plan: 74 y/o F s/p liver tx, ESRD on HD, admitted for ERCP to r/o biliary stricture/sphinterotomy. . # GI bleed admitted for ERCP Post-sphincerotomy, patient had bleeding from the sphincterotomy site. She had EGD x2 with injection of epinephrine but this did not stop the bleeding. She eventually got IR angio which did not demonstrate any bleeding. A second IR angio showed a gastric bleed which was considered secondary to EGD induced trauma and the gastric bleeding vessel was embolized. The next day, the left femoral arterial sheath was pulled which caused a massive bleed into the thigh. Vascular surgery was consulted and they performed a vascular repair after draining the hematoma and placed 2 JP drains. She was extubated after which she developed some stridor which was most likekly from edema [**2-28**] volume overload and intubation. She was given short course of steroids for this stridor. She also developed mild chest pain after angio which resolved with NTG, IV Metoprolol. EKG was unchanged from before. CE's were cycled. She developed sepsis with a temperature spike, and was placed on empiric Abx coverage. 2/2 Blood Cx's from [**12-13**] eventually grew Coag neg Staph. She received a short course of Unasyn prophylaxis while in the MICU. She was also started on Vancomycin which was continued throughout her admission when JP drain's remained in. On the day of discharge, one of her JP drain's had put out less than 100cc/day, and it was pulled. Her other JP drain was left in placed at time of discharge to have vascular surgery pull the drain as an outpatient. Pt was sent home with VNA services to monitor the drain. . 2. Groin bleed: Patient developed a L groin hematoma/bleed after pulling the angio sheath s/p angiography/embolization. Vascular surgery was consulted and they took the pt to the OR for surgical repair of the L femoral artery along with placing 2 JP drains. Vancomycin was continued for prophylaxsis while drains were in place due to her h/o MRSA. Pt had 1 JP drain pulled on day of discharge since it's output had declined to less than 100cc/day. Pt was to have vascular surgery follow up with Dr. [**Last Name (STitle) **] and was due to have her drain pulled as an outpatient. . 3. ESRD: Pt with ESRD who received HD through an AV graft in her R arm. During her admission to the MICU, it was found that her AV graft had become clotted, and was unusable for HD. A R femoral Quinton catheter was placed in order to provide her with HD access. Pt was taken to the OR twice during this admission for an AV graft embolectomy, and these procedures were both unsuccessful at disloding the clot. Pt refused any further intervention at this admisssion, stating that she would rather follow up with her outpatient transplant surgeon who placed her AV graft. At time of discharge, there was no palpable thrill or bruit throught the graft, and no dopplerable flow could be appreciated. Pt had a tunneled HD line through her R IJ was placed by IR the day prior to discharge, and pt received a short HD course through her newly placed tunneled HD line prior to discharge which functioned successfully. Her R femoral line was pulled on the day of discharge, and pt was to follow up in outpatient HD. . 5. Liver Tx: Pt is s/p liver tx. Neoral was continued during this admission without any complications. . 6. DISPO - Pt was discharged with newly placed tunneled HD line in place, along with L groin JP drain. Pt was to f/u with her PCP, [**Name10 (NameIs) **] GI doctor, nephrologist, as well as vascular surgery to have her JP drain pulled as an outpatient. Medications on Admission: Protonix 20 mg [**Hospital1 **] Cyclosporine 100 mg QD Allopurinol 100 mg QD Baby ASA [**Name2 (NI) **] 800 mg 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. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours). Disp:*1 inhaler* Refills:*2* 7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 inhaler* Refills:*2* 8. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*60 Tablet(s)* Refills:*2* 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 10. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 11. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous with HD 3x/week until drain is pulled for 10 days: Continue vanco with HD until L groin JP drain is pulled. . Disp:*qs units* Refills:*0* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: * Common Bile duct stricture s/p sphincterotomy * Bleeding from Sphincterotomy site s/p embolization x2 * Upper and Lower GI bleed s/p EGD x 2 and angioembolization of gastric bleeder * Left groin bleed after angio s/p vasc surgery repair * Right arm AV graft clot s/p failed AV thrombectomy x2 . Secondary Diagnoses: * s/p liver transplant * ESRD on HD * Hypercholesterolemia * Gout * GERD Discharge Condition: Afebrile, pain free, stable to be discharged home. Discharge Instructions: 1. Please take all your medications and follow up with all your appointments. . 2. Please see Dr. [**Last Name (STitle) **] in 1 week after discharge to have your drain and staples removed. Call ([**Telephone/Fax (1) 1798**] to schedule that appointment. . 3. Please report to the ED or to your physician if you have any further bleeding per rectum, dark colored stools, vomiting blood, bleeding from your groin, dizziness/weakness or any other concerns. Followup Instructions: Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **] [**8-5**] days. . Please make an appointment to see your Gastroenterologist in 10 days. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2114-12-31**]

[ "211.1", "276.52", "585.6", "428.0", "995.92", "578.9", "286.9", "998.11", "274.9", "414.8", "996.73", "707.03", "403.91", "998.12", "458.29", "576.2", "453.9", "V42.7", "038.10" ]

icd9cm

[ [ [] ] ]

[ "44.43", "39.49", "38.95", "39.95", "39.31", "44.14", "44.44", "96.71", "51.10", "45.24", "51.85", "88.47" ]

icd9pcs

[ [ [] ] ]

10703, 10764

4805, 9173

307, 623

11199, 11252

1968, 4782

11757, 12063

1668, 1686

9335, 10680

10785, 11082

9199, 9312

11276, 11734

1701, 1949

11103, 11178

238, 269

651, 1499

1521, 1595

1611, 1652

68,460

178,567

40903

Discharge summary

report

Admission Date: [**2153-4-5**] Discharge Date: [**2153-4-10**] Date of Birth: [**2122-2-24**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Latex Attending:[**First Name3 (LF) 5134**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: Mechanical Intubation and extubation Lumbar puncture History of Present Illness: 31 year old man with a history of spina bifida s/p VP shunt, question seizure [**5-11**], who presents from OSH after presenting with a seizure. Per discussion with patient's mother, patient was at home this morning sitting in his wheelchair at 10:30am on [**2153-4-5**] when she noticed he started having generalized movements of all 4 extremities. He almost fell out of his chair and his mother caught his fall, however, he still hit his head slightly and developed a small abrasion on his forehead. Per his mother, he began foaming a bit and bleeding from his mouth, but she could not confirm tongue biting, fecal/urinary incontinence. He was a bit disoriented for a few minutes after the seizure per his mother. [**Name (NI) **] family, the patient had been in his usual state of health up until today. The only complaints he recently had were headaches recently and diarrhea in the recent past that had resolved. She decided to call EMS. . EMS arrived 10 minutes after he started seizing. He reportedly had 2 seizures within 15 minutes before valium given IV. In the field he was intubated and given diazepam 5mg IV, versed 5mg IV, etomidate IV, and succinylcholine IV and was transferred to [**Hospital 8641**] Hospital. At [**Hospital 8641**] Hospital he had the following vital signs: 99.7 140 151/84 12 100% on ventilation. He was noted to be still seizing lasting minutes with generalized motor activity with incontinence of urine. Post-ictal obtundation was also noted. He received ativan 2mg IV x 4, fosphenytoin 1gm IV ONCE, phenobarbital 1gm IV ONCE. . In the ED, he had the following vital signs: 102.6 120/76 110 100% CPAP: [**4-5**] FiO2 40%. In the ED, he began to shake both upper arms, which were thought to be rigors. Rectal exam was brown trace guiac positive. Neurology was consulted who recommended bedside EEG, keppra, and LP. Neurosurgery saw the patient who recommended shunt series, repeat CT head, and LP by flouro given his spina bifida history. Repeat CT head was unchanged from prior OSH scan, notable for persitent right ventricular enlargement. He was given acyclovir 600mg IV ONCE, Zosyn 4.5gm IV ONCE, vancomycin 1gm IV ONCE, ceftriaxone 2gm IV ONCE, propofol gtt titrate to sedation, and tylenol 1,300mg PR ONCE, levophed gtt titrated to MAP>65, keppra 1gm IV ONCE. His last set of vitals were 100.6 105 111/63 21 100% on CMV 450/14/40/5. Total in: 7L, total out: 2.1L. . ROS: Per HPI. No recent chest pain, shortness of breath, cough, sputum, dysuria, abdominal pain, fevers, chills, nausea, vomitting, neurologic symptoms such as focal weakness, black outs, or recent seizures. Denies sick contacts or recent travel. Past Medical History: 1) Spina bifida: S/p VP shunt, wheelchair bound, contractures, unable to void 2) Mental retardation (mild) 3) Frequent UTIs from straight cathing 4) Partial SBO of unknown etiology, resolved with supportive care 5) One seizure episode in [**5-11**], not started on AED due to no activity found on EEG 6) GERD 7) Hypertension 8) Hyperthyroidism 9) ?Cerebral palsy 10) Hip and hamstring surgery [**52**]) Spinal surgery after birth Social History: Lives at home with his mother, wheelchair bound, works at a grocery store. Two brothers heavily involved in his life, mother overwhelmed with COPD. Does not smoke, drink, or use drugs. Family History: Remote family h/o spina bifida 2 generations prior. Physical Exam: Admission Exam VS: Temp: BP: / HR: RR: O2sat Has GEN: Intubated, sedated young man with frontal bossing, NAD HEENT: Pinpoint 1mm b/l but PERRL, anicteric, MMM, no jvd, negative Svostek's sign RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, lower extremities with contractures SKIN: no rashes/no jaundice/no splinters NEURO: Heavily sedated with propofol. 0+DTR's-patellar and biceps, does not withdraw in any of all four extremities. Downgoing toes. Discharge Physical Exam Tm:98.2 BP:129-142/92-97 P:93-109 RR:18 O2sat:94-98%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. Horizontal nystagmus 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: Surgical scar at lower back consistent with spina bifida. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact. [**4-5**] UE strength and sensation. LE sensation intact. 0/5 strength. No DTRs at [**Name2 (NI) **]. Pertinent Results: OSH Labs [**2153-4-5**]: U/A: Cloudy Blood MOD pH 5 Prot 30 Nitrate NEG Leuk NEG WBC rare Bact none seen . TSH 6.8 (H) . Dilantin: <0.5 . Mg 2.7 TB 0.6 TP 7.7 Alb 4.1 AST 21 ALT 42 AP 76 Na 136 K 4.4 Cl 99 CO2 11 Glc 239 BUN 10 Cr 0.9 Ca 8.7 . WBC 18 HCT 46.6 PLT 544 . N 63 L 30 E 2.4 . ABG: 7.35/45/186 on AC 500/12 50% RR 12 [**Hospital1 18**] LABS ON ADMISSION: [**2153-4-5**] 06:15PM BLOOD WBC-12.5* RBC-3.77* Hgb-10.6* Hct-30.3* MCV-80* MCH-28.2 MCHC-35.1* RDW-13.3 Plt Ct-279 [**2153-4-5**] 06:15PM BLOOD Neuts-82.9* Lymphs-11.5* Monos-4.9 Eos-0.3 Baso-0.4 [**2153-4-5**] 06:15PM BLOOD PT-11.6 PTT-27.3 INR(PT)-1.0 [**2153-4-5**] 05:00PM BLOOD Glucose-116* UreaN-10 Creat-0.7 Na-135 K-6.2* Cl-105 HCO3-21* AnGap-15 [**2153-4-6**] 03:27AM BLOOD ALT-20 AST-22 LD(LDH)-172 AlkPhos-39* TotBili-0.8 [**2153-4-5**] 08:30PM BLOOD Calcium-6.4* Phos-2.5* Mg-1.9 Iron-30* [**2153-4-5**] 08:30PM BLOOD calTIBC-200* VitB12-548 Folate-9.6 Ferritn-85 TRF-154* [**2153-4-6**] 03:27AM BLOOD TSH-1.9 [**2153-4-6**] 03:27AM BLOOD Free T4-1.3 [**2153-4-5**] 03:42PM BLOOD Type-ART Temp-38.3 pO2-479* pCO2-46* pH-7.36 calTCO2-27 Base XS-0 Intubat-INTUBATED [**2153-4-6**] 03:38AM BLOOD O2 Sat-83 [**2153-4-6**] 03:38AM BLOOD freeCa-1.31 MICRO: [**2153-4-7**] URINE URINE CULTURE-PENDING INPATIENT [**2153-4-7**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2153-4-6**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY INPATIENT [**2153-4-5**] URINE Legionella Urinary Antigen -FINAL INPATIENT [**2153-4-5**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2153-4-5**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2153-4-5**] URINE URINE CULTURE-FINAL {KLEBSIELLA PNEUMONIAE} EMERGENCY [**Hospital1 **] URINE CULTURE (Final [**2153-4-7**]): KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2153-4-5**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] REPORTS: CXR AP [**2153-4-5**]: IMPRESSION: No acute cardiopulmonary abnormality. Discontinuity of the left ventriculoperitoneal shunt catheter. Endotracheal tube and nasogastric tubes in standard positions. LUMBAR SP [**2153-4-5**] There is moderately severe rotatory thoracolumbar scoliosis convex to the right centered at L1. Multilevel degenerative changes with facet arthropathy are moderate in extent. There is considerable pelvic tilt. Lucency overlying the L3-L5 vertebral bodies may represent known spina bifida; however, this could represent an overlying bowel loop. There are mild-to-moderate degenerative changes of both femoroacetabular joints. A ventriculoperitonal shunt is noted as is a nasogastric tube. The study and the report were reviewed by the staff radiologist. [**2153-4-6**] ANKLE FILM There is soft tissue swelling medially and laterally. There are no signs for acute fractures or dislocations. CT HEAD [**2153-4-5**] IMPRESSION: No interval change from OSH study [**2153-4-5**]. Ventricular asymmetry but the right ventricular morphology does not suggest that it is dilated or distended. The asymmetry may be due to partial agenesis of the corpus callosum. LENI LLE U/S [**2153-4-6**] CONCLUSION: No evidence of DVT in the left lower extremity. Brief Hospital Course: A/P: 31 year old man with a history of spina bifida s/p VP shunt, question seizure [**5-11**], who presents from OSH after presenting with a seizure and now hypotensive. 1. Hypotension: He dropped his pressures to the 80s in the ED after intubation. The etiology was most likely [**1-3**] sepsis, given his warm extremities, fever, and white count. Initially, the most likely source of infection was thought to be meningoencephalitis given his recent headache, seizures. Of chief concern is a bacterial process versus HSV encephalitis. He was also at high risk for a VP shunt infection. Urosepsis was also high on the list given his history of recurrent UTIs and his unhygenic self-cathing habits (he needs to be reeducated on this). Fortunately, his pressures quickly improved and he was weaned off of levophed overnight the night of [**2153-4-5**]. He was continued overnight vanc/zosyn for sepsis NOS, and ceftriaxone 2gm and acyclovir for meningitis tx started on [**2153-4-5**]. On [**2153-4-6**], zosyn and ceftriaxone were discontinued in favor of cefepime. CSF was very difficult to obtain, but with help of neurosurg and after 2 attempts, VP shunt CSF fluid was aspirated and sent off. Once CSF was negative (His VP shunt LP was found to be negative with 0 WBCs on [**2153-4-7**]), vanc and cefepime were discontinued on [**2153-4-8**]. His urine culture revealed pan-sensitive klebsiella, which was started on [**2153-4-8**]. Acyclovir was discontinued once it was deemed that HSV encephalitis was unlikely and HSV PCR eventually returned negative. He was discharged on po cefpodoxime 100 mg po BID to complete 14 day course. 2. Respiratory failure: No hypoxemia noted at time of intubation. Patient's respiratory failure was related to mental status precluding ability to protect airway in the setting of status epilecticus. He was extubated without difficulty on [**2153-4-7**]. He was noted to be hypoxic to the low 90s during the night of [**2153-4-7**] requiring 2-3 liters of O2, this normalized to 100% on RA by daytime on [**2153-4-8**]. The MICU team suspected OSA and recommended an outpatient sleep study. 3. Altered mental status: Patient with very probable seizure based on corroborated history from mother and OSH notes stating mouth foaming/bleeding, urinary incontience, and tonic/clonic movements per patient's mother and EMS. His altered mentation was very likely a post-ictal state. CT head negative. The most likely cause of seizure is febrile infection. Hypocalcemia was not present upon presentation at OSH and unlikely to be contributing given negative Svostek sign although this was corrected. He was treated with IV Keppra 1gm [**Hospital1 **] and treated for possible CNS infection as above until ruled out. His mental status cleared quickly after extubation. He was discharged on keppra 1500 mg po BID indefinitely per neuro for seziures and will follow up with his neurologist in NH. 4. Anemia: Microcytic. Iron studies revealed iron deficiency anemia and he was started on iron. He did have trace guiac positive brown stools in ED but Hcts remained stable throughout his course. he will need outpatient follow up and perhaps a PCP directed GI referral for endscopy. 5. High bicarbonate: Stable throughout hospitalization. ? related to OSA and chronic CO2 retention. Will need further work up as an outpatient. 6. Hypothyroidism: High TSH likely sick euthyroid. T4 normal. Follow up for PCP 1. Anemia 2. Possible OSA Medications on Admission: 1) Lisinopril 20mg PO daily 2) Metoclopramide 10mg PO QHS 3) Levothyroxine 150mcg PO daily Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. levothyroxine 150 mcg Capsule Sig: One (1) Capsule PO once a day. 3. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*19 Tablet(s)* Refills:*0* 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis 1. Seizure 2. Urinary tract infection Secondary Diagnosis 1. Spina bifida Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with an episode of seizure requiring intubation. You were started on medication called KEPPRA to help control your seizures. You were also noted to have urinary tract infection and started on antibiotics. Following medications were made your medical regimen START LEVICITERAZE START CEFPODOXIME 100 mg by mouth twice a day for 9 more days (End date: [**2152-4-19**]) for urinary tract infection Followup Instructions: Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16107**] Location: [**Location (un) **] HEALTH FAMILY PRACTICE Address: [**Location (un) 30815**], [**Location (un) **],[**Numeric Identifier 30816**] Phone: [**Telephone/Fax (1) 75860**] Appt: We are working on a follow up appt for you within the next week. The office will call you at home with an apt. If you dont hear from them by tomorrow, please call them directly to book an appt. Dr. [**Last Name (STitle) 89315**] [**Name (STitle) **] (neurologist) [**Telephone/Fax (1) 89316**] Wednesday [**2153-4-18**] at 10 am

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icd9cm

[ [ [] ] ]

[ "38.97", "03.31", "01.02", "89.19", "96.71" ]

icd9pcs

[ [ [] ] ]

13027, 13033

8983, 11124

289, 344

13170, 13170

5101, 5454

13761, 14381

3703, 3756

12588, 13004

13054, 13149

12473, 12565

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3771, 5082

242, 251

372, 3031

5469, 8960

13185, 13297

3053, 3485

3501, 3687

29,730

126,253

32328

Discharge summary

report

Admission Date: [**2187-12-17**] Discharge Date: [**2188-1-10**] Date of Birth: [**2107-10-17**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Pancreatic Pseudocyst Splenic Artery Pseudoaneurysm Major Surgical or Invasive Procedure: ERCP with stent placement Ultrasound-guided imaging for vascular access, visceral artery first order catheterization with abdominal aortogram and celiac artery imaging followed by Perclose groin closure. 1. Exploratory laparotomy. 2. Pancreatic pseudocyst gastrostomy. 3. Open cholecystectomy (partial cholecystectomy). 4. G-tube placement. 5. J-tube placement. 6. Repair of duodenotomy. 7. Mesenteric biopsy. History of Present Illness: This is a 80-year-old woman who was admitted here from [**2187-10-29**] to [**2187-11-22**] recovering form a severe bout of gallstone pancreatitis. She was originally transferred to [**Hospital1 18**] from [**Hospital 1562**] Hospital with necrotizing pancreatitis. She was very sick and required intubation and respiratory support for a number of weeks. She suffered a minor stroke, which affected her proximal left upper extremity. She ultimately recovered from all this and was finally discharged to rehab facility a few weeks ago. She was recovered well and has minimal residual left arm weakness. She has lost weight, approximately 20 lbs in 3 months and has a poor appetite, with early satiety. This is the effect of her very large significant pancreatic pseudocyst, which is secondary to her necrotic body and tail. She reports no change in bowel movement. No fever, chills, or changes in urination. She required a sphincterotomy and stent placement during her previous hospitalization to remove gallstones from her bile duct and this is the source of [**Last Name **] problem originally. Past Medical History: Gallstone pancreatitis Necrotizing pancreatic pseudocyst A-fib Syncope Glaucoma HTN IDDM TIA/Stroke - minimal residual effect PSH: Tonsillectomy and Adenoidectomy ERCP with sphincterotomy and stent [**10-14**] Physical Exam: 97.3, 70, 122/68, 20, 97% RA, 105 lbs Gen: NAD, sitting up in bed, A+O x 3 HEENT: anicteric, EOMI CV: irregular rate and rhythm (chronic A-fib) Chest: Clear, good air movement with faint crackles at bases Abd: soft, nondistended, nontender. BS x 4. Ext: warm, well perfused. Minimal LUE weakness on bicep flexsion, shoulder flexion. Pertinent Results: [**2187-12-18**] 06:30AM BLOOD WBC-6.7# RBC-3.37* Hgb-9.8* Hct-31.1* MCV-92 MCH-29.2 MCHC-31.7 RDW-15.7* Plt Ct-498* [**2187-12-19**] 05:25AM BLOOD PT-38.1* PTT-41.4* INR(PT)-4.1* [**2187-12-18**] 06:30AM BLOOD Glucose-168* UreaN-11 Creat-0.5 Na-137 K-4.2 Cl-102 HCO3-28 AnGap-11 [**2187-12-18**] 06:30AM BLOOD ALT-6 AST-12 AlkPhos-58 Amylase-30 TotBili-0.3 [**2187-12-18**] 06:30AM BLOOD Lipase-31 [**2187-12-18**] 06:30AM BLOOD Albumin-2.3* Calcium-8.1* Phos-3.3 Mg-1.8 Iron-17* Cholest-85 [**2187-12-18**] 06:30AM BLOOD calTIBC-148* Ferritn-165* TRF-114* . PELVIS U.S., TRANSVAGINAL [**2187-12-24**] 1:16 PM IMPRESSION: 1. Normal endometrial thickness. 2. Non-visualization of the ovaries. No adnexal masses are seen. 3. Moderate amount of free pelvic fluid. . EGD [**2187-12-25**] A large pseudocyst was noted replacing the body and tail of the pancreas measuring atleast 7.5x5.5 cm. There was abundant debris noted within the pseudocyst and thus was not amenable to endoscopic drainage. . Brief Hospital Course: This is 80 year old female, well know to the service with a know pancreatic pseudocyst and a possible splenic artery pseudoaneurysm. She was admitted for evaluation of the splenic artery pseudoaneurysm and treatment of her pancreatic pseudocyst. Possible Splenic artery pseudoaneurysm: Her INR at time of admission was 4.3. She received vitamin K and we watched her INR trend down. She then went with Vascular for an Angio on [**12-21**] and was found to have no splenic pseudoaneurysm. Chronic A-fib: Prior to admission, she was on Coumadin. She was then on a Heparin gtt and we watched her PTT and she was kept therapeutic. After her EGD procedure, she was restarted on a Heparin gtt. FEN: She was ordered for a regular diet, but still was struggled with her daily PO intake; multiple health shakes, supplements and ensure puddings were ordered, and the nursing staff facilitated her po intake. Her urine output was monitored closely, and the patient was put on IV fluids when appropriate. Cyst-Gastrostomy: She went for EGD on [**12-25**] for Cystgastrostomy which showed her pseudocyst replacing body & tail of pancreas (7.5x5.5 cm.) There was abundant debris noted within the pseudocyst and thus was not amenable to endoscopic drainage. She went for operative repair on [**2187-12-27**]. She was extubated and brought to the PACU for initial recovery; she was transferred to the SICU for her insulin drip and as she had been reintubated. Neuro: She had IV dilaudid initially for pain control, and when appropriate, was transferred to oral medications. The patient tolerated the procedure well. CV: From a cardiovascular standpoint, following the operation, her vital signs were monitored closely; she was continued on her home medications. She was briefly put on neosynephrine for blood pressure control, as her SBP dipped below 80s at times. She was gradually weaned from the neosynephrine in the SICU. As the patient has a history of atrial fibrillation, and was persistently tachycardic in the SICU, she was put on an amiodarone drip and bolused. She subsequently received metoprolol and was put back on coumadin. Pulm: The patient was extubated but had to be reintubated secondary to respiratory distress/ respiratory failure and acute pulmonary edema. She was closely monitored with continuous oxygen saturation monitoring, and was extubated on POD 1. On [**12-30**], the patient became hypotensive, tachycardic and was tachypneic; she was reintubated and put on levophed with good result. The patient was weaned again for extubation. GI/GU: The patient was made NPO following the surgery and an NGT had been placed. TPN was started as the patient would be NPO for an indeterminant period of time. Her diet was advanced when appropriate (after the NGT was removed on [**2188-1-2**]), which the patient tolerated well; her TPN was tapered off. She received IVF and her urine output was closely monitored with a Foley catheter in place. As the patient's oral intake was still inadequate, tube feeds were increased, which she tolerated well. Nutrition was consulted for appropriate tube feed administration/nutritional needs Heme: Her hematocrit was monitored closely. When appropriate, the patient was transfused red blood cells for a decreased hematocrit. Endo: [**Last Name (un) **] was consulted for perioperative management of her blood sugars. Preoperatively, an insulin drip could not be started, however she was put on an insulin drip post operatively, for which she was brought to the ICU for management. When adequately controlled, the patient was transitioned to a sliding scale of insulin. ID: The patient's white blood count and temperature were routinely monitored. Proph: Throughout her stay, and postoperatively, the patient was put on a heparin drip for prophylaxis as well as pneumoboots. She was transitioned to coumadin once tolerating po intake. On discharge, the patient was doing well, tolerating a regular diet with adequate intake (including tube feeds). Her pain was well controlled, she was ambulating, and voiding appropriately. Medications on Admission: Metoprolol 12.5 qpm Metformin 500 [**Hospital1 **] vitamin D 30mg tid Spirolactone 12.5 qam Lisinopril 5 qam Glyburide 2.5 mg qam Xalatan eye drop qd Coumadin Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks: [**Month (only) 116**] take OTC equivalent. Disp:*14 Tablet(s)* Refills:*2* 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*60 Tablet(s)* Refills:*3* 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Oxycodone 5 mg Capsule Sig: [**1-9**] Capsules PO every 4-6 hours. Disp:*35 Capsule(s)* Refills:*0* 7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once). Disp:*20 Tablet(s)* Refills:*2* 9. Outpatient Lab Work INR, PT [**Name (NI) 21867**]10 Please fax results to your PCP, [**Name10 (NameIs) **] the doctor managing your coumadin dosing. Discharge Disposition: Home With Service Facility: VNA of Central & [**Hospital3 29991**] [**Hospital3 **] Discharge Diagnosis: pancreatic pseudocyst Discharge Condition: stable Discharge Instructions: Continue Probalance tube feeds at 75 ml/hr for 14 hours (during the evening). Incision Care: Keep clean and dry. -Continue wet to dry dressing changes on the lower aspect of the incision daily. If dressing appears to become saturated more rapidly, please start doing wet to dry dressing changes twice daily. -You may shower, and wash surgical incisions if they are appropriately closed or covered with an airtight bandage. -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. . 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 skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([**10-22**] lbs) until your follow up appointment. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in [**1-9**] weeks; please call his office to schedule an appointment. Please follow up with your PCP or gynecologist in [**1-9**] weeks after discharge; you were diagnosed with vaginal atrophy in the hospital which caused you to have postmenopausal bleeding. Please follow up with your PCP regarding your blood sugars, which may require changes in your home medications. You should also schedule an appointment with the [**Hospital **] clinic; call [**Telephone/Fax (1) 75535**] to schedule an appointment. Completed by:[**2188-1-14**]

[ "518.81", "783.7", "438.22", "577.2", "575.11", "365.9", "250.00", "401.9", "427.31", "427.89", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "46.71", "45.13", "51.10", "38.91", "43.19", "51.21", "88.42", "54.23", "96.71", "33.24", "46.39", "96.6", "52.22", "96.04", "99.15" ]

icd9pcs

[ [ [] ] ]

8823, 8909

3537, 7628

368, 780

8974, 8982

2517, 3514

11053, 11646

7838, 8800

8930, 8953

7654, 7815

9006, 9085

9101, 11030

2163, 2498

276, 330

808, 1913

1935, 2148

22,609

148,434

24656

Discharge summary

report

Admission Date: [**2196-11-11**] Discharge Date: [**2196-11-23**] Date of Birth: [**2133-12-21**] Sex: M Service: MEDICINE Allergies: Ultram / Vicodin Attending:[**First Name3 (LF) 134**] Chief Complaint: STEMI Major Surgical or Invasive Procedure: cardiac catheterization with stenting of the RCA History of Present Illness: HPI: 62 y/o male with HTN, DM, Dyslipidemia, PVD presents from [**Hospital3 1280**] Hospital after an inferior MI. He presented there this am from a nursing home with one day of chest pain. Pain was located across the chest without raditation to arms, jaw, or back. It was associated with SOB, nausea, diaphoresis. Pain was [**10-8**] at its worst. Pain did not resolve until he underwent catherization. ECG on presentation revealed an inferior STEMI. BP was 80/40. Temp 101.5. Patient was taken to cath lab where PTCA was performed on mRCA. TIMI III flow was achieved, however stent could not be deployed. Patient was transfered to [**Hospital1 18**]. On arrival, patient c/o [**2-8**] chest discomfort. He denied SOB, N/V, abd pain. He complained of left elbow pain. Past Medical History: DM h/o cardiomyopathy - resolved HTN Rheumatoid Arthritis Anxiety Depression PVD B/L non-healing elbow, heel ulcers h/o cardiac catherization [**2192**] - no CAD Social History: Lives in [**Name (NI) **] Has sister involved in care Denies ETOH, IVDA, tobacco use Family History: N/C Physical Exam: Exam: T96.7 BP 93/64 HR 103 RR28 95%3L N/C Gen: chronically ill appearing male NAD HEENT: PERRL, anicteric, MMM NECK: supple, no JVD CV: RRR no m/r/g Lungs: CTA anteriorly Abd: soft, NT, ND +BS Groin: no hematoma Ext: no edema, pulses non-palpable b/l. Right PT dopplered. Left elbow wound with copious purulent material Right heel - necrotic ulcer Left heel - exposed masticated bone Neuro: A/A OX3 Pertinent Results: WBC 18.6 HCT 34.7 PLT 261 BUN 22 CR .5 CK 835 MB 144 Trop 1.24 Mg 1.5 . ECG: (OSH) 11:38 - complete heart block, STEMI III>II, aVF, V3-V6, ST depressions I,L,V2 (OSH) 11:40 - right side leads - 1/2mm STE V3-V5 (OSH) 14:53 - post-angio - Sinus tach at 100, Q-wave III, aVF, ST depression I,L, V5-V6 ([**Hospital1 18**]) 18:48 - Sinus tach at 100, Q-wavw III, aVF, TWI V4-V6 ([**Hospital1 18**]) 19:01 - right side leads - Qwave V4-V6 [**2196-11-16**] Cath report PTCA COMMENTS: Initial angiography showed an 80-90% stenosis of the distal RCA. We planned to treat this lesion with PTCA and stenting. Eptifibatide was given prophylactically. A 7 French JR4 guide provided suboptimal support (an AL0.75 and a MP guide would not engage). A Prowater wire crossed the lesion with ease and was positioned in the distal vessel. Pre-dilation was performed with a 3.0x15 mm Maverick balloon for multiple inflations at 6-8 atm. Angiography showed a type IIb dissection at the proximal edge of the lesion. We then attempted to deliver a 3.0x18 mm and subsequently a 3.0x8 mm Vision stent but could not advance either stent beyond the mid RCA. The wire was then exchanged for a Choice Floppy wire, which facilitated the delivery of the 3.0x8 mm Vision stent to the dissection site and the stent was deployed at 14 atm. Attempts to deliver a second 3.0x8 mm Vision stent further distally to completely cover the lesion failed due to vessel tortousity and poor guide support. Final angiography showed a <20% residual stenosis, no dissection and TIMI 3 flow. The patient left the lab in stable condition. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful stenting of the RCA. [**2196-11-14**] ECHO Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (severe global hypokinesis with akinesis of the inferior wall). No masses or thrombi are seen in the leftventricle. Right ventricular systolic function appears depressed. The aortic root is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with mild mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. [**2196-11-14**] Feet plain films RIGHT FOOT, TWO VIEWS: There are extensive vascular calcifications noted. An extensive soft tissue defect is noted on the plantar surface of the heel. There is an overlying dressing, which obscures fine bony detail. There are no fractures, dislocations, bony destruction, or periosteal reaction. Note is, however, made of diffuse increased density in the posterior calcaneus, which appears to be due to thickened and ill- defined trabeculae, more prominent in the left foot. The joint spaces are grossly preserved. LEFT FOOT, TWO VIEWS: Extensive vascular calcifications are noted. There is a smaller soft tissue defect seen on the plantar surface of the heel. Note is made of diffuse increased density in the posterior calcaneus, which appears to be due to thickened and ill- defined trabeculae. No fractures, dislocations, bony destructions or periosteal reaction is identified. The joint spaces are grossly preserved. IMPRESSION: 1. Bilateral soft tissue defects on the plantar surfaces of the heel. 2. Bilateral trabecular thickening, left greater than right, within the calcaneus. This finding can represent chronic infection though given that these findings are not specifically in the area of the posteroinferior calcaneus where the soft tissue lies this is less likely; neuroarthropathy or healing insufficiency fracture are also in the differential. IMPRESSION: Severe left ventricular systolic dysfunction (multivessel CAD vs toxic/metabolic state). Brief Hospital Course: A/P: 62 y/o male with multiple cardiac risk factors who presents with inferior STEMI associated with heart block, now s/p cardiac catherization with PTCA of mRCA but without stent deployment. Pt now intubated, in HF, ?septic with long standing ext wounds. . 1) STEMI: The pt received a cath with balloon angioplasty of the RCA. However, a stent was unable to be placed. The pt's presenting symptoms resolved during cath. He was transferred to [**Hospital1 18**] with plans of having a repeat cardiac cath for a further attempt at opening the lesion. At [**Hospital1 18**] the pt was placed on ASA, Plavix, Lipitor 80mg, and lopressor, titrated up as tolerated by his blood pressure. He was kept on these medications throughout his hospitalization. He was placed on integrillin for 18 hours. Upon admission he was also placed on stress dose steroids as the patient was on chronic steroids for arthritis. Initially the pt was planned for an elective cardiac cath 3 days after admission ([**2196-11-14**]). However, given the fact that he spiked a temperature as high as 103.2 and was frequently tachycardic with low blood pressures, it was felt that the pt was questionably septic. The pt's chronic b/l heel and left elbow wounds were felt to be a likely source of sepsis. The ccu team felt that given the possibility of sepsis, a stent would not be warranted given its potential as a nidus of infection. The pt was planned for balloon angioplasty of his RCA rather than stenting. During this period a swan ganz catheter was placed. His swan readings were followed and did not indicate a septic physiology. Also, the pt's blood cultures never demonstrated the growth of any organism. Therefore the pt was again felt to be a candidate for stenting. The pt was intubated during a period of respiratory distress (discussed below). Once stable the pt was kept intubated and was taken to cath where the pt received successful stenting of his mid RCA with less than 20% residual flow. Post Cath pt had some Sinus tachycardia which was treated with increase in BB. Pt also had one episode of chest pain along with some abdominal pain and distention. ECG was unchanged and pt's pain improved with maalox and simethicone and did not recur. - ASA, Plavix, Lipitor 80mg, Toprol XL 100mg qd. Lisinopril was held given SBP in the 90s-100s. Would consider restarting as BP tolerates given benefits of ACEI in a post MI patient and pt with known CAD. - initially stress dose steroids as patient is on chronic steroids for arthritis, now tapering down home dose 5mg. - Goal HR<80 and SBP<120, so can adjust BB accordingly. . 2) CHF: The pt had an echo performed which demonstrated an EF of 25% with inferior wall AK. Throughout his hospitalization, the pt was diursed with lasix as needed. An ACE-I has been held as his BP has been low and would not tolerate another antihypertensive in addition to BB. 3) Rhythm: The pt was intermittently in sinus tach for periods of time. The ddx was post-MI arrythmia vs. pain associated with extremity wounds vs. anxiety. The pt's sinus tach was controlled with with increased BB as his BP tolerated as well as pain control with fentanyl and percocet. 4) Respiratory distress: A few days into his hospital course the pt experienced labored breathing with a rr in the 40s. He maintained this rate for a period of [**3-3**] hours and appeared to betiring he was intubated and kept intubated until post cath at which time he was extubated without difficulty. The etiology of the pt's resp distress was unclear though was likely related to CHF/volume overload. However, during his distress the pt, though diuresed was non-responsive symptomatically to lasix. Follwoing his extubation he experienced no further episodes of dyspnea. 5) Infection/Ext wounds: The pt has long-standing left elbow wound and b/l feet wounds. The elbow wound had been debrided in the past, but was grossloy purulent. His feet both have necrotic ulcers, the ulcer on the left extending down to the calcaneus. Plain films of feet show no apparent osteomyelitis, though given pt with exposed bone on right LE, it was clinically felt felt that the pt had OM. As above, the pt was questionably septic given tachy and low BP, though had nml svr's by swan and never had positive blood cxs. The pt has been followed by vascular, podiatry and ortho. Ortho drained, debrided, and packed the left elbow. For the pt's ext wounds, both podiatry and vascular recommended future surgical intervention after the pt had stabilized from a cardiopulmonary standpoint. In the meantime the services recommended an eight week course of zosyn and vanc. The pt's course began on [**11-11**]. He will be followed for his wounds by the ortho team at [**Hospital **] upon discharge. While admitted, the pt's pain was controlled by fentanyl, percocet, and/or oxycodone. He remained afebrile on antibiotics and the antibiotics should be continued. After speaking with Podiatry consult, antibiotics were changed to Unasyn on the day of discharge given pt's diahrrea, see below. Pt will follow up with podiatry clinic, where wound care and antibiotic coverage can be readdressed should any changes occur. 6) Diabetes: The pt is on Metformin as an outpatient. During the admission, the pt's Metformin was held and he was covered with ISS. Now restarted on Metformn. He was and should continue to be given tight glucose control given infection, MI. . 7) Rheumatoid Arthritis: The pt was placed on stress dose steroids (fludro/hydro) given his long-standing out-pt steroid treatment. His pain was controlled as above. . 8) Adrenal insufficiency: Given the pt's long-standing steroid administration, he was presumed to be adranally insufficient in mounting a stress response to the MI. He was maintained on stress dose steroids and is being tapered down to his out-pt dose 5mg daily. . 9) Diarrhea/Abdominal pain--The pt experienced loose stools following cath. DDX included included C diff on abx vs. rxn to abx themselves. The pt was C diff negative X3. Therefore the pt's diarrhea was felt to be [**3-2**] to abx instead of infection. He was srted on immodium for control. The following morning pt complained of bloating and distention. He had not had a BM in >12 hrs. ECG was done which showed to changes. Pt was given simethicone and maalox which relieved the pressure. His pain was thought likely secondary to gas and bloating. He was given immodium, metamucil and keopectate were also added. This helped intermittently, however pt continued to have diahrrea and antibiotics were changed as above. . 10) Depression/Anxiety: The pt was continued on Wellbutrin, Risperdol. . 11) F/E/N: The pt was maintained on a low Na/cardiac healthy, diabetic diet. He was NPO prior to his cath. His lytes were repleted as necessary. . 12) PPx: The pt was maintained on SQ heparin. . 13) Dispo: to [**Location (un) **] rehab. Medications on Admission: Lisinopril 5 Daily Lipitor 10 Daily MVI Omeprazole 20 Daily Percocet b4 dressing changes Risperdal 1.5 Daily Toprol XL 200 Daily Welbutrin 100 [**Hospital1 **] ISS Methylprednisolone 4mg Daily Arava (Leflunomide) 20 Daily Metformin 500 [**Hospital1 **] Vitamin C 500 Daily Motrin prn Augmentin Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Risperidone 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 4. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO QD (). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Clopidogrel 75 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. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Insulin Sliding Scale with meals as indicated. 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q2-3H (every 2-3 hours) as needed for pain. 15. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 18. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 19. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a day). 20. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Until [**2196-11-25**] and then change to 5mg daily (patient on maintance dose of 5mg). 21. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO DAILY (Daily): Continue until pt stops having diahrrea. Hold for K>4.5. 22. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 23. Bismuth Subsalicylate 262 mg/15 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for diarrhea. 24. Unasyn [**3-1**] g Piggyback Sig: One (1) Intravenous every six (6) hours for 7 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital - [**Location (un) 701**] Discharge Diagnosis: STEMI Bilateral heel ulcers. Respiratory distress Elbow wound Discharge Condition: stable Discharge Instructions: Pt or ECF staff should contact physician if pt: experiences chest pain shortness of breath temp >101 has bleeding, pain or swelling at cath site. Pt has been having diahrrea, his stool was negative for C. Diff X 3 and was given some immodium, metamucil and keopectate was ordered as well. This should be monitored to make sure that the diahrrea is under control. . Please follow up with Podiatry for your heel ulcers and apporpriate antibiotic therapy as listed below. Followup Instructions: Pt to be followed by Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital **] [**Hospital 1110**] Rehab. Pt will be followed by his [**Hospital1 **] orthopedic physicians there for his extremity wounds. Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2196-11-25**] 3:30 Completed by:[**2196-11-24**]

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icd9cm

[ [ [] ] ]

[ "00.45", "83.94", "36.06", "96.71", "38.93", "89.64", "86.28", "00.66", "00.40", "99.20", "99.04", "96.04" ]

icd9pcs

[ [ [] ] ]

15454, 15532

5904, 12798

285, 336

15638, 15647

1907, 3505

16165, 16597

1448, 1453

13142, 15431

15553, 15617

12824, 13119

3522, 5881

15671, 16142

1468, 1888

240, 247

364, 1144

1166, 1329

1345, 1432

62,586

135,593

5400

Discharge summary

report

Admission Date: [**2175-8-30**] Discharge Date: [**2175-9-7**] Date of Birth: [**2125-6-18**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 6088**] Chief Complaint: Ischemic right lower leg with non healing 3rd toe amp site. Major Surgical or Invasive Procedure: [**2175-8-30**]: Right proximal Superficial femoral artery to mid Posterior tibial bypass w GSV. History of Present Illness: 50-year-old diabetic gentleman who presented with gangrene of his right 3rd toe on [**2175-8-23**] for which he underwent amputation. Noninvasive arterial studies at that time demonstrated diffuse tibial disease. He underwent a diagnostic angiography that showed severe disease in his below-knee popliteal artery and tibials with reconstitution of a posterior tibial artery down to his foot which was not amenable to a catheter based intervention. He, therefore, presented today for an SFA to posterior tibial artery bypass. Past Medical History: PMHx: CAD s/p CABG, severe bivent cardiomyopathy w systolic CHF (LVEF 27% on ECHO [**2175-6-30**]) s/p ICD, DM wnephropathy & retinopathy, HTN, Dyslipidemia, DJD, Left rotator cuff tear -ECHO [**2175-6-30**]: Normal LV cavity size with severe global LV systolic dysfunction and apical aneurysm/dyskinesis. Mild mitral regurgitation. LVEF 27%. PSHx: CABG [**5-31**] ([**Known lastname **]-LAD, SVG-OM1, SVG-OM2, SVG-PDA, SVG-Diag), single-chamber Biotronik ICD, Lumax 540 VR-T Social History: SocHx: Worked as a bus driver, currently on disability due to shoulder injury. No history of / current tobacco use. Prior h/o heavy EtOH consumption approximately 3-4y ago with approximately 12-14 beers/day, current use is reportedly minimal. No illicit drug use. The patient lives with his second wife and two children. He has three children from previous marriage. Originally from [**Country 7192**]. Physical Exam: Alert and oriented x 3 VS:BP 108/69 HR 72 RR 16 Carotids: 2+, no bruits or JVD Resp: Lungs clear Abd: Soft, non tender Ext: Pulses: Left Femoral palp , DP dop ,PT dop Right Femoral palp , DP dop ,PT dop Feet warm, well perfused. Incisions: Right leg incision stapled. Clean and dry, open to air. Wounds: Amp site is clean, wound bed with 100% granulation tissue. Pertinent Results: [**2175-9-5**] 07:10AM BLOOD WBC-7.2 RBC-3.12* Hgb-9.6* Hct-29.4* MCV-94 MCH-30.9 MCHC-32.7 RDW-12.9 Plt Ct-453* [**2175-9-6**] 04:40AM BLOOD Glucose-161* UreaN-27* Creat-2.1* Na-140 K-4.7 Cl-107 HCO3-28 AnGap-10 Renal Ulrasound [**2175-9-6**] Simple right renal cyst. Otherwise unremarkable renal ultrasound. Brief Hospital Course: The patient was brought to the operating room on [**2175-8-30**] and underwent a Prox SFA to mid PT bypass w insitu GSV. The procedure was without complications. His postoperative course was complicated by the following: CARDIAC: On POD 1, the patient c/o nausea and received a cardiac work-up, including enzymes and an EKG. The EKG showed no change from previous, and enzymes were stable (Trop .02, MB 2.) RENAL: Post-operatively, the patient was noted to have a creatinine of 3.4, having been discharged a week earlier with a normal creatinine. The renal service was consulted. The rise in creatinine was likely due to ATN caused by lisinopril, ibuprofen, bactrim and volume depletion in the period between prior discharge and surgery. Fluid balance and diet was carefully managed, and the patient's creatinine improved with time to 2.1 at discharge. He is scheduled to follow up with his PCP [**Last Name (NamePattern4) **] [**2175-9-11**] for repeat renal function and electrolytes. WE HAVE HELD HIS LISINOPRIL, PRESCRIBED FOR CHF, SECONDARY TO HIS KIDNEY INJURY WHICH WILL NEED TO BE RESTARTED WHEN HIS CREATININE NORMALIZES. ID/WOUND. The patient was initially placed on vanc/cipro/flagyl then transitioned to oral augmentin to treat his toe amp site for which he will remain on for one week. The toe amp site was debrided at the bedside on [**2175-9-5**]. He and his family will manage the wound at home with three times daily dressing changes using wound gel and moist gauze. He was given a heel wedge [**Last Name (un) 21924**] shoe for ambulation and will follow up with Dr. [**Last Name (STitle) **] in one week. FEN: The patient's K was noted to be 5.7 on POD 4, and the patient was treated with insulin/dextrose, keyaxalate, and calcium gluconate. No peaked T waves were observed. K on discharge was 4.7. He was seen by nutrition and instructed on a low potassium, renal diet. DIABETES: He was followed by the [**Last Name (un) **] Diabetes team for blood sugar management. They recently stopped his metformin and started lantus insulin at HS with humolog with meals as his A1C was 12.7 earlier this month. His blood sugars have been in good control while in house. Medications on Admission: aspirin 81', simvastatin 40', carvedilol 3.125", lisinopril 2.5', Glargine 20 Units Bedtime, Sulfameth/Trimethoprim DS'', MetRONIDAZOLE 500'''. Discharge Medications: 1. Amoxicillin-Clavulanic Acid 500 mg PO Q12H RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by mouth twice daily x 7 days Disp #*14 Tablet Refills:*0 2. Glargine 17 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus] 100 unit/mL 17 Units before BED Disp #*1 Bottle Refills:*0 RX *insulin lispro [Humalog] 100 unit/mL Up to 14 Units per sliding scale four times a day Disp #*1 Bottle Refills:*0 3. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every 4-6 hours Disp #*20 Tablet Refills:*0 4. Simvastatin 40 mg PO DAILY RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 5. Carvedilol 3.125 mg PO BID RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice daily Disp #*28 Tablet Refills:*0 6. Aspirin 81 mg PO DAILY 7. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Peripheral Arterial Disease Diabetes Acute Kidney Injury Chronic Systolic CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a bypass surgery on your right leg to improve the circulation to your right foot and heal your amputation site. During your hospitalization, you were seen by the diabetes doctors [**First Name (Titles) 1023**] [**Last Name (Titles) 21925**] your insulin. You were also seen by the kidney doctors because of evidence of some kidney injury likely secondary to dehydration, medications and IV dye from your prior angiogram. You will need to follow a renal/low potassium diet until your kidney function improves. We have arranged for your PCP to check your renal function on [**2175-9-11**]. You will needed to care for your amputation site as follows: Wound Gel (DuoDerm Gel) to the wound. Apply small amount three times per day cover with gauze dressing. It is important that the area remains moist but not wet or be allowed to dry out. Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**12-23**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery EXCEPT LISINOPRIL ?????? Take one 81mg aspirin daily Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED When: MONDAY [**2175-9-11**] at 9:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 6662**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: VASCULAR SURGERY When: THURSDAY [**2175-9-14**] at 11:00 AM With: [**Hospital 21926**] CLINIC [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: ADULT SPECIALTIES When: WEDNESDAY [**2175-9-27**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21927**], MD [**Telephone/Fax (1) 21928**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Completed by:[**2175-9-7**]

[ "583.81", "362.01", "V45.02", "250.42", "276.50", "584.5", "V49.72", "V45.81", "E935.6", "401.9", "428.22", "250.52", "428.0", "E942.9", "440.24", "E931.0", "272.4", "425.4" ]

icd9cm

[ [ [] ] ]

[ "39.29", "86.28" ]

icd9pcs

[ [ [] ] ]

6043, 6049

2715, 4915

362, 461

6171, 6171

2379, 2692

9408, 10432

5111, 6020

6070, 6150

4942, 5088

6322, 9385

1956, 2360

263, 324

489, 1017

6186, 6298

1039, 1519

1535, 1941

13,680

141,461

21216

Discharge summary

report

Admission Date: [**2140-12-11**] Discharge Date: [**2140-12-14**] Date of Birth: [**2102-9-16**] Sex: F Service: MED Allergies: Toradol / Bee Sting Kit Attending:[**First Name3 (LF) 30**] Chief Complaint: narcotics overdose Major Surgical or Invasive Procedure: none History of Present Illness: 38 yo female with history chronic LBP, disc herniation, narrow spinal canal, morbid obesity, depression presented to the EW with several days n/v, LBP and hematuria. Received 2mg Dilaudid in the EW and became minimally responsive, diaphoretic, 02 sats high 60s on RA. Pt started on narcan bolus and drip, became responsive, combative and distrustful of physicians. Her tox screen then tested positive for opiates, methadone and benzos. Empty methadone bottle found in her room but she denied taking anything but dilaudid. EW course also notable for CT of the abdomen which showed demonstrated a possible small R kidney stone (w/u for hematuria). Pt sent to ICU for close respitory monitoring, possibly initiation of BIPaP. Past Medical History: Degenerative Disk Disease Narrow Spinal Column chronic low back pain uterine fibroids morbid obesity borderline personality disorder Herniated disk Hyperlipidimia Depression Social History: No longer lives with abusive husband. Is presently staying at shelter in [**Location (un) 5131**], homeless. Has 4 children who live with their father in [**Name2 (NI) **]. etoh: rare tob: significant smoker in past though reports quiting 12y PTA Physical Exam: Vitals upon presentation to ED T = 98.1, HR = 73, BP = 123/69, 97% RA Gen: teary, appears uncomfortable, obese HEENT: NC/AT, sclera anicteric, PERRL, EOMI, mmm, o/p clear CV: RRR, distant hs [**3-21**] body habitus Pulm: CTA bilaterally from anterior, no w/r/r Abd: obese, s, nt, nd, nabs Extr: no c/c/e, palpable DP bilaterally Neuro: AAOX3 Neurologic Exam-non focal. Pertinent Results: [**2140-12-11**] 12:08PM GLUCOSE-99 UREA N-12 CREAT-0.5 SODIUM-140 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-32* ANION GAP-12 [**2140-12-11**] 12:08PM CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-1.9 [**2140-12-11**] 12:08PM WBC-12.0* RBC-4.33 HGB-11.9* HCT-37.1 MCV-86 MCH-27.5 MCHC-32.1 RDW-17.2* [**2140-12-11**] 12:08PM PLT COUNT-313 [**2140-12-11**] 12:08PM D-DIMER-1358* [**2140-12-11**] 12:50AM URINE HOURS-RANDOM [**2140-12-11**] 12:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-POS [**2140-12-10**] 10:58PM TYPE-ART PO2-133* PCO2-73* PH-7.26* TOTAL CO2-34* BASE XS-3 [**2140-12-10**] 07:27PM URINE HOURS-RANDOM [**2140-12-10**] 07:27PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-POS [**2140-12-10**] 07:27PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.019 [**2140-12-10**] 07:27PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2140-12-10**] 07:27PM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2140-12-10**] 07:00PM GLUCOSE-102 UREA N-19 CREAT-0.6 SODIUM-139 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-30* ANION GAP-12 [**2140-12-10**] 07:00PM ALT(SGPT)-41* AST(SGOT)-32 ALK PHOS-96 AMYLASE-26 TOT BILI-0.2 [**2140-12-10**] 07:00PM LIPASE-25 [**2140-12-10**] 07:00PM TOT PROT-7.0 ALBUMIN-4.0 GLOBULIN-3.0 [**2140-12-10**] 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2140-12-10**] 07:00PM WBC-8.7 RBC-4.30 HGB-12.1 HCT-36.6 MCV-85 MCH-28.2 MCHC-33.1 RDW-16.4* [**2140-12-10**] 07:00PM NEUTS-54.7 LYMPHS-33.9 MONOS-9.7 EOS-1.0 BASOS-0.7 [**2140-12-10**] 07:00PM HYPOCHROM-2+ ANISOCYT-1+ MICROCYT-1+ [**2140-12-10**] 07:00PM PLT COUNT-308 Brief Hospital Course: 38 year old female with h/o chronic lower back pain, h/o opiate dependence who admitted with lower back pain, nausea, vomiting and hematuria who then developed hypoxia upon receipt of IV dilaudid suspected to be secondary to narcotic overdose who required a narcan drip. 1. Hypoxia--We thought that her hypoxia was a result of her gettting a small dose of Dilaudid after having taken a questionable amount of methadone and benzodiazapines recently and even in the EW. Upon arrival to the [**Hospital Unit Name 153**] she was sating well on 100% mask but this would drop w/sleep to high 80s. She was then started on CPAP. Also, Patient was started on a narcan drip after which her O2 sats improved such that she was able to be gradually weaned off the supplemental oxygen and she was transferred to the floor. 2. LBP-We controlled her pain with NSAIDS and the pain service reommended that she be discharged with a small amount of oxycodone along with close follow up with the pain clinic at [**Hospital6 **]. 3. Substance abuse-The patient was evaluated by psychiatry. She was thought to have questionable borderline personality disorder along with probable narcotic dependence since she had been prescribed 40 pills on [**12-5**] and one week later the bottle was empty. She had also been acquiring narcotics from two sources in direct violation of her narcotic contract. her PCP at [**Hospital1 **] was also unaware that she had been acquiring narcotics from two sources. Although they suspected an opiod overdose they did not think that this was a suicide attempt and she did not express any suicidal ideations. In light of this opiod overdose we thus decided it best that the patient obtain all of her care at [**Hospital6 **] to which the patient was in agreement. (See discharge plannng for more details.) 4. Obstructive Sleep Apnea. The patient was suspected to have obstructive sleep apnea as she required CPAP at night. Prior to discharge she was referred to the obstructive sleep apnea clinic for further follow up. Medications on Admission: methadone 10mg (filled [**12-5**]) dilaudid 6mg po q4h neurontin 900mg tid protonix 40mg Discharge Medications: 1. Oxycodone HCl 5 mg Capsule Sig: [**2-19**] Capsules PO 4-6 hrs prn as needed for pain. Disp:*20 Capsule(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: [**2-19**] Capsules PO bid prn as needed for constipation. Disp:*30 Capsule(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO bid prn. Disp:*30 Tablet(s)* Refills:*2* 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Opioid Overdose. 2. Polysubstance Abuse. 3. Morbid Obesity. 4. Sleep Apnea. 5. Acute on chronic back pain. 6. Nauseau and Vomiting. 7. Depression. Secondary 1. Uterine Fibroids. 2. Right Nephrolithiasis. Discharge Condition: Good. Tolerating po intake without incident and ambulating independently. Discharge Instructions: Please return to the emergency room if you experience shortness of breath, severe back pain, new pain or pain not relieved by medications, fever, chills, nausea or vomiting. Please take all medications as prescribed. You have been started on oxycodone 10 mg q 4-6 hours as needed. You other pain medications have been stopped except for neurontin. Followup Instructions: Please call [**Doctor Last Name 2048**] at [**Telephone/Fax (1) 6856**] to make an appointment to see Dr. [**First Name (STitle) **] re your sleep apnea. [**Doctor Last Name 2048**] is expecting your call. Please call [**Telephone/Fax (1) 56180**] for a follow up primary care appointment at [**Hospital6 **]. You have an appointment with Dr. [**Last Name (STitle) 56181**] at [**Hospital1 2177**] Pain Clinic on [**12-28**] at 11:00 am. Please call [**Telephone/Fax (1) 56182**] if you have questions. Please call [**Telephone/Fax (1) 56183**] for an appointment with psychiatry.

[ "276.3", "278.01", "305.91", "592.0", "311", "724.2", "786.09", "787.01", "285.9", "301.9", "218.9", "965.00", "304.91", "564.00", "E850.2", "780.57" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6368, 6374

3724, 5758

298, 304

6635, 6710

1922, 3701

7108, 7697

5898, 6345

6395, 6614

5784, 5875

6734, 7085

1533, 1903

240, 260

332, 1056

1078, 1254

1270, 1518

156

199,280

4481

Discharge summary

report

Admission Date: [**2120-12-31**] Discharge Date: [**2121-1-27**] Date of Birth: [**2057-11-11**] Sex: M Service: CARDIOTHORACIC Allergies: Lorazepam / Benzodiazepines Attending:[**First Name3 (LF) 1283**] Chief Complaint: 63 yo male with h/o 8cm AAA resection with aortobifemoral graft in [**12-11**], who was diagnosed in [**5-12**] with type B dissection from distal aorta to L subclavian to aortobifem graft. Pt admitted [**2120-12-31**] elective thoracoabdominal aortic aneurysm repair with reimplant SMA/celiac/L renal/R renal fem-fem bypass on [**12-31**]. Bronchoscopy on [**1-2**] notable for mod thin secretions and several blood clots. Pt was reintubated due to mucus plugs, requiring several bronchs while intubated. Pt also developed acute renal failure, volume overload. Pt was extubated on [**2121-1-15**], is currently NPO with NG TFs, and we were consulted to evaluate pt for swallow. PMH / PSH: CAD, DVT, OA both knees, MRSA pneumonia, s/p knee/ankle/elbow sx, gum sx, deviated septum, emphysema, (+) h/o smoking, depression Major Surgical or Invasive Procedure: PROCEDURE: Repair of thoracoabdominal aneurysm, reimplantation intercostal arteries, and reimplantation of the superior mesenteric artery, celiac access, and the right and left renal arteries. PREOPERATIVE DIAGNOSIS: Thoracoabdominal aneurysm following type B dissection, medically managed. Surgery was indicated due to increase in size of the aneurysm to about 8 cm. The patient was essentially asymptomatic. POSTOPERATIVE DIAGNOSIS: Thoracoabdominal aneurysm following type B dissection, medically managed. Surgery was indicated due to increase in size of the aneurysm to about 8 cm. The patient is essentially asymptomatic. PREOPERATIVE DIAGNOSIS: Thoracoabdominal aortic aneurysm. POSTOPERATIVE DIAGNOSES: Thoracoabdominal aortic aneurysm. PROCEDURE: 1. Repair of thoracoabdominal aortic aneurysm. 2. Reimplantation of the left renal artery, superior mesenteric artery and celiac artery. 3. Reimplantation of the right renal artery. 4. Left femoral artery, left femoral vein bypass. PROCEDURE INDICATIONS: 1. Respiratory failure. 2. Assessment of airways patency. SCOPE: Number 6. PREOPERATIVE DIAGNOSIS: Respiratory failure. POSTOPERATIVE DIAGNOSIS: Severe mucous plugging in the left main stem. PROCEDURE: 1. Flexible bronchoscopy. 2. Therapeutic aspiration of thick mucous plugging in the left main stem. ice: CSU Date: [**2121-1-14**] Date of Birth: [**2057-11-11**] Sex: M Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 17274**] FIRST ASSISTANT: [**Name6 (MD) 19185**] [**Name8 (MD) 19186**], MD PREOPERATIVE DIAGNOSIS: Respiratory failure. POSTOPERATIVE DIAGNOSIS: Patent airways. PROCEDURE: Flexible bronchoscopy. [**2121-1-18**] Date of Birth: [**2057-11-11**] Sex: M Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 19187**] ASSISTANT: [**Name6 (MD) 19185**] [**Name8 (MD) 19186**], MD PROCEDURE: Flexible bronchoscopy and therapeutic aspiration. Service: CSU Date: [**2121-1-22**] Date of Birth: [**2057-11-11**] Sex: M Surgeon: [**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], MD 2367 PREOPERATIVE DIAGNOSIS: Loculated left pleural effusion with pulmonary collapse. Postoperative respiratory insufficiency and tracheobronchitis. POSTOPERATIVE DIAGNOSIS: Loculated left pleural effusion with pulmonary collapse. Postoperative respiratory insufficiency and tracheobronchitis. PROCEDURE: 1. Left thoracoscopy with partial lung decortication. 2. Percutaneous tracheostomy tube placement. 3. Flexible bronchoscopy with aspiration of tracheobronchial tree. History of Present Illness: 63 year old man with h/o 8cm AAA resection with aortobifemerol graft in [**12-11**], who was diagnosed in [**5-12**] with type B dissection from distal aorta to L subcalvian to aortobifem graft. Pt admited [**2120-12-31**] for elective thoracoabdominal aortic aneurysm repair with reimplant SMA/celiac/L renal/R renal fem-fem bypass on [**2120-12-31**]. Bronchoscopy on [**1-2**] notable for mod thin secretions and several blood clots. Pt was reintubated due to mucus plugs, requiring several bronchs while intubated. Pt also developed acute renal failure, volume overload. Pt was extubated on [**2121-1-15**]. Chest CT on [**2121-1-20**] showed bilateral effusions with near total collapse of R lung and on [**1-22**] pt was bronched and trached. We were consulted to assess his ability to tolerated wearing a Passy-Muir Speaking Valve. HPI / Subjective Complaint: 63 y/o male with 8cm AAA resection with aortobifemoral graft in [**12-11**], but then presented to [**Hospital1 **] in [**5-12**] with back pain. Found to have type B dissection from distal aorta to L subclavian to aortobifem graft. Underwent thoracoabdominal aortic aneurysm repair with reimplant SMA/celiac/L renal/R renal fem-fem bypass on [**12-31**]. Bronchoscopy on [**1-2**] notable for mod thin secretions and several blood clots. Past Medical History: PMH / PSH: DVT, OA both knees, MRSA pneumonia, ankle sx, knee sx, elbow sx, gum sx, deviated septum, emphysema PAST MEDICAL HISTORY: Deep venous thrombosis, osteoarthritis. PAST SURGICAL HISTORY: Status post 8 cm abdominal aortic aneurysm repair, status post wound dehiscence. Social History: SOCIAL HISTORY: History of tobacco use. One pack per day tobacco history. Quit [**12-11**]. Lives in [**Location 4310**] with his wife. Two to three alcoholic beverages per week Family History: NC Physical Exam: On admit Axo x3 NAD well developed CTA/Bl S-NT/ND no RT/no guarding EXT good distal pulses warm well perfused extremities Pertinent Results: Admission labs [**2120-12-31**] 10:14PM WBC-4.5 RBC-3.62*# HGB-11.0*# HCT-30.0*# MCV-83 MCH-30.4 MCHC-36.7* RDW-13.8 [**2120-12-31**] 10:14PM WBC-4.5 RBC-3.62*# HGB-11.0*# HCT-30.0*# MCV-83 MCH-30.4 MCHC-36.7* RDW-13.8 [**2120-12-31**] 10:36PM TYPE-ART RATES-8/ TIDAL VOL-800 O2-100 PO2-193* PCO2-41 PH-7.34* TOTAL CO2-23 BASE XS--3 AADO2-489 REQ O2-81 INTUBATED-INTUBATED VENT-CONTROLLED [**2120-12-31**] 10:28PM PT-17.9* PTT-42.0* INR(PT)-2.0 Discharge labs [**2121-1-27**] 03:57AM BLOOD WBC-8.8 RBC-2.93* Hgb-9.0* Hct-27.0* MCV-92 MCH-30.8 MCHC-33.4 RDW-17.6* Plt Ct-319 [**2121-1-26**] 03:50AM BLOOD WBC-9.7 RBC-3.07* Hgb-9.2* Hct-28.0* MCV-91 MCH-30.1 MCHC-33.0 RDW-17.5* Plt Ct-314 [**2121-1-27**] 03:57AM BLOOD Plt Ct-319 [**2121-1-27**] 03:57AM BLOOD Glucose-112* UreaN-29* Creat-0.9 Na-139 K-4.4 Cl-103 HCO3-32* AnGap-8 [**2121-1-26**] 03:50AM BLOOD Glucose-104 UreaN-27* Creat-1.0 Na-140 K-3.8 Cl-104 HCO3-30* AnGap-10 [**2121-1-12**] 12:04AM BLOOD ALT-44* AST-33 AlkPhos-175* Amylase-23 TotBili-2.4* [**2121-1-27**] 03:57AM BLOOD Mg-2.2 [**2121-1-27**] 12:53AM BLOOD Type-ART pO2-84* pCO2-55* pH-7.42 calHCO3-37* Base XS-8 [**2121-1-26**] 05:03AM BLOOD O2 Sat-97 Brief Hospital Course: The following procedures are earmarks of the events that have occured t mark the hospital course: PROCEDURE: Repair of thoracoabdominal aneurysm, reimplantation intercostal arteries, and reimplantation of the superior mesenteric artery, celiac access, and the right and left renal arteries. PREOPERATIVE DIAGNOSIS: Thoracoabdominal aneurysm following type B dissection, medically managed. Surgery was indicated due to increase in size of the aneurysm to about 8 cm. The patient was essentially asymptomatic. POSTOPERATIVE DIAGNOSIS: Thoracoabdominal aneurysm following type B dissection, medically managed. Surgery was indicated due to increase in size of the aneurysm to about 8 cm. The patient is essentially asymptomatic. PREOPERATIVE DIAGNOSIS: Thoracoabdominal aortic aneurysm. POSTOPERATIVE DIAGNOSES: Thoracoabdominal aortic aneurysm. PROCEDURE: 1. Repair of thoracoabdominal aortic aneurysm. 2. Reimplantation of the left renal artery, superior mesenteric artery and celiac artery. 3. Reimplantation of the right renal artery. 4. Left femoral artery, left femoral vein bypass. PROCEDURE INDICATIONS: 1. Respiratory failure. 2. Assessment of airways patency. SCOPE: Number 6. PREOPERATIVE DIAGNOSIS: Respiratory failure. POSTOPERATIVE DIAGNOSIS: Severe mucous plugging in the left main stem. PROCEDURE: 1. Flexible bronchoscopy. 2. Therapeutic aspiration of thick mucous plugging in the left main stem. ice: CSU Date: [**2121-1-14**] Date of Birth: [**2057-11-11**] Sex: M Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 17274**] FIRST ASSISTANT: [**Name6 (MD) 19185**] [**Name8 (MD) 19186**], MD PREOPERATIVE DIAGNOSIS: Respiratory failure. POSTOPERATIVE DIAGNOSIS: Patent airways. PROCEDURE: Flexible bronchoscopy. [**2121-1-18**] Date of Birth: [**2057-11-11**] Sex: M Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 19187**] ASSISTANT: [**Name6 (MD) 19185**] [**Name8 (MD) 19186**], MD PROCEDURE: Flexible bronchoscopy and therapeutic aspiration. Service: CSU Date: [**2121-1-22**] Date of Birth: [**2057-11-11**] Sex: M Surgeon: [**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], MD 2367 PREOPERATIVE DIAGNOSIS: Loculated left pleural effusion with pulmonary collapse. Postoperative respiratory insufficiency and tracheobronchitis. POSTOPERATIVE DIAGNOSIS: Loculated left pleural effusion with pulmonary collapse. Postoperative respiratory insufficiency and tracheobronchitis. PROCEDURE: 1. Left thoracoscopy with partial lung decortication. 2. Percutaneous tracheostomy tube placement. 3. Flexible bronchoscopy with aspiration of tracheobronchial tree. Major issues are below which have been resolved prior to D/C Neuro: Pt was intubated and sedated for some time and had a waxing and [**Doctor Last Name 688**] course with regards to confusion, he at times was floridly confused but after resolution of electrolye and pulmonary issues his nerologic issues resolved, was evaluated by neurologic team and cleared from their prospective CV: pt has had stable course from cardiovascular propspective, was supported initially with pressors and then was given agents for control Pulm: Pt was admitted postoperativly from his thoracoabdominal repair his renal funtion was marginal in the first several days postoperatively he with he had emphysema with difficulty weening from the vent and was extubated and re-intubated early in his post -op course, he was finally extubated and needed several subsequent bronchoscopy evalutations and finally his pulmonary issues led him to a tracheostomy from which he has been stable from a pulmonary function. Renal: pt was followed by renal service for ATN in post op period which resolve overtime to normal creatinine prior to D/C FEN: all electorlyte abnormalities were corrected prior to D/C, free water was used to correct dehydration and increased NA Dispo to rehab because of chronic debilitation and trach mask Medications on Admission: FLUOXETINE HCL 10MG--One every day - increase to 2 every day as needed Discharge Medications: 1. Acetaminophen 500 mg/5 mL Liquid Sig: Five (5) ml PO Q4H (every 4 hours) as needed for fever or pain. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day) for 5 days. 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-9**] Puffs Inhalation Q6H (every 6 hours). 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 10. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ascorbic Acid 100 mg/mL Drops Sig: Five (5) ml PO DAILY (Daily). 13. Heparin Sodium Lock Flush 100 unit/mL Solution Sig: One (1) ML Intravenous DAILY (Daily) as needed: for PICC catheter . Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Thoraco-abdominal aneurysm Discharge Condition: good Discharge Instructions: may shower, no bathing for 1 month no creams, lotions, ointments to incisions [**Last Name (NamePattern4) 2138**]p Instructions: with Dr. [**Last Name (Prefixes) **] upon discharge from rehab with Dr. [**Last Name (STitle) **] in [**3-12**] weeeks Completed by:[**2121-1-27**]

[ "518.5", "478.29", "780.57", "518.0", "584.5", "286.9", "428.0", "998.11", "293.0", "427.31", "486", "441.03", "510.9", "519.1" ]

icd9cm

[ [ [] ] ]

[ "38.45", "33.24", "34.51", "96.05", "31.1", "39.61", "00.14", "34.03", "00.13", "88.72", "38.44", "99.00", "96.6", "38.93", "39.59" ]

icd9pcs

[ [ [] ] ]

12215, 12315

6901, 6982

1119, 3679

12386, 12392

5693, 6878

5532, 5536

10981, 12192

12336, 12365

10885, 10958

6999, 10859

12416, 12495

12546, 12696

5238, 5321

5551, 5674

257, 1081

3707, 5019

5174, 5215

5353, 5516

60,306

134,518

1284

Discharge summary

report

Admission Date: [**2102-8-3**] Discharge Date: [**2102-8-10**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1253**] Chief Complaint: Left Sided Pleuritic Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: 87F with history of HTN, HLD, memory impairment presented to ED with dyspnea and chest pain, found to have large almost saddle emboli. Per pt and OMR, had recent URI [**7-20**] with associated mild hypoxia at adult daycare. Underwent PCP [**Name9 (PRE) **] at that time, completed azithromycin course, treated symptommatically with nebulizer treatments. Symptoms initially improved. 5 Days ago started having pain in left side, worse with inspiration and presing on abdomen. SOB unchanged in past 2 weeks. Last night unable to sleep [**3-8**] cough. Home VNA found her with O2 sat of 89% on RA today, administered nebs with improvement. No recent surgeries, immobilizations. Presented to ED today with worsening shortness of breath, pleuritic chest pain and hypoxia of 89% on RA at home. Mild cough, non-productive. . In the ED, initial vitals: 98.4 90 143/77 18 98% 4L Nasal Cannula. Chest x-ray concerning for possible atelectasis vs. pneumonia, BNP elevated 2368. EKG sinus rhythm, TWI in inferior and V2-V6 leads, no ST changes. CTA showed large saddle PE. Guaic negative, startd heparin gtt. Admitted to ICU for further management, transfer vitals HR 89 BP 100/p RR 19 97%4L. . On the floor, patient is comfortable, no real complaints except for left sided pleuritic pain. cough improving. no swelling or pain in legs. headache today. All of this was communicated via translator Past Medical History: -hypertension -hyperlipidemia -shoulder pain -R kidney stones status lithotripsy and ureteral stent Social History: She has 8 children (3 of whom have passed away), and lives in [**Location 686**] with her daughter, [**Telephone/Fax (1) 7971**]. She is [**Location 7972**] and does not speak English. She attends a daycare. Denies tobacco, alcohol and recreational drug use. Family History: Daughter with LUE DVT on Warfarin Unknown if patient has family history for cardiac sudden deaths. There is no known history of renal disease or renal stones in her family. Physical Exam: Physical Exam: Vitals: T: 97 BP: 148/71 P: 95 R: 14 O2: 95%4L General: alert, no acute distress, in bed HEENT: Sclera anicteric, MMM, oropharynx clear, no thrush Neck: supple, JVP not elevated with patient at 60 degrees, no thyromegally, no lad, no carotid bruits Lungs: bibasilar crackles, decreased BS at left posterior lung base with no rhonchi. no wheeze. no splinting, symmetric excursion. Pain to palpation over axial aspect of left lower rib cage. CV: Regular rate and rhythm, normal s1, fixed split p2, no appreciable murmurs, no gallops Abdomen: slight distension. soft, minimal tenderness in LUQ over rib cage, bowel sounds present, no rebound tenderness or guarding. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. + vericose veins. no palpable cords or other e/o DVT. Discharge: Afebrile 124/90 P65 R24 96%RA Breathing comfortably. Minimal bibasilar rales. good AE. Pertinent Results: [**2102-8-3**] 12:50PM BLOOD WBC-8.0 RBC-4.49 Hgb-14.9 Hct-42.8 MCV-95 MCH-33.1* MCHC-34.7 RDW-14.0 Plt Ct-254 [**2102-8-8**] 04:45AM BLOOD WBC-6.2 RBC-4.10* Hgb-13.9 Hct-39.3 MCV-96 MCH-33.8* MCHC-35.3* RDW-13.4 Plt Ct-248 [**2102-8-3**] 12:50PM BLOOD Glucose-106* UreaN-21* Creat-0.9 Na-137 K-3.1* Cl-98 HCO3-27 AnGap-15 [**2102-8-7**] 05:33AM BLOOD Glucose-86 UreaN-13 Creat-0.7 Na-141 K-3.9 Cl-107 HCO3-26 AnGap-12 [**2102-8-4**] 10:34PM BLOOD ALT-18 AST-30 AlkPhos-48 TotBili-0.3 [**2102-8-4**] 10:34PM BLOOD Lipase-39 [**2102-8-3**] 12:50PM BLOOD cTropnT-<0.01 [**2102-8-3**] 10:00PM BLOOD cTropnT-<0.01 [**2102-8-4**] 05:43AM BLOOD cTropnT-<0.01 [**2102-8-3**] 12:50PM BLOOD proBNP-2368* [**2102-8-6**] 09:30AM BLOOD Calcium-9.2 Phos-2.4* Mg-1.7 [**2102-8-4**] 10:46PM BLOOD Type-[**Last Name (un) **] pO2-112* pCO2-37 pH-7.43 calTCO2-25 Base XS-0 ECG Study Date of [**2102-8-3**] Sinus rhythm. Left ventricular hypertrophy. Right bundle-branch block. Compared to the previous tracing of [**2100-2-10**] right bundle-branch block has appeared. The ST-T wave changes in the anterolateral leads appear to exceed the repolarization abnormalities associated with right bundle-branch block and there is T wave inversion in leads II, III and aVF. These findings suggest acute anterolateral ischemic process. The rate has increased. Clinical correlation is suggested. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2102-8-3**] IMPRESSION: 1. Massive PE with evidence with evidence of right heart strain. 2. Significant eccentric plaque along the thoracic aorta. 3. 2-mm right upper lobe nodule is visualized. One-year followup CT is recommended if elevated risk factors (smoking, malignancy) are present. TTE (Complete) Done [**2102-8-4**] IMPRESSION: Moderate to severe pulmonary hypertension with dilated and hypokinetic right ventricle. Normal global and regional left ventricular systolic function. Mild aortic and mitral regurgitation. _ _ ________________________________________________________________ Anticoagulation Warfarin Dose [**2102-8-6**] 09:30AM INR(PT)-1.4* 5 mg [**2102-8-7**] 05:33AM INR(PT)-1.7* 5 mg [**2102-8-8**] 04:45AM INR(PT)-2.0* 5 mg [**2102-8-9**] 04:45AM INR(PT)-2.4* 3 mg [**2102-8-10**] 04:40AM INR(PT)-2.8* 3 mg (pending after discharge) _ _ _ ________________________________________________________________ Brief Hospital Course: Ms. [**Known lastname 7973**] is an 87 year old portugese speaking woman with a PMHx significant for HLD and HTN who presented on [**8-3**] to the ED with a chief complaint of dyspnea associated with pleuritic flank pain. # Pulmonary embolism--As mentioned in the HPI, pt denied any antecedent trauma, surgeries, cancer diagnoses, or immobilization. She denies recent weight loss or rectal/vaginal bleeding. She felt asymmetric leg swelling 3-4 weeks ago and prior to presentation, she experienced 3 weeks of gradually improving rhinorrhea, cough, and SOB. For this she had been treated with a 5 day course of Azithromycin per her PCP 3 weeks prior to presention. Upon presentation to the [**Name (NI) **], pt was found to have an SpO2 of 89%, but was hemodynamically stable with BP 120's-130's/50's-60's. On EKG she demonstrated symptoms of right heart strain with S1,T3 and a new RBBB. A CTA was performed which demonstrated a saddle pulmonary embolus. She was begun on a heparin gtt and transferred to the [**Hospital Unit Name 153**]. Throughout her stay in the ICU, her BP remained stable in the range of 140-170/70-90's. A TTE performed on the second day of admission demonstrated normal LV function, severe pulmonary hypertension with a dilated and hypokinetic right ventricle. Hemodynamically, however, Ms. [**Known lastname 7973**] remained stable without hypotension or tachycardia. Given her advanced age and lack of hemodynamic instability the decision was made not to administer tPA. Ms. [**Known lastname 7973**] was begun on warfarin in anticipation of long-term anticoagulation. Her INR was followed closely, and a therapeutic INR (goal [**3-9**]) was overlapped with the heparin gtt x 48 hours. She will follow up closely with her PCP, [**Name10 (NameIs) **] she has an [**Hospital3 **] appointment the day following discharge. Please see results section for recent INR's and warfarin dosing. Of note, Ms. [**Known lastname 7973**] has not had a colonoscopy since [**2091**] (which was normal), and has not had a mammogram since [**2094**] (which was normal). The cessation of these cancer screens was age appropriate, however the PCP may elect to repeat these tests in light of her PE. In addition, given that this PE was unprovoked, the patient should have a hypercoag work-up as an outpt given that this may impact her length of therapy as well as screening for her family. Per report, her daughter has a history of DVt. # HTN, benign-- her blood pressure medications were initially held due to acute pulmonary embolism, but these were resumed, and her blood pressure remained well controlled. - continued Valsartan 160 mg PO/NG DAILY - continued HCTZ 25 mg po q day - continued Nifedipine 30 mg po q day # Hyperlipidemia Continued atorvastatin. # Memory impairment/likely early dementia - continued Namenda (MEMAntine) 5 mg Medications on Admission: Atorvastatin 20 mg daily Fluticasone 50 mcg 2 sprays each nostril daily HCTZ 25 mg daily Lactulose [**3-9**] tsp daily prn constipation Memantine (Namenda) 5 mg [**Hospital1 **] Mirtazapine 15 mg qhs Nifedipine ER 30 mg daily Valsartan 160 mg daily Tylenol prn Colace 100 mg [**Hospital1 **] Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) sprays each nostril Nasal once a day as needed for allergy symptoms. 3. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 4. lactulose 10 gram/15 mL Solution Sig: [**3-9**] teaspoons PO once a day as needed for constipation. 5. memantine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 8. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 11. warfarin 3 mg Tablet Sig: One (1) Tablet PO daily at 4 pm: Please follow up with your PCP [**Name Initial (PRE) 7974**]. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pulmonary Embolism Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with shortness of breath and were found to have a large blood clot in your lungs. Since this was a large clot, you were admitted to the intensive care unit for monitoring. You needed a blood thinner in your IV called heparin, this was continued until the oral medication, coumadin was at the right level. It is VERY important that you keep your follow up appointments because this medication needs frequent monitoring and dose adjustments. Followup Instructions: Department: [**Hospital1 7975**] INTERNAL MEDICINE When: FRIDAY [**2102-8-11**] at 10:00 AM [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: [**Hospital1 7975**] INTERNAL MEDICINE When: THURSDAY [**2102-8-17**] at 11:00 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

[ "441.9", "401.1", "294.8", "789.09", "415.19", "564.09", "416.8", "272.4", "V13.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9907, 9913

5699, 8555

282, 288

10003, 10003

3257, 5676

10652, 11262

2137, 2311

8897, 9884

9934, 9982

8581, 8874

10154, 10629

2341, 3238

211, 244

316, 1721

10018, 10130

1743, 1844

1860, 2121

66,264

173,568

9141

Discharge summary

report

Admission Date: [**2102-12-25**] Discharge Date: [**2103-1-15**] Date of Birth: [**2061-5-10**] Sex: F Service: SURGERY Allergies: Ultram Attending:[**First Name3 (LF) 301**] Chief Complaint: diarrhea, lightheadedness Major Surgical or Invasive Procedure: 1. Total colectomy, abdominal with ileostomy. 2. Gastrostomy tube placement. History of Present Illness: 41F s/p lap gastric bypass in [**2092**] followed by a revision of the jejunojejunostomy 1 month later for a ? obstruction. She was lost to follow up since [**2093**] and her surgical weight loss and medications are unknown. Over the past year she was being seen by gastroenterology for persistent dry heaves, inability to tolerate POs and a 60lb weight loss. During her last admission she has a documented C.diff infection on [**2102-11-23**] and she was discharged on [**2102-11-30**] on a 14 day course of PO Vanc. She presented to the ED today with fatigue, lightheadedness and diarrhea. While in the ED she had a precipitous decline in her clinical status, she became septic, had to be intubated, and levophed had to be started to maintain an adequate blood pressure. Past Medical History: 1. Seizure disorder, has not had seizure in 4+ years. Described as grand mal seizure possibly in the setting of ultram. 2. Status post gastric bypass in [**2092**]. 3. DJD L5-S1, facet DJD and L4-L5 annular tear. 4. Systolic/diastolic congestive heart failure due to cardiomyopathy of unclear etiology, likely viral diagnosed in 9/[**2101**]. EBV IGM neg, CMV IGM equivocal, Lyme neg 5. Depression. 6. Chronic back pain with narcotic dependence 7. Nausea, weight loss, nutritional deficiencies of unclear etiology, possibly related to depression, malabsorption or related to her gastric bypass. 8. Normocytic anemia per notes attributed to iron deficiency in the past although no evidence in lab values here. Social History: She works as an administrative assistant. Denies any previous or current tobacco use, no current alcohol use. No illegal drugs or IV drug use. Family History: Father with cirrhosis of the liver. Physical Exam: Physical exam on admission: VS 97.9, 104, 100/46, 24 on vent Gen: intubated and sedated Chest: tachycardic, lungs clear Abd: soft, markedly distended Rectal: guaiac positive Ext: no edema Physical exam on discharge: VS Gen: weak but alert and oriented x3, NAD CV: RRR Chest: CTAB Abd: soft, appropriately tender near incision, erythematous and abd with flaky skin and excoriations Wound: 1.5x1.5 opened area of midline incision inferiorly, packed with iodoform gauze, also small 1.0x1.0 area of midline incision superior to umbilicus with is opened and pack with iodoform gauze rest of incision clean/dry/intact with steris; G tube in place and functioning Ext: erythematous inferiorly, 1+ edema bilaterally Pertinent Results: [**2102-12-25**] 03:05PM WBC-37.0*# RBC-3.82* HGB-10.4* HCT-33.4* MCV-88 MCH-27.4 MCHC-31.3 RDW-16.1* [**2102-12-25**] 03:05PM NEUTS-88* BANDS-3 LYMPHS-6* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2102-12-25**] 03:05PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL CT abd/pelvis [**2102-12-25**]: 1. Bibasilar opacities concerning for infection and/or aspiration. 2. Diffuse colonic wall thickening, consistent with pancolitis, unchanged from [**2102-10-31**]. 3. Cholelithiasis. 4. NG tube in gastric pouch with sideport at GE junction. 5. Ascites, similar to [**2102-10-31**]. 6. Fatty liver. 7. Status-post gastric bypass. CT abd/pelvis [**2103-1-9**]: 1. No evidence of loculated fluid collection or abscess formation within the abdomen or pelvis. 2. Persistent ascites with simple fluid tracking along bilateral paracolic gutters into the pelvis. 3. Unchanged diffuse hepatic steatosis without focal lesion. 4. Cholelithiasis without cholecystitis. 5. Unchanged pancreatic cystic lesions. 6. Unchanged anasarca. Brief Hospital Course: Mrs. [**Known lastname 18036**] had been admitted to [**Hospital1 18**] with C. difficile pancolitis from [**Date range (1) 31488**] and discharged home at that time on PO vancomycin. She represented to the ED on [**12-25**] with headache and weakness and decompensated, requiring intubation and pressors. She was initially admitted to the MICU but then, after consultation with ID, GI, Medicine, Surgery, and the MICU, it was decided to take her to the operating room for total abdominal colectomy with end ileostomy. She was kept intubated for 4 days and extubated on [**12-29**], and transferred to the floor a day later. She recovered on the floor slowly but surely and was finally discharged home on [**2103-1-15**] to complete another 7 days of flagyl. The rest of her stay is summarized below by system. Neuro: In addition to her chronic back pain, Mrs. [**Known lastname 18036**] had the addition of the new pain from the operation. She was started on methadone standing and dilaudid prn and her pain control is being given over to her PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. By the time of discharge, her pain was well controlled on this regimen. CV: Upon admission she required pressor support and significant resuscitation for her sepsis, which continued after she went to the OR. She was monitored in the ICU with a Swan-Ganz catheter and was given fluids, blood products, derivatives, and pressors as needed. She underwent echocardiography on [**12-28**] which showed a LVEF of 70% and otherwise normal function except for new moderate PA hypertension. Pressors were weaned appropriately and she was able to be transferred to the floor where she remained hemodynamically stable. Vital signs were monitored regularly. Pulm: She was intubated in the ED and remained so until [**12-29**] when she was finally weaned from the ventilator and extubated. After extubation, she was weaned off oxygen appropriately and left the hospital on room air. GI/GU: She was quite surprised on awakening that she had a new ostomy and this will require a long time for her to adjust. An ostomy/wound care nursing consult was obtained and the ostomy was changed regularly and monitored for signs of breakdown. By the end of her hospital stay, Mrs. [**Known lastname 18036**] was becoming slowly more comfortable managing her ostomy, but still required nursing help. Due to the antibiotic received throughout her stay, she began to develop a vaginal yeast infection which was treated with fluconazole. F/E/N: Electrolytes and fluids were monitore during her stay. She received appropriate repletion when necessary. Tube feeds were started on [**12-27**], but not continued for long. She was started on TPN on [**12-28**] and continued on that until [**1-2**]. Her diet was advanced appropriately to a bariatric stage V diet. She was not taking in enough orally however to meet her needs, thus tube feeds were started through her gastric remnant. The patient complained of being stuck to the IV pole while getting tube feeds and ultimately refused further feedings until it was suggested that she take the tube feeds as boluses. The patient learned how to do this herself and was ultimately much happier with this arrangement, giving herself four cans of replete with fiber daily. She was discharged home with qid tube feeds and a regular diet. Heme: The patient was coagulopathic upon presentation due to her sepsis and required in total 6 units of packed RBCs, 6 units of FFP, 2 cryoprecipitates, and 11 vials of albumin for repletion of cofactors, treatment of her coagulopathy, anemia, and sepsis. As she normalized following her operation, she no longer required further products. ID: The patient was put on PO vanc and IV flagyl on admission as well as variably cefepime, zosyn, and tigecycline. After discharge from the unit, the patient was maintained on vancomycin and flagyl and eventually the vancomycin was dc'd. Her flagyl was transitioned to po and she was discharged on a 7 day course of flagyl. Her wound started to show some breakdown inferiorly and [**4-5**] staples were removed on [**1-6**] and a wound culture sent. For this she was started on unasyn, which was continued for a short course. On the day before discharge, another few staples were removed above the umbilicus with some serous drainage. The patient refused removal of further staples at that time and it was decided that the wound could be monitored for a little longer. Psych: The patient has baseline depression and anxiety and this was exacerbated by the long and difficult hospital course as well as by the surprise finding, upon wakening, that she no longer had a colon and would have to pass stool through an ostomy for at least a number of months. These stressors were difficult for her and she had a tough time with acclimating herself to the idea. She initially refused to work with the ostomy nurse but later showed some willingness to start taking over some of the ostomy care herself. She was seen by psych consult in house who thought that the anxiety component was much more prevalent and recommended treatment with benzodiazepines. She was discharged with a short prescription for ativan and will follow up with her PCP for further management of her pain and anxiety. Medications on Admission: Cyanocobalamin 1,000 mcg/mL once a month. Calcium Carbonate 500 mg PO QAM Cholecalciferol 1000 units PO DAILY Venlafaxine 200 mg PO DAILY Topiramate 100 mg PO HS Omeprazole 40 mg PO once a day. Levetiracetam 500 mg PO BID Acetaminophen 500 mg PO TID Morphine 30 mg Tablet Sustained Release PO Q12H Morphine 15 mg PO Q6H prn Ondansetron 8 mg Tablet, Rapid Dissolve PO three times a day as needed for nausea. Vitamin D-3 1,000 unit Tablet PO once a day. Ferrous Sulfate 325 mg PO once a day. Compazine 5 mg PO three times a day as needed for nausea. Tizanidine 4 mg PO at bedtime for muscle spasm. Discharge Medications: 1. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): For lower extremity swelling. Please follow up with your primary care doctor for further diuretic (water pill) needs. . Disp:*60 Tablet(s)* Refills:*2* 4. 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* 5. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Multivitamin Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 10. Methadone 5 mg Tablet Sig: Three (3) Tablet PO Q 8H (Every 8 Hours). Disp:*250 Tablet(s)* Refills:*0* 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain. Disp:*54 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: C. difficile pancolitis and sepsis 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: 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 [**4-9**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call your doctor or come to the emergency room if you experience 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 or have ileostomy output. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. *Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Continue giving yourself the tube feeds as directed at least until your follow up with Dr. [**Last Name (STitle) **]. It will be helpful to your doctors [**First Name (Titles) **] [**Last Name (Titles) 31489**] for you to document your oral intake by keeping a log of what you eat and how many cans of tube feeds you give yourself so that the sufficiency of your oral intake can be assessed. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. You can call his office at ([**Telephone/Fax (1) 9000**] to set up an appointment. Please follow up with your primary care provider as soon as you can. You should discuss not only your recent hospitalization but also any need for diuretics (water-pills) for your lower extremity swelling as well as for your future pain and anxiety medication needs.

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icd9cm

[ [ [] ] ]

[ "45.82", "96.04", "46.20", "96.6", "43.19", "86.04", "38.93", "96.72", "99.15" ]

icd9pcs

[ [ [] ] ]

11344, 11394

3968, 9260

292, 371

11473, 11473

2869, 3945

14168, 14586

2088, 2125

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227, 254

399, 1178

2168, 2329

11487, 11626

1200, 1911

1927, 2072

25,206

113,829

44871

Discharge summary

report

Admission Date: [**2186-8-30**] Discharge Date: [**2186-9-8**] Date of Birth: [**2138-1-7**] Sex: M Service: HISTORY OF PRESENT ILLNESS: A 48-year-old male with a history of Crohn's disease admitted on [**8-30**] with a headache a right hand numbness and weakness. A CT of the head in the Emergency Room showed a left-sided enhancing mass worrisome for a brain abscess. The patient was in his usual state of health until one month prior when he was diagnosed with epididymitis after noticing right urethral discharge. He was treated with ciprofloxacin 500 mg p.o. b.i.d. times one month. Four days prior to admission the patient noted right-sided weakness, fevers to 102, with severe [**9-27**] frontal headache. No evidence of seizures and denies any falls or urinary incontinence. He was noted to have photophobia and neck stiffness prior to admission. In the Emergency Department he had a lumbar puncture and a head CT performed, and the head CT noted a left-sided enhancing mass worrisome for a brain abscess. He was given morphine, ceftriaxone, Flagyl, vancomycin, and Decadron and admitted to Neurosurgery and then the Neurosurgery Intensive Care Unit. While in the Neurosurgery Intensive Care Unit he was continued on ceftriaxone, Flagyl, vancomycin, and Decadron, as well as Dilantin. On [**8-31**] he was noted to have a stereotactic CT-guided biopsy of the brain lesion with multiple cultures sent. Cerebrospinal fluid cultures were negative to date, and the biopsy results were Gram stain negative. He was neurologically stable and was transferred to the floor. At the time of evaluation the patient described a [**3-28**] headache that was described as "best in several days," and felt his sinus rhythm numbness and weakness was "improving." He denied any fever, chills, and night sweats. No photophobia. No shortness of breath or chest pain. No abdominal pain. No nausea, vomiting, or diarrhea. He denied any change in his bowel movements or dysuria or hematuria. PAST MEDICAL HISTORY: (His past medical history is notable for) 1. Crohn's disease, status post colectomy 15 years ago; notable for a history for a history of psoriasis, arthritis, and fistula related to his Crohn's disease. 2. C7-C6 and C6-C7 laminectomy with screws done in [**2186-8-19**] secondary to herniation of the disk. MEDICATIONS ON DISCHARGE: Medications prior to admission included Vioxx 25 mg p.o. q.d., ciprofloxacin 500 mg p.o. b.i.d. times one month. MEDICATIONS ON TRANSFER: On transfer, he was receiving vancomycin 1 g intravenously q.12h., Flagyl 500 mg intravenously q.8h., ceftriaxone 2 g intravenously q.12h., Decadron 4 mg intravenously q.6h. (tapered by 1 g every two to three days), Zantac 150 mg p.o. b.i.d., Dilantin 100 mg p.o. q.8h., morphine 2 g intravenously q.4h. p.r.n., Tylenol p.r.n., regular insulin sliding-scale, Percocet, as well as morphine sulfate p.r.n. ALLERGIES: No known drug allergies. FAMILY HISTORY: No family history of cancer. Mother passed away at age 67 from chronic obstructive pulmonary disease and diabetes. Father died at age 69 secondary to a myocardial infarction, and he has three siblings that are healthy. SOCIAL HISTORY: Tobacco history revealed he smoked three to four cigarettes per day and smoked heavily for two years in the distant past. Alcohol wise, he denies any alcohol or intravenous drug use. He lives in Rivi??????re, [**State 350**]. He has one son who is age 18. Married, is a glass maker, and has no other sexual partners. PHYSICAL EXAMINATION ON PRESENTATION: Generally, he alert and oriented times three, in no apparent distress. He was resting comfortably. His speech was noted to be slightly slurred. Vital signs revealed a temperature of 96.7, pulse of 71, blood pressure of 104/70, respiratory rate 20, oxygen saturation 97% on room air. Head, ears, nose, eyes and throat revealed normocephalic and atraumatic. Pupils were equal, round, and reactive to light. Extraocular movements were intact. Mucous membranes were dry. The oropharynx was clear without any lesion. Neck was supple. No lymphadenopathy. No masses. No jugular venous distention and 2+ carotids, without any bruits. Chest was notable for bibasilar rales, right greater than left, with right-sided rales noted to be approximately one-third of the way up. Cardiovascular revealed a regular rate and rhythm, without any murmurs, gallops or rubs. The abdomen was soft, nontender, and nondistended, with normal active bowel sounds. No hepatosplenomegaly. Colostomy was noted in the right lower quadrant with no erythema. Extremities revealed no cyanosis, clubbing or edema with 2+ pulses bilaterally and symmetric. Skin was warm and dry without any rashes. Neurologically, his cranial nerves II through XII were intact. A mild right facial asymmetry was noted on smile. There was normal sensation across his face. His motor examination revealed 5/5 strength on the left, and 4/5 strength in the right upper extremity and right lower extremity, and sensation was diminished in the right upper extremity. Mini-Mental examination was 28/30, on which he lost a point space on serial sevens. Deep tendon reflexes were diminished on the right side compared to the left, and toes were downgoing bilaterally. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories upon transfer revealed white blood cell count of 13.5, hematocrit 36.4, platelets 230. Coagulations were within normal limits. Coagulation studies were within normal limits. Sodium 136, potassium 3.8, chloride 102, bicarbonate 22, blood urea nitrogen 16, creatinine 0.7, glucose of 110. Magnesium of 1.5, calcium 8.1, phosphate 1.3. AST 8, ALT 10, alkaline phosphatase 74, total bilirubin of 0.4, albumin 3. Differential showed 84% neutrophils, 0 bands, and 11.4% lymphocytes. A cerebrospinal fluid from a lumbar puncture performed on [**8-30**] showed a white blood cell count of 2325, 60 red blood cells, 80% neutrophils in tube 4; and tube 1 was notable for 2125 white blood cells, 90 red blood cells, with 81% neutrophils, total protein was 172, glucose was 37. The biopsy of the brain mass was Gram stain negative with no polymorphonuclear leukocytes. Culture was negative to date with negative acid-fast bacillus, fungal cultures, as well as nocardia were pending at the time of transfer to the floor. In addition, blood cultures from [**8-30**] were negative to date, and cerebrospinal fluid cultures showed 1+ polymorphonuclear leukocytes with no microorganism, and fungal cultures were pending. His urine culture was negative, and a [**8-30**] GC and chlamydia culture were also negative. RADIOLOGY/IMAGING: CT of the abdomen showed multifocal pneumonia, a normal prostate, questionable small fluid collection at the inferior tip of the liver. No evidence of an small-bowel obstruction. An magnetic resonance imaging of the head performed on admission showed a 1.8-cm X 1.4-cm moderately enhancing irregular mass lesion in the left posterior frontal white matter; question abscess versus neoplasm, which was described as lymphoma versus fungal versus toxoplasmosis. Electrocardiogram showed normal sinus rhythm at 85 beats per minute, with normal intervals, normal axis. No ST-T wave changes, mild atrial enlargement. An echocardiogram showed normal left atrium, normal right atrium, normal left ventricle with an ejection fraction of greater than 55%, normal right ventricle, normal aortic valve, 1+ mitral regurgitation, trivial tricuspid regurgitation, trivial pulmonary regurgitation, and no effusion or vegetation noted. HOSPITAL COURSE: Mr. [**Known lastname 95985**] was admitted to the [**Hospital1 1444**] on [**2186-8-30**] with a right-sided weakness and numbness and found on CT and magnetic resonance imaging to have a left posterior frontal lesion, thought to be a brain abscess. He was transferred to the floor on [**2186-9-2**], and his hospital course will be dictated from that time. The patient was continued on his antibiotic regimen including vancomycin, ceftriaxone, and Flagyl. His biopsy results were followed and waiting for their culture and speciation. The etiology of his abscess was uncertain; however, felt secondary possibly to his Crohn's disease as well as his recent epididymitis. His biopsy results were pending, but the Gram stain was negative that was worrisome in this biopsy. A repeat magnetic resonance imaging was performed to assess abscess size, status post the stereotactic drainage. Subsequently, two days later, the magnetic resonance imaging showed a significant amount of vasogenic edema surrounding the lesion. There was no hemorrhage or hydrocephaly noted but a small susceptibility defect which may not be within the center of the ring enhancing lesion. No other new findings were noted compared to the magnetic resonance imaging dated [**8-30**]. Over the course of this time, the patient was continued on ceftriaxone, vancomycin, and metronidazole. He continued to receive morphine and Percocet p.r.n. for the pain with subsequent trending downward of his headaches by hospital day [**2-25**]. He reported mild improvement of his right arm numbness and reported improvement of his neurologic function on the right side of his body. His physical examination improved so that his right facial droop as well as motor examination improved on the right side of his body. On [**2186-9-4**], a repeat lumbar puncture was attempted. Access was attempted using a 20-gauge lumbar puncture needle; however, access was attempted in several locations; however, the spinous processes were not located. Since this lumbar puncture was an elective procedure continued attempts were deferred, and further attempts were discussed with the Infectious Disease and Neurology team. To further work up the etiology of the patient's brain abscess a scrotal ultrasound was performed that showed no neoplasm, hydrocele of approximately 3.5 cm, as well as a transesophageal echocardiogram to look for possible vegetation with endocarditis being a source of septic emboli. On [**2186-9-7**], the tissue cultures returned with mild growth of Streptococcus milleri. Based on these results, the patient's vancomycin was discontinued. He was continued on intravenous ceftriaxone as well as oral metronidazole. After several discussions regarding his further course of care and plans; since the patient's headache was resolving, and a repeat lumbar puncture showed documented resolving white blood cell count in cerebrospinal fluid, Mr. [**Known lastname 95985**] was deemed stable for discharge with several followups. At the time of hospital discharge, the patient had markedly improved headache without having received Percocet or morphine. He will continue Tylenol for the headaches p.r.n. His right-sided weakness had markedly improved at the time of discharge as well. DISCHARGE STATUS: The patient was discharged home with [**Hospital6 407**]. DISCHARGE INSTRUCTIONS: He will continue the Dilantin and Decadron taper. In addition, he will continue ceftriaxone intravenously and Flagyl for up to a 6-week course. DISCHARGE FOLLOWUP: He was to follow up with his primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], one week after discharge. In addition he will have an ENT followup on [**9-21**] for his continued hoarseness for a vocal cord evaluation. In addition, he was to have an echocardiogram on [**9-11**] at 11 a.m. to evaluate for endocarditis and to rule out septic emboli as a source of his brain abscess. In addition, he was to follow up in the Infectious Disease Clinic in early [**Month (only) 359**] to adjust antibiotic course at that time. MEDICATIONS ON DISCHARGE: 1. Dilantin 100 mg p.o. q.8h. 2. Decadron 1 mg p.o. q.6h. times two days. 3. Flagyl 500 mg p.o. t.i.d. times six weeks. 4. Ceftriaxone 2 g intravenously q.12h. times six weeks. 5. Percocet 2 tablets p.o. q.6h. p.r.n. DISCHARGE DIAGNOSES: 1. Streptococcus milleri brain abscess. 2. Continued headaches. 3. Hoarseness. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 16316**] Dictated By:[**Last Name (NamePattern1) 14434**] MEDQUIST36 D: [**2187-1-15**] 17:35 T: [**2187-1-16**] 18:25 JOB#: [**Job Number **]

[ "V44.3", "555.9", "305.1", "276.5", "486", "702.19", "324.0", "041.09" ]

icd9cm

[ [ [] ] ]

[ "38.93", "01.13", "88.72", "42.23", "03.31" ]

icd9pcs

[ [ [] ] ]

2972, 3194

12039, 12423

11795, 12018

7627, 10978

11003, 11149

11171, 11769

154, 2011

2511, 2954

2034, 2344

3211, 7609

29,903

174,890

28758

Discharge summary

report

Admission Date: [**2163-10-8**] Discharge Date: [**2163-10-9**] Date of Birth: [**2101-5-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 3556**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: Intubation attempted Central line placed History of Present Illness: Patient is a 62 yo M w/PMHx of NSCL and SCC recently admitted at the VA and treated for pneunomia in [**8-/2163**], who presents with hemoptysis of one day's duration. Patient relates that he awoke at 2:30 am and noted a small amount of blood when he coughed. At approximately 6:30 am, the amount of blood had increased, and he sought medical attention at the [**Hospital3 **] ED. He relates that he coughed up about 100cc of bright red blood at that time. He was transferred to [**Hospital1 18**] for further evaluation and management. . In the [**Hospital1 18**] ED, his vitals were T 97.6, HR 120, BP 102/64, and oxygen saturation of 100% on 4L NC. He received 1 L NS, as well as levaquin 750 mg. . In the setting of a recent admission to the [**Hospital **] hospital for a pneumonia, and apparently in light of abnormal findings there, patient underwent a bronchoscopy on [**2163-9-22**] at [**Hospital1 18**] through interventional pulmonology which showed normal upper airways. The right main stem and right upper lobe were normal and the right lower lobe ended in a large cavity filled with purulent secretions. Biopsies were taken and eventually showed extremely scant fragments of atypical squamous epithelium and bronchial tissue with necrotic debris and necrotic bronchial cartilage. The left lower lobe demonstrated a long main stem stump with surgical clips. Biopsies were also taken and showed scant bronchial tissue and necrotic debris; no viable malignancy was identified. . A CT done on [**9-29**] showed a cavitary lesion continuous with an ulcerated bronchus intermedius. . ROS: Denies fever, chills, chest pain, N/V, palpitations, HA, lightheadedness, dizziness. Notes he did feel SOB, has noted some weight loss and increasing fatigue. . Past Medical History: 1. NSCLC s/p pneumonectomy ([**2151**]) and photodynamic therapy activation and rigid bronchoscopy clean ([**7-11**]) out. 2. SCC diagnosed in [**2161**] at [**Location **], s/p chemotherapy. 3. Chronic obstructive pulmonary disease, on 2L home O2 4. Hyperlipidemia. Social History: Lives w/ wife. Retired post-office worker. Significant smoking history of >80 pack years, quit [**2150**]. Has prior history of asbestos exposure while working in shipyard for the Navy. Family History: Father with emphysema and lung cancer. Mother with cancer metastatic to bone. One sister with lung cancer, another sister with lung and breast cancer. Children healthy. Physical Exam: Vitals - T 97.2 HR 126, BP 105/65, SaO2 95% on 5L General - Chronically ill, thin male laying in bed, in NAD although occasionally coughing up blood-tingled sputum. Speaking in full sentences without any distress. HEENT - NC/AT. MMM, no JVD. Cardiovascular - Tachycardic, RR, no M/G/R appreciated, hyperdynamic precordium. Pulmonary - Absent lung sounds over left lung field, no egophony or tactile fremitus noted over right field. Decreased BS at right base. Abdomen - soft, NT, ND, +BS Extremities - warm, well perfused, no clubbing/cyanosis/edema. Neurology - alert, oriented, no focal deficits. Psych - pleasant, appropriate Pertinent Results: PFTs ([**2163-9-29**]): Marked obstructive ventilatory defect. The reduced FVC is likely due to gas trapping but a coexisting restrictive defect cannot be excluded. Suggest lung volume measurements if clinically indicated. The reduced DLCO suggests a perfusion limitation. There are no prior studies available for comparison. FVC 41% predicted FEV1 27% predicted FEV1/FVC 67% predicted DSB 23% predicted . CT CHEST ([**2163-9-29**]): 1. Cavitary lesion continuous with an ulcerated bronchus intermedius has non-aggressive appearing thickened wall with smooth margins, but a small focus of soft tissue surrounding the right middle lobe bronchus could be tumor. CT FDG PET-CT might be able to localize tumor, but discrimination from the inflammation of the large pocket may be problem[**Name (NI) 115**]. 2. Focal fibrosis and traction bronchiectasis in the posterior segment of the right upper lobe may be sequelae to radiation therapy. 3. Status post left pneumonectomy with unremarkable left main bronchus stump. 4. Severe apical predominant emphysema. . CXR ([**2163-10-8**]): The patient is status post left pneumonectomy, with stable opacification of the left hemithorax and shift of the mediastinum. The left lung is relatively well aerated. There is persistent left perihilar opacity, which may correspond to a cavitated lesion, seen on the recent CT. There is no pleural effusion and no pneumothorax. There is increase in interstitial markings above the minor fissure, which may represent early or atypical pneumonia or asymmetric edema. Interstitial septal thickening due to lymphangitic tumor spread is also in the differential diagnosis. . EKG: Sinus tachycardia @ rate of 128, some TWI in V5, V6, new as compared to [**2162-2-3**] EKG. Early R wave progression (V1-V2) unchanged. . [**2163-10-8**] 11:15PM GLUCOSE-82 UREA N-8 CREAT-0.5 SODIUM-138 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-33* ANION GAP-14 [**2163-10-8**] 11:15PM CALCIUM-8.7 PHOSPHATE-3.4 MAGNESIUM-1.8 [**2163-10-8**] 11:15PM WBC-11.7* RBC-3.54* HGB-10.9* HCT-32.5* MCV-92 MCH-30.8 MCHC-33.6 RDW-15.5 [**2163-10-8**] 11:15PM PLT COUNT-337 [**2163-10-8**] 01:33PM GLUCOSE-92 UREA N-6 CREAT-0.5 SODIUM-137 POTASSIUM-3.9 CHLORIDE-93* TOTAL CO2-35* ANION GAP-13 [**2163-10-8**] 01:33PM estGFR-Using this [**2163-10-8**] 01:33PM WBC-10.4 RBC-3.83* HGB-11.7* HCT-35.6* MCV-93 MCH-30.4 MCHC-32.7 RDW-15.2 [**2163-10-8**] 01:33PM NEUTS-88.2* BANDS-0 LYMPHS-8.0* MONOS-3.4 EOS-0.2 BASOS-0.2 [**2163-10-8**] 01:33PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2163-10-8**] 01:33PM PLT SMR-NORMAL PLT COUNT-337# [**2163-10-8**] 01:33PM PT-11.9 PTT-29.1 INR(PT)-1.0 Brief Hospital Course: Patient was a 62 year-old man with a history of NSCLC s/p pneumonectomy who presented with hemoptysis. . # Hemoptysis: Patient presented at outside hospital coughing up bright red blood. In setting of his NSCLC and SCC, it was concerning for several pathologies, including malignancy, malignant erosion into a bronchial blood vessel, infection, AVM/fistula, irritation, or trauma. . On night of admission, interventional pulmonology, thoracic surgery, and interventional radiology all were involved in evaluation of the patient. Thoracic surgery determined that there was no appropriate surgical intervention. Embolization was considered, but not immediately pursued due because the patient only had one functional lung and obviously would have little reserve capacity if embolization were to be completed. At the time of initial evaluation, the patient was stable and demonstrated no further evidence of bleeding. His hematocrit was monitored overnight and stable. He was started on broad antibiotic therapy (Vancomycin, Levofloxacin, and Zosyn) to cover for any possible infectious component to his symptoms. He was also given Codeine to suppress his cough. . On the morning after admission, the intensive care team evaluated the patient on morning rounds, who reported he was doing well. As the team was leaving, patient began to cough up copious amounts of bright red blood. The patient quickly progressed to PEA arrest. The full medical intensive care team, along with the assistance of the full surgical intensive care team, coded the patient for approximately 30 minutes. During this time he underwent intubation, central line placement, and fiberoptic bronchoscopy. With every chest compression, he had a large amount of blood coming up from the right mainstem. Due to the absence of left lung and location of the tumor erosion/cavity, it was not possible to obtain control of the bleeding. At the end of the code, he had 2 - 3 liters of blood outside the body as a result of hemoptysis. The most likely explanation was that the tumor eroded into the main pulmonary artery. He at no time regained a spontaneous pulse during the code. Interventional pulmonology and interventional radiology were also involved. He had been confirmed as a full code status the night before. After the patient failed to respond to any interventions, he was pronounced dead. His family was notified and at the bedside shortly after he expired. Medications on Admission: Spiriva 18 mcg cap inhaled daily - Advair 250/50, puff daily - Preventil 90 mcg 1 puff 2x daily - Albuterol 0.5% neb 3-4x daily - Flunisolide Nasal Soln 25 mcg spray, 2 puffs each nasal 2x day. - Simvastatin 40 mg daily - Codeine/Guafanesin PRN cough - Prednisone 20 mg (tapering down from prior PNA/COPD exacerbation) Discharge Medications: None, expired. Discharge Disposition: Expired Discharge Diagnosis: Expired. Discharge Condition: Expired. Discharge Instructions: Expired. Followup Instructions: Expired. [**Known firstname **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "V46.2", "272.4", "V16.1", "427.1", "197.0", "518.81", "V10.11", "786.3", "427.5" ]

icd9cm

[ [ [] ] ]

[ "33.23", "99.60", "38.93", "96.04", "96.71", "96.07", "99.04" ]

icd9pcs

[ [ [] ] ]

9076, 9085

6231, 8667

325, 367

9137, 9147

3498, 6208

9204, 9331

2664, 2834

9037, 9053

9106, 9116

8694, 9014

9171, 9181

2849, 3479

275, 287

395, 2155

2177, 2445

2461, 2648

347

119,310

8837

Discharge summary

report

Admission Date: [**2118-5-23**] Discharge Date: [**2118-6-1**] Date of Birth: [**2058-6-7**] Sex: M Service: #58 HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 59 year-old gentelman with a history of insulin dependent diabetes, hypertension, hypercholesterolemia who is status post coronary artery bypass graft times four in [**2114-12-1**]. In [**2117-8-1**] he had an echocardiogram that showed moderate aortic stenosis and a left ventricular ejection fraction at 55%. In [**2117-10-31**] he underwent a PCI and had stent to his obtuse marginal one. In [**2118-3-1**] he had a positive ETT, which showed an ejection fraction of 40% with global hypokinesis. Cardiac catheterization in [**2118-3-31**] showed his aortic valve with a gradient of 55 mmHg and aortic valve area of 0.8 cm squared. Moderate pulmonary hypertension and 100% stenosis of his obtuse marginal graft. He was referred to Dr. [**Last Name (Prefixes) **] for replacement of his aortic valve. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft times four. 2. Hypertension. 3. Hypercholesterolemia. 4. Insulin dependent diabetes mellitus. 5. Osteoarthritis. 6. Status post retinal surgery. 7. Status post TNA. 8. Status post percutaneous transluminal coronary angioplasty times two. 9. Morbidly obese. PREOPERATIVE MEDICATIONS: 1. Aspirin 325 mg po q.d. 2. Plavix 75 mg po q.d. 3. Glucophage 1000 mg po b.i.d. 4. Glyburide 10 mg po b.i.d. 5. K-Dur 10 mg po q day. 6. Lasix 20 mg po q.d. 7. Lipitor 80 mg po q.d. 8. Univasc 15 mg po q.d. 9. Zetia 10 mg po q day. 10. Prilosec 20 mg po q.d. 11. Paxil 10 mg po q.d. 12. Lopresor 50 mg po b.i.d. 13. Humalog 75/25 25 units q.a.m. 39 units q.p.m. 14. Humulin insulin 15 units q.a.m., Humulin sliding scale q.p.m. ALLERGIES: Penicillin, which gives him hives. SOCIAL HISTORY: The patient has a remote history of a 45 pack year smoking history. Quit many years ago. The patient is an accountant. The patient was originally scheduled for surgery on [**5-9**], but when the patient was seen in the preoperative holding area the patient was found to have a significant upper respiratory infection. The patient was given a one week course of antibiotics and surgery was rescheduled for [**5-23**]. HO[**Last Name (STitle) **] COURSE: The patient was admitted on [**2118-5-23**] and taken to the Operating Room with Dr. [**Last Name (Prefixes) **] for a redo sternotomy and an aortic valve replacement with a 25 mm pericardial valve. The patient was transferred to the Intensive Care Unit in stable condition on an epinephrine Amiodarone drip. The patient was weaned and extubated from mechanical ventilation on postoperative day number one. The patient had adequate cardiac index on epinephrine. Epinephrine was weaned to off. The patient was started on Lopressor for control of hypertension and tachycardia. The patient became agitated on the evening of postoperative day number one and started on low dose Haldol. Postoperative day number two the patient began working with physical therapy. The patient was started on Lasix postoperative day number two with adequate diuresis. The patient required a nitroglycerin drip to control his blood pressure. Postoperatively, the patient had a continued leukocytosis of unknown origin. The patient was afebrile. On postoperative day number four the patient was able to walk 300 feet with physical therapy. Postoperative day number four the patient was noted to have a moderate amount of serosanguinous drainage fro the distal portion of his sternal incision. The patient continued to have drainage. It was decided that the wound would be covered with Dermabond. The wound was cleaned and prepped in a sterile fashion. Dermabond was applied to the distal portion of the sternal incision. However, the incision continued to drain serosanguinous fluid and required repeat Dermabond applications over the next several days. The patient continued to work with physical therapy and was able to achieve a level five. The patient's pacing wires were removed without difficulty. The patient remained hemodynamically stable. The patient had been on antibiotics for prophylaxis of a sternal wound Vancomycin and Levofloxacin. On postoperative day number seven the Vancomycin was stopped. On postoperative day number seven the patient required placement of a PICC line as the patient had no further intravenous access. The patient tolerated this procedure well. The patient continued to have drainage from the sternal incision and had difficulty understanding and following the repeat instructions for maintaining strict sternal precautions and not using his arms. However, on postoperative day nine the patient had no drainage from his sternum and was deemed stable for discharge to home. CONDITION ON DISCHARGE: Temperature max 99.3, pulse 85 in sinus rhythm. Blood pressure 150/80. Respiratory rate 16. Room air oxygen saturation 92%. Weight on [**2118-6-1**] is 156.2 kilograms. Preoperatively the patient weighed 153.7 kilograms. White blood cell count 13.1, hematocrit 26.5, platelet count 481, potassium 4.3, BUN 16, creatinine 0.8. The patient is awake, alert and oriented times three, pleasant gentleman. Heart is regular rate and rhythm. No murmurs, rubs or gallops. Respiratory breath sounds with scattered wheezes bilaterally. Gastrointestinal, abdomen is obese, positive bowel sounds, soft, nontender, tolerating a regular diet. Sternal incision upper part Steri-Strips are intact. The lower part of Dermabond is intact. There is no erythema. There is no drainage. The sternum is stable. DISCHARGE MEDICATIONS: 1. Lasix 40 mg po b.i.d. times ten days. 2. Potassium chloride 20 milliequivalents po b.i.d. times ten days. 3. Lipitor 80 mg po q day. 4. Plavix 75 mg po q.d. 5. Protonix 40 mg po q.d. 6. Enteric coated aspirin 325 mg po q.d. 7. Colace 100 mg po b.i.d. 8. Glucophage 1000 mg po b.i.d. 9. Glyburide 10 mg po b.i.d. 10. Paxil 5 mg po q day. 11. Moexipril 7.5 mg po q.d. 12. Levofloxacin 500 mg po q day. 13. Lopressor 100 mg po b.i.d. 14. Percocet 5/325 one to two tabs po q 4 hours prn. 15. Insulin per patient's home regimen, which is 75/25 25 units q.a.m. and 39 units q.p.m. and a humulin insulin sliding scale. Th[**Last Name (STitle) 1050**] is to return to Far Two for a wound check. The patient is to follow up with his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in two weeks. The patient is to follow up with Dr. [**Last Name (Prefixes) **] in one month. DISCHARGE DIAGNOSES: 1. Status post redo sternotomy with aortic valve replacement with a 25 mm pericardial valve. 2. Insulin dependent diabetes. 3. Hypertension. 4. Postoperative sternal drainage now resolved. The patient is discharged to home in stable condition. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2118-6-1**] 01:08 T: [**2118-6-1**] 13:19 JOB#: [**Job Number 12317**]

[ "278.01", "272.0", "715.90", "424.0", "V45.81", "250.01", "416.0", "401.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "35.21", "38.93", "39.62", "39.61", "86.59" ]

icd9pcs

[ [ [] ] ]

6662, 7176

5720, 6641

1388, 1881

1027, 1362

1898, 4870

4895, 5697

23,949

171,752

48764

Discharge summary

report

Admission Date: [**2140-12-23**] Discharge Date: [**2140-12-30**] Date of Birth: [**2077-5-3**] Sex: F Service: Orthopedic HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 102494**] is a 63-year-old man who was involved in a motor vehicle accident, who reportedly had loss of consciousness during the accident and he became combative at the scene. He was a cab driver. There was and other known injury at the time and he was brought to the emergency room from the scene. In the emergency room attempted central line insertion was made with complication of injured jugular vein, for which he went to the operating room for repair. Orthopedically he was found to have a superior posterior acetabular fracture on his right side. Upon transferring out from the trauma service for his jugular vein repair, he was brought to the operating room for repair for his acetabulum. PAST MEDICAL HISTORY: Significant for cardiac disease status post left anterior descending coronary artery stent and stenosis of the posterolateral branch. He also had type 2 diabetes mellitus, hypertension, hypercholesterolemia, history of intravenous drug use and a history of tuberculosis skin test positive. SOCIAL HISTORY: He is married. He is a cab driver. He has a history of cocaine use. ALLERGIES: Codeine causes nausea and vomiting. MEDICATIONS: His current medications include Metformin, glyburide, Colace, furosemide, Tylenol #3, Lasix, lisinopril and Lopressor. HOSPITAL COURSE: As indicated above the patient underwent uncomplicated procedure for anterior repair of the internal jugular vein. Subsequently the patient was brought to the operating room for repair of the acetabular fracture. This was done on [**12-29**]. He tolerated the procedure with 400 cc of estimated blood loss and 3,500 cc of lactated Ringer solution. There were no complications after the operation. Postoperatively his hematocrit was stable at 29 and his electrolytes were also within the normal range. Upon transfer to the floor he was found to be in sustained premature ventricular contractions. The medical service and his medical attending were notified. Work-up included cardiac enzymes, electrolytes and EKG and these were all within normal range and his echocardiogram showed no acute ischemic change. The patient was evaluated by the medical service and his primary care physician. [**Name10 (NameIs) **] arrhythmias were known as old and there were no acute complications. Clinically the patient remained stable with no complaints. From an orthopedic standpoint the repair was without complications. The incision remained clear, dry, and intact. His lower extremity neuromuscular examination remained stable without complications. The patient was tolerating pain control medicine and he was eating hospital food and making good amounts of urine. He did not require additional diuretics at the time of discharge. The patient will be discharged to a rehabilitation facility. DISCHARGE MEDICATIONS: 1. Lovenox 30 mg q. 12 hours for six weeks. 2. Percocet [**12-8**] every four to six hours as needed. 3. Lopressor 5 mg t.i.d. 4. Metformin 1 gram t.i.d. 5. Glyburide 10 mg b.i.d. 6. Keflex 500 mg q.i.d. for 14 days. 7. Lasix 80 mg q. day. 8. Lisinopril 20 mg q. day. 9. Atorvastatin 10 mg q. day. FOLLOW UP: The patient should have his staples removed in 14 days and dry sterile dressing change every day. He is going to be followed up in three weeks in the orthopedic clinic by Dr. [**First Name (STitle) 1022**]. DISCHARGE DIAGNOSIS: Acetabulum fracture status post motor vehicle accident. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation facility. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) **] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2140-12-30**] 11:53 T: [**2140-12-30**] 11:56 JOB#: [**Job Number 102495**]

[ "780.09", "427.89", "916.0", "998.2", "808.0", "250.00", "425.4", "E812.0", "496" ]

icd9cm

[ [ [] ] ]

[ "79.39", "96.71", "39.32", "38.93", "33.23", "96.04" ]

icd9pcs

[ [ [] ] ]

3014, 3313

3555, 3612

1497, 2991

3325, 3534

169, 893

916, 1208

1225, 1479

3637, 3937

72,233

117,765

6190

Discharge summary

report

Admission Date: [**2115-2-14**] Discharge Date: [**2115-2-17**] Date of Birth: [**2056-9-4**] Sex: F Service: NEUROSURGERY Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 1835**] Chief Complaint: The patient is a 58 year old female who was diagnosed with metastatic breast CA in [**2106**]. The patient has done well throughout the years on a number of treatment regimens including Herceptin and Xyloda. The patient had noticed in [**Month (only) 404**] some retro-orbital pain as well as some tingling sensation in the left leg which lead to some further work up and an incidentally found left sided cerebellar lesion was discovered. The patient presented to brain tumor clinic and the consensus was formed that she should undergo open resection. The patient was extensively counseled. Major Surgical or Invasive Procedure: Suboccipital craniotomy. History of Present Illness: The patient had noticed in [**Month (only) 404**] some retro-orbital pain as well as some tingling sensation in the left leg which lead to some further work up and an incidentally found left sided cerebellar lesion was discovered. Past Medical History: The patient was diagnosed with breast cancer back in '[**06**]. She had a bone marrow transplant for and then she has been treated with chemotherapy since [**2109-1-30**] for liver metastases. Patient had a recent torso CAT scan in [**2114-4-1**] which was normal and no liver mass was was seen; however, her oncologist has been following her CA, which has been increasing from 4.8 in [**2113-12-2**] to 7.6 now. The patient has a history of depression, hypercholesterolemia, hypertension, gastroesophageal reflux, history of an deep venous thrombus. Social History: Pt married with 2 daughters. Nonsmoker, social Family History: Significant family history for breast cancer. Physical Exam: PE: taken from chart - First exam is post-operative exam VS 105/55, 75,16,97T, 99%sat GEN: WDWN white female Neuro: awake alert oriented x 3 interactive, alert and appropriate. Face is symmetric, EOMI with few beats nystagmus in left gaze. VFF. Tongue ML. MAE equally bilaterally, no pronator drift, no ataxia or dysmetria in upper exremeties. Lungs; CTA cor: nl S1S2 Today [**2115-2-17**] the patient exam is as follows VSS AF Neuro: she is awake alert and oriented with a non focal neurological exam. She has a negative rhomberg test. Her gait is steady and she is ambulating freely throughout the unit. Pertinent Results: [**2115-2-14**] 07:48PM PLT COUNT-114* [**2115-2-14**] 07:48PM WBC-10.1# RBC-3.71* HGB-12.7 HCT-35.9* MCV-97 MCH-34.2* MCHC-35.3* RDW-20.0* [**2115-2-14**] 07:48PM OSMOLAL-313* [**2115-2-14**] 07:48PM CALCIUM-7.3* PHOSPHATE-4.8* MAGNESIUM-2.0 [**2115-2-14**] 07:48PM GLUCOSE-196* UREA N-17 CREAT-0.9 SODIUM-139 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-21* ANION GAP-15 Brief Hospital Course: Pt was admitted through SDA for the proposed procedure. Pt underwent anesthesia and awoke from procedure without complications. After meeting PACU criteria, pt was transferred to a regular floor. Her post operative CT scan was evaluated and found to be stable with postoperative chnages. She also underwent a postoperative MRI for evaluation of the tumor bed. Pt was seen and evaluated this post operative day number two and found to be stable. She has slight nystagmus in the left gaze which she had pre-operatively. She is starting to ambulate, she is tolerating po intake and voiding freely. She remains afebrile. Her incision is clean and dry without signs of infection. Her lovenox was started on [**2115-2-16**] at a lower dose then her normal dose. This will continue for 10 days and then she will start her usual dose of 100mg [**Hospital1 **]. Her central line was d/c'd. She is tolerating an oral diet, her pain is well controlled, she is voiding freely and has had a BM this am. She feels well enough to go home today and will be discharged to home. She agrees witht he plan. She is to follow up with the brain tumor clinic next monday for further eval and staple removal. Medications on Admission: Medications before [**2115-2-13**]: AMITRIPTYLINE 25 mg--1 tablet(s) by mouth at bedtime as needed for nerve pain ATIVAN 1MG--One by mouth every 6 hours for nausea or anxiety ATROVENT 18 mcg/Actuation--2 puffs every 6 hrs for cough BACLOFEN 10 mg--1 tablet(s) by mouth every 6 hours as needed for spasm DIOVAN 160 mg--1 tablet(s) by mouth once a day GUAIFENESIN AC 10-100 mg/5 mL--5 to 10 ml by mouth for cough every 4 to 8 hrs LIPITOR 40MG--Take one a day LOVENOX 100MG/ML--Inject 100mg sc twice a day OMEPRAZOLE 20 mg--2 capsule(s) by mouth twice a day PERCOCET 5MG-325MG--2 tablet(s) by mouth every 6 hours as needed for pain PREDNISONE 20MG--Take 2 tablets 16, 8, and 2 hours prior to ct. Pramipexole Dihydrochloride 0.25 mg--[**12-3**] tablet(s) by mouth at bedtime as needed for restless leg syndrome TYLENOL 500MG--Take one tablet twice a day for pain VALIUM 2 mg--1 tablet(s) by mouth once as needed for mri take approximately 30 minutes before mri. may repeat as needed VALIUM 5 mg--1 tablet(s) by mouth every eight (8) hours as needed for muscle spasms XELODA 500MG--Take 2 by mouth in morning and 3 by mouth in the evening for two weeks followed by one week off. ZANTAC 150MG--Take one tablet twice a day ZOLOFT 100MG--Take one tablet every day No medications DC'd on [**2115-2-13**]. No medications prescribed on [**2115-2-13**]. --------------- --------------- --------------- --------------- pt prescreened for CNS lapatinib trial. She is not eligible at this time but will be reconsidered inthe future. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO HS PRN () as needed for restless leg syndrome. 5. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 1 days. Disp:*4 Tablet(s)* Refills:*0* 6. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day) for 10 days: after 10 days - continue with your previous dosing of 100mg twice a day . Disp:*20 20 syringes* Refills:*0* 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain; fever. 10. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: s/p suboccipital crani for tumor resection Discharge Condition: neurologically stable Discharge Instructions: Please keep your incision clean and dry. No showering for at least 5 days from your date of surgery. Monitor your incision for signs of infection including redness, swelling or drainage. Call the office immediately if you notice any of these. Please limit your activities to light activities. No exercising. Followup Instructions: please follow up with Dr. [**Last Name (STitle) **] next Monday in the Brain [**Hospital 341**] clinic. This is in the [**Hospital Ward Name 23**] building on the [**Location (un) **] of the [**Hospital Ward Name **]. You should call the Brain tumor clinic for an appointment to be seen on [**2115-2-25**]. [**Telephone/Fax (1) **] It is very important that you be there. Your staples will be taken out at that time. Completed by:[**2115-2-17**]

[ "198.3", "198.5", "174.8" ]

icd9cm

[ [ [] ] ]

[ "02.12", "01.59" ]

icd9pcs

[ [ [] ] ]

6943, 6949

2920, 4118

884, 911

7036, 7060

2521, 2897

7418, 7870

1827, 1874

5690, 6920

6970, 7015

4144, 5667

7084, 7395

1889, 2502

250, 846

939, 1171

1193, 1746

1762, 1811

24,677

163,764

6771

Discharge summary

report

Admission Date: [**2200-8-28**] Discharge Date: [**2200-8-29**] Date of Birth: [**2142-4-26**] Sex: M Service: [**Hospital Unit Name 196**] Allergies: Penicillins / Tetracyclines Attending:[**First Name3 (LF) 2704**] Chief Complaint: elective catheterization with aspirin desentization Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 58 yo white male w/ h/o CAD s/p catheterization in 3/99 who now presnts for aspirin desentization and repeat cath s/p positive MIBI study. Pt presented with CP in 3/99 and had angioplasty of 80% stenosed RCA (vessel too small for stents) and states 6 months afterwards he had the same vessel angioplastied again. States since then he has felt well up until 6 months ago when he began having CP again. C/o SSCP that comes on when he walks about a block. States the pain only lasts a few minutes and accompanied by SOB but no N/V/diaphoresis. No radiation. Pain resolves if he stops to rest. States he does not take SL Nitro b/c the pain resolves on its own. He had a stress test [**2200-5-27**] which showed mild to moderate, partially reversible myocardial perfusion defects involving the anterior wall, apex, and septum, with transient ischemic dilatation of the LV and global hypokinesis (LVEF 30%). Pt now returns for repeat cath. Pt states approx 25 years ago he took an aspirin and shortly after developed hives and profuse vomiting. Since then he has not tried to take aspirin again. He is now admitted for aspirin desensitization before catheterization. Past Medical History: CAD - s/p cath [**2-/2195**] with RCA 80% stenosed - angioplasty but too small for stent. HYPERCHOLESTEROLEMIA HYPOTHYROIDISM ANEMIA OSTEOARTHRITIS TINEA PEDIS ONYCHOMYCOSIS s/p APPENDECTOMY COLON POLYPS LEFT BUNDLE BRANCH BLOCK HYPERTENSION Social History: Lives with wife. Smoked 1 ppd x 15 years. Quit 5 years ago. EtOH - drinks 1-2 beers qnight. Denies withdrawal symptoms. No other drug use. Family History: Mother died at age 62 of colon cancer. Father died at age 71 of PNA Sister has CAD. Physical Exam: t: 98.7 BP: 157/66 HR:79 RR:20 O2sat:97% RA Gen: in NAD HEENT: PERRLA, EOMI, no sceral icterus Neck: supple, no lymphadenopathy CV: RRR, II/VI holosystolic murmur heard best at LLSB. Lungs: CTA bilaterally. No wheezes or crackles Abd: obese, S/NT/ND. +BS. No HSM Ext: no c/c/e. Pulses 2+ bilaterally DP/PT. R femoral 2+. L femoral not palpated. Bruit auscultated in L groin. Neuro: A&Ox3. non-focal. strength 5/5 throughout. Sensation in tact to light touch. Pertinent Results: Cardiac catheterization ([**2200-8-26**]): 1. Selective coronary angiography revealed a right dominant system. The LMCA was angiographically normal. The LAD had a 50% lesion after the takeoff of D1. The D1 had a 60% lesion proximally. The LCX had a 50% lesion after the high OM1 (which bifurcates). The RCA has diffuse irregularities, which are <50%. 2. Limited hemodynamics on entry show mildly elevated left-sided filling pressures (LVEDP 20 mm Hg). 3. Left ventriculography showed a globally hypokinetic ventricle with a LVEF of 26%. There was no gradient across the LV on pullback. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Severe systolic ventricular dysfunction. Mild diastolic ventricular dysfunction. Brief Hospital Course: 58 yo M with h/o CAD s/p angioplasty in '[**94**] who now returns for repeat cath and aspirin desentization. 1. CV: A. CAD - Continue Plavix, Lipitor, Metoprolol, Lisinopril. H/o aspirin allergy - pt underwent aspirin desensitization the night before his catheterization. He tolerated the protocol well with no complications. Similarly, his catheterization was tolerated well with no complications and it was felt that the pt has diffusely mild disease that did not require intervention at this time. After the procedure the pt's groin had good hemostasis. No hematomas were found. B. HTN - continue Imdur, Norvasc, Metoprolol, Lisinopril. 2. Endo: continue Levoxyl. 3. PPX: on protonix. 4. Dispo: Pt remained in the MICU the night before his catheterization and was stable after the procedure and was sent home with followup instructions. FULL CODE. Medications on Admission: IMDUR 60MG--One by mouth every day LIPITOR 80MG--One by mouth every day METOPROLOL 100MG--One by mouth twice a day NITROGLYCERIN 0.4MG--Use as directed NORVASC 5MG--One by mouth every day OMEPRAZOLE 20MG--One every day PLAVIX 75MG--One by mouth every day PROTONIX 40MG--Take one by mouth every day ZESTRIL 20MG--One by mouth twice a day LEVOXYL 137 mcg--1 tablet(s) by mouth once a day Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease Discharge Condition: Good Discharge Instructions: Do not do any heavy lifting for the next week. Avoid injury to your groin site -- do not bicycle, perform squats or sharp bending at the groin for the next few weeks Followup Instructions: Your primary care physician and Dr. [**Last Name (STitle) **] per your routine.

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4641, 4647

3352, 4205

360, 386

4715, 4721

2600, 3187

4937, 5020

2019, 2105

4668, 4694

4231, 4618

3204, 3329

4745, 4914

2120, 2581

269, 322

414, 1581

1603, 1847

1863, 2003

27,941

131,931

31459

Discharge summary

report

Admission Date: [**2122-9-18**] Discharge Date: [**2122-10-29**] Date of Birth: [**2045-11-27**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: Outside hospital transfer for intracerebral hemorrhage Major Surgical or Invasive Procedure: endotracheal intubation PICC placement nasogastric tube placement Lumbar Puncture x 2 History of Present Illness: 76yo man with PMH significant for HTN, hyperlipidema, DM, old lacunar stroke by head CT, presents with one day abnormal behavior and lethargy and acute worsening in mental status, transferred from an OSH with ICH. Reportedly, he was found by his family in bed when he would usually be taking care of his wife. They brought him to [**Hospital3 3583**], where he was found to be febrile and thought to have a LLL PNA. He had a head CT on admission that showed only an old lacunar infarct. He was found to have GPC bacteremia, and started on vancomycin and levofloxacin. During the day on [**9-17**], however, he stoppedf following commands, and was only responding "yup" to questions. He went for head CT, where he was found to have a right frontal ICH with SAH of unknown size (reports did not accompany patient on transfer, and referring MD is not available). He was intubated for airway protection and transferred. Prior to intubation he was noted to have nystagmus, equal pupils, movement of his right side, and "twitching" of his left side. He was sent to [**Hospital1 18**]. Past Medical History: DM hyperlipidemia HTN Social History: married. Lives on [**Hospital3 **]. Has eight children. No current tobacco. no ETOH or illicits. Family History: NC Physical Exam: PE: VS: T 103, BP 130/90, HR 110, 100% FiO2 0.40 Genl: intubated, sedated (propofol off 45mins before) Neck: not supple CV: RRR, nl S1, S2 Chest: vented breath sounds Abd: soft, NTND, BS+ Ext: warm and dry Neurologic examination: Mental status: opens eyes minimally to stim, does not follow commands, does not fixate on face Cranial nerves: pupils equal and symmetric, does not move eyes past midline to left, +right beating nystagmus Motor: hypertonic throughout, moves all extremities antigravity to noxious; moves right more spontaneously than left Sensory: responds to noxious in all extremities DTRs: 2 throughout except slightly increased in LUE compared to RUE DISCHARGE EXAMINATION: Mental status- Waxing and [**Doctor Last Name 688**] ability to vocalize. Eyes open, tracks examiner. Unable to follow simple commands. Occasionally will respond with "good morning" "no pain" "I feel fine." Cranial Nerves- PERRL 5-2mm. Tracks examiner with limited upgaze. face symmetric. tongue at midline. Motor- Antigravity on the right with left arm paralysis. limited spontaneous movement of the left leg, but withdraws to noxious stimuli. Sensory- Intact to light touch throughout (grimaces to noxious on left arm). Pertinent Results: Admission Labs: pH 7.52 pCO2 31 pO2 339 HCO3 26 BaseXS 3 freeCa:1.10 Lactate:1.1 135 100 15 ------------< 168 3.5 24 1.0 Ca: 8.7 Mg: 2.1 P: 2.0 ALT: 28 AP: 61 Tbili: 1.3 Alb: 3.6 AST: 47 LDH: 283 [**Doctor First Name **]: 32 Lip: 22 CBC 5.2 > 36.6 < 78 N:79 Band:4 L:9 M:8 E:0 Bas:0 PT: 12.6 PTT: 30.2 INR: 1.1 Fibrinogen: 530 CT HEAD W/O CONTRAST [**2122-9-18**] 1:53 AM FINDINGS: There is a 2.1-cm right frontal intraparenchymal hematoma with subarachnoid hemorrhage in the adjacent cerebral sulci in the frontal lobe. There is mild perilesional edema noted around the parenchymal hematoma. There is no mass effect, shift of normally midline structures, or hydrocephalus. There is no intraventricular hemorrhage. Dural calcifications are noted in the frontal region, parasagittal in location. A small hyperdense focus noted in the left frontal region, most likely represents volume averaging from adjacent frontal bone (series 4, image 12). No osseous lytic or sclerotic lesions are noted. IMPRESSION: Right frontal intraparenchymal hematoma with subarachnoid hemorrhage in the adjacent frontal sulci on the right side with no mass effect or midline shift. Please note that on the preliminary report, subdural extension was wrongly mentioned; it is subarachnoid extension. CTA HEAD W&W/O C & RECONS [**2122-9-18**] 10:23 AM FINDINGS: CT OF THE HEAD WITHOUT CONTRAST: A 2.1-cm right frontal intraparenchymal hematoma is again redemonstrated with subarachnoid hemorrhage. Edema is again noted surrounding the hematoma. Otherwise there is again change with no mass effect, no shift of the normally midline structures and no evidence of hydrocephalus. There is no intraventricular hemorrhage. Dural calcifications are again noted in the frontal region. The ventricles and the extra-axial cerebrospinal fluid spaces are slightly prominent likely due to age-appropriate parenchymal involution. The patient has an ET tube and an OG tube in place. CTA OF THE HEAD: There are punctate atherosclerotic calcifications in bilateral distal vertebral arteries. The left vertebral artery is dominant and the right vertebral artery has narrower caliber due to hypolasia; in addition there appears to be effective PICA termination with marrow segment after the origin of PICA. There is no flow- limiting stenosis of the vertebral arteries. There are degenerative changes noted in the cervical spine that is visualized, more severe in the C1- C2 articulation but also seen in the C2-C3 region. There are also atherosclerotic calcifications noted in bilateral carotid arteries particularly at the bifurcation of the common carotid artery and in the carotid siphons. There is moderate stenosis of the right proximal internal carotid artery but without any flow-limiting stenosis. There is no evidence of aneurysm formation or other vascular abnormalities. However, we cannot exclude underlying vascular lesion in the region of the right frontal hematoma itself. Based on the axial images obtained there is no obvious evidence of venous thrombosis. However, this is pending confirmation by review of the 3D venous reconstructions. There are degenerative changes noted in the visualized portions of the cervical spine. IMPRESSION: 1. No evidence of aneurysm or other vascular abnormality. However,we cannot exclude underlying vascular lesion in the region of hemorrhage. Would recommend CT angiogram to evaluate for underlying vascular lesion in the region of hemorrhage after resolution of the hematoma. 2. Based on the axial images no evidence of venous thrombosis. However, this result is pending review of the venous reconstructions. 3. Atherosclerotic disease involving predominantly bilateral internal carotid and left common carotid bifurcation. No flow-limiting stenosis or occlusion. MR [**Name13 (STitle) 6452**] W & W/O CONTRAST [**2122-9-19**] 2:42 PM CERVICAL SPINE: FINDINGS: At C3-4 level, there is mild-to-moderate spinal stenosis seen with mild indentation on the spinal cord. At other levels in the cervical region at C2-3, C4-5 to C7-T1, mild degenerative changes are identified. No abnormal signal seen within the spinal cord. Prevertebral soft tissue thickness is maintained. No evidence of discitis or osteomyelitis. Mild increased signal is seen in the posterior soft tissues which indicate mild soft tissue edema. IMPRESSION: Mild-to-moderate spinal stenosis at C3-4 level with slight extrinsic indentation on the spinal cord. Mild degenerative changes at other levels. No evidence of discitis or osteomyelitis. THORACIC SPINE: FINDINGS: Anterior osteophytes are identified at T1-2 level and also in the lower thoracic region. There is no abnormal signal seen within the vertebral bodies or discs or abnormal enhancement identified. There is no discitis or osteomyelitis seen. Mild increased signal between the osteophytes at T1-2 level could be secondary to degenerative change. There is no spinal cord compression seen or intrinsic spinal cord signal abnormalities. IMPRESSION: No definite evidence of discitis or osteomyelitis in the thoracic region. LUMBAR SPINE: FINDINGS: From L1-2 to L3-4, mild degenerative changes noted. At L4-5, thickening of the ligaments and bulging disc with severe facet degenerative changes result in severe spinal stenosis. There is mild-to- moderate right foraminal narrowing seen. At L5-S1 level, bilateral spondylolysis is identified with grade 1 spondylolisthesis of L5 over S1. There is severe narrowing of both neural foramina seen due to elongation from spondylolisthesis and uncovering of the disc. IMPRESSION: Severe spinal stenosis at L4-5 level due to disc and facet degenerative changes. Grade 1 spondylolisthesis of L5 over S1 due to bilateral spondylolysis with severe bilateral foraminal narrowing. No evidence of discitis or osteomyelitis in the lumbar region. MR HEAD W & W/O CONTRAST [**2122-9-19**] 12:46 AM BRAIN MRI: As seen on the previous CT, there is an area of acute hemorrhage in the right frontal lobe with some mild surrounding edema. In addition, several linear areas of increased signal seen in the adjacent subarachnoid space indicating subarachnoid hemorrhage as seen on the CT. On the diffusion images, several punctate areas of slow diffusion are identified throughout the right cerebral hemisphere. There are no corresponding areas of hemorrhage seen in this region and these findings indicate acute infarcts. There is no midline shift or hydrocephalus seen. Following gadolinium, no evidence of abnormal enhancement seen. A subtle linear area of enhancement to the lateral aspect of the frontal hemorrhage appears to be due to displaced vascular structures. IMPRESSION: 1. Multiple areas of right frontal hemorrhage with the largest in the right posterior frontal region with surrounding edema. 2. Multiple small acute infarcts in the right cerebral hemisphere involving predominantly the right middle cerebral artery territory indicate multiple small acute infarcts and given the multiplicity could be due to embolism. 3. No evidence of abnormal enhancement identified following gadolinium administration. 4. Subarachnoid hemorrhage. MRA OF THE HEAD: The head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. No evidence of vascular occlusion or stenosis seen. MRV OF THE HEAD: Head MRV demonstrates normal flow signal in the superior sagittal and transverse sinus as well as in the deep venous system. IMPRESSION: Normal MR venogram of the head. CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST [**2122-10-4**] 9:17 PM FINDINGS: CHEST: Small mediastinal nodes are noted, however, there is no significant mediastinal or hilar lymphadenopathy. The heart is normal in size, and coronary arteries are densely calcified. There is small pericardial effusion, probably physiological range. There is bilateral pleural thickening with bibasilar atelectasis. In the lung window, note is made of plate-like atelectasis in the right superior segment of right lower lobe. There is bibasilar atelectasis with mild peribronchial thickening in lower lobes. The evaluation of lung parenchyma is somewhat limited due to motion artifact. ABDOMEN: There is no evidence of free air, free fluid or fluid collection in the peritoneal cavity. There is no focal liver lesion or intra- or extra- hepatic ductal dilatation. Gallbladder is mildly distended, without evidence of calcified stone or pericholecystic fluid. Spleen, pancreas, left adrenal gland and the visualized portion of large and small intestines are within normal limits. Appendix is normal. There is 1.7 cm right adrenal nodule, measuring 26 [**Doctor Last Name **], which is indeterminate. There is no hydronephrosis. There is mild nonspecific fat stranding surrounding both kidneys, however, there is no enhancing mass in the kidney. PELVIS: The visualized portion of large and small intestines are within normal limits. Rectum is filled with fluid. There is nonspecific fat stranding posterior to the rectum. There is no lymphadenopathy or abscess or free air. There are marked degenerative changes of thoracolumbar spine with osteophyte formation. There is irregularity of the anterior inferior endplate at L4, with soft tissue surrounding L4-5 disc space anteriorly. There is disc desiccation at 3-4. IMPRESSION: 1. No evidence of intra-abdominal abscess. 2. Atelectasis in the lungs. 3. 1.7 cm right adrenal nodule, which is indeterminate. 4. Fluid-filled rectum. 5. Marked degenerative changes with irregularity of the inferior anterior endplate of L4, with soft tissue at L4-5 disc space and protruding anteriorly. The finding can be due to severe degenerative changes, however, it can also represent discitis in this patient with fever. Clinical correlation and further evaluation by MRI is recommended. MR [**Name13 (STitle) 6452**] W & W/O CONTRAST [**2122-10-5**] 4:13 PM Since the previous MRI study, there are now destructive changes and signal changes seen at the anterior aspect of L4 vertebral body with ncreased signal in the adjacent anterior superior portion of L5 vertebra. There are now oft tissue changes seen in both psoas muscles medially with small pockets of high signal on T2 images and low signal on post-gadolinium T1-weighted images indicating small abscesses. The findings are indicative of discitis and osteomyelitis with inflammation of the psoas muscle and small abscesses in the medial aspects of both psoas muscle at L4-5 level. These findings are new since the previous MRI study. Otherwise, mild degenerative changes are seen in the upper lumbar region. There is severe spinal stenosis seen at L4-5 level due to disc and facet degenerative changes. At L5-S1 level, again grade I spondylolisthesis and severe right-sided and moderate-to-severe left-sided foraminal stenosis identified. IMPRESSION: Since the previous MRI examination of [**2122-9-19**], new signal changes are seen at the anterior aspect of L4 and L5 vertebral body with adjacent soft tissue changes consistent with discitis and osteomyelitis. Small few millimeters areas of signal abnormalities within the medial psoas muscles at L4-5 level indicate small abscesses. Again noted is severe spinal stenosis at L4-5 level due to disc and facet degenerative changes. No evidence of epidural abscess. Other changes as above are also unchanged. The findings were conveyed to the surgical resident at the time of interpretation of the study. IN-111 WHITE BLOOD CELL STUDY [**2122-9-24**] Following the injection of autologous white blood cells labeled with (Tc-[**Age over 90 **]m or In-111), images of the whole body were obtained. These images show aggregation of white blood cells in the left lower lung lobe. After correlation with a recent CXR dated [**2122-9-25**] the findings might be related to an inflammatory or infectious process in that area. IMPRESSION: Inflammatory or infectious process in the left lower lung lobe. Transesophageal Echocardiogram ([**2122-10-7**]): Conclusions: No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is normal. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: No evidence of valvular vegetations. Compared with the prior study (images reviewed) of [**2122-9-18**], findings are similar. EEG Study Date of [**2122-10-21**] IMPRESSION: Abnormal portable EEG due to the slow and disorganized background, even at the most apparently alert portions of the tracing. This suggests a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of prominent focal slowing (but encephalopathies may obscure focal findings). There were no epileptiform features. CT Head- [**2122-10-19**] FINDINGS: There is continued evolution of the right frontal hemorrhagic infarct. The area of hemorrhage has decreased significantly in the interim, now limited to small linear areas within the area of infarction. There also is a small amount of residual subarachnoid blood. The area of hyperdensity representing edema is approximately stable in size. No new areas of hemorrhage are seen. The focal area of hypodensity in the right occipital lobe is slightly more conspicuous than on the prior exam, consistent with evolving nonhemorrhagic infarction in this locale (3:3). The hypodensity in the anterior limb of the left internal capsule is unchanged, consistent with chronic small vessel angiopathy. The visualized paranasal sinuses are clear. Partial opacification of the mastoid air cells bilaterally is again seen. Bony structures and surrounding soft tissue structures are unremarkable. IMPRESSION: 1. Continued expected evolution of the right frontal hemorrhagic infarction. No new intracranial hemorrhage. 2. Increased conspicuity, but stable size of the nonhemorrhagic infarct in the right occipital region. Brief Hospital Course: Mr. [**Known lastname 12101**] is a 76 year old gentleman with past medical history significant for hypertension, DM, hyperlipidemia admitted with unusual behavior, left sided hemiparesis, LLL consolidation, MRSA [**Hospital 11091**] transferred from OSH on [**9-18**] with new intracranial hemorrhage found to have both ischemic and hemorrhagic strokes in the right hemisphere on MRI here. An embolic stroke syndrome was hypothesized based on the multifocal nature of the patient's lesions. An embolic source was not identified (TEE negative x 2, moderate right ICA stenosis - no thrombus). An alternative hypothesis is the presence of proximal embolic event with subsequent watershed infarctions, with dissolution of the clot. Neurological ICU course: The patient was easily extubated. MRI, MRA, MRV failed to demonstrate AVM, aneurysm, venous thrombosis or tumor. EEGs were unrevealing. MAPS were maintained less than 130. Unfortunately the patient did not have a meaningful or substantial improvement in his functional status while admitted to the ICU. He remains able to breath on his own, but doesn't follow commands, keeping his eyes closed most of the time and mumbling incoherently rarely to noxious stimuli. He has functional pupillary and corneal reflexes bilaterally with some baseline anisocoria. He has OCRs. He will move his right upper extremity spontaneously and moves his right toes to noxious stimuli. He has increased tone in the right upper extremity. He doesn't move the left side of his body at all. His toes are upgoing bilaterally. Head CT on [**9-27**] did not show worsening hemorrhage. Neuro Floor Course: Pt was transferred to the floor with the above exam. His fevers resolved continued vancomycin and meropenem for RLL pneumonia. His mental status improved and he was able to speak in [**3-7**] word utterances. However he was still unable to follow simple commands. The remainder of his course is delineated below by system. 1) Infectious Disease- The patient was treated for over two weeks for the MRSA + blood cultures (both here on admission and at the OSH) with vancomycin. Fevers persisted and a source was not found despite a comprehensive w/u including CT abd/pelvis, LP, numerous cultures, recent CXR, LENIs and upper extremity ultrasounds (had small superficial thrombus on the latter). Vancomycin was held [**9-29**] for fear of drug fever. Daptomycin was started the same day. Cultures became positive for MRSA again. The patient was restarted on Vancomycin on [**10-4**]/7 and the daptomycin was stopped. A torso CT showed possible lumbar discitis that was confirmed on lumbar MRI. The infectious disease consult service has been following. They requested that the patient be maintained on 6 weeks of vancomycin starting from [**2122-10-4**]. The patient developed a red right conjunctiva. Opthalmology was consulted. They suggested that this may have resulted from erythromycin irritation. Upon their recommendation the patient was switched to Bacitracin ophthalmic and artificial tears. The patient was made CMO on [**2122-10-28**] and therefore his vancomycin course was cut short. He was kept on artificial tears for comfort. 2) Pulmonary- Following extubation the patient had a persistent [**Last Name (un) 6055**]-[**Doctor Last Name **] pattern of respiration. Serial chest x rays revealed resolving RLL pneumonia. He likely has obstructive sleep apnea with evidence for desaturations at night without underlying lung parenchymal process. His persistent encephalopathy also plays a large role in his [**Last Name (un) 6055**]-[**Doctor Last Name **] pattern. 3) Nutrition- Tube feeds were given via NG. The patient pulled out his NG tube on multiple occasions and required IR for placement. His living will states that he would not want a gastrostomy tube placed for artificial nutrition. After he pulled out his NGT on [**2122-10-25**] the family agreed that it should not be replaced. 4) Goals of Care- Numerous family meetings with patient's wife and children took place and after considerable time (~three weeks) in which the patient's mental and physical status failed to substantially improve and in accordance with wishes the patient expressed both verbally and in writing prior to his illness he was sent home with hospice care. Medications on Admission: Medications on transfer: vancomycin 1gm q24hrs levofloxacin 750mg daily protonix IV qam labetolol 100mg q12hrs lipitor 10mg daily SSI tylenol prn colace prn reglan prn phenergan prn atrovent, albuterol prn Discharge Medications: 1. Lorazepam Intensol 2 mg/mL Concentrate Sig: [**2-3**] ml PO q4h PRN for 7 days. Disp:*qs qs* Refills:*0* 2. Morphine Concentrate 20 mg/mL Solution Sig: 1-2 mg PO Q2H (every 2 hours) as needed for 7 days. Disp:*qs qs* Refills:*0* 3. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). Disp:*qs qs* Refills:*0* Discharge Disposition: Home With Service Facility: Hospice of [**Hospital3 **] Discharge Diagnosis: Right Fronto-parietal infarction with hemorrhagic conversion High Grade MRSA Bacteremia Discharge Condition: left arm hemiplegia. Patient is verbal, but only occasionally comprehensible and frequently inappropriate. Discharge Instructions: You were admitted for a brain hemorrhage and high grade bacterial infection within your blood. You are being discharged on hospice care. It is expected that you will remain at home, but should you decide to reverse the goals of your care, you are welcome back here at any time. Followup Instructions: You have no follow up appointments. If you wish to contact any of the physicians who you saw you here. Please call [**Telephone/Fax (1) 2756**] and have the Neurologist on pain paged. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2122-10-29**]

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icd9cm

[ [ [] ] ]

[ "03.31", "96.07", "38.93", "96.6", "88.72", "96.72" ]

icd9pcs

[ [ [] ] ]

22472, 22530

17511, 21836

372, 459

22662, 22771

3001, 3001

23099, 23408

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27172

Discharge summary

report

Admission Date: [**2104-4-11**] Discharge Date: [**2104-4-28**] Date of Birth: [**2035-11-22**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: chest pain/ SOB/cardiac catherization Major Surgical or Invasive Procedure: s/p cabg x4 [**2104-4-17**] s/p aortogram/ bil iliac stents [**2104-4-18**] s/p left femoral/profunda endarterectomy/patch angioplasty/aortogram [**2104-4-22**] History of Present Illness: Patient is a 68-year-old male with CAD, COPD, PVD who presented to [**Hospital3 1280**] on [**2104-4-9**] with c/o chest pain, SOB and cough. He was found to have an elevated troponin I of 0.6 and inferior-lateral ST depressions. He was intially treated for a COPD exacerbation with steroids, nebulizers and antibiotics. He was taken for cardiac catherization on [**4-10**], but they were unable to cross the bifurcation of iliac and aorta an so the cath was aborted. He was transfered to [**Hospital1 18**] for catherization. Cath here revealed diffuse 3 vessel disease, no intervention perfromed. . Pt currently thought to have a COPD flare up and started on steroids at OSH with solumedrol 40mg IV q8hrs and zithromax 250mg daily for bronchitis. He ruled in for an MI this admission with a peak troponin of 0.60. He had an episode of [**2-15**] CP at midnight last night and was started on Nitro gtt at 20 mcg. Pt transferred on Heparin and Integrillin drips, after cath Integrillin drip discontinued. He received a Plavix bolus of 300 mg on [**4-9**] and has been receiving 75 mg daily. He is also receiving a full strength ASA. Patient denies ever having chest pain during the admission, currently asymptomatic. He denies chronic shortness of [**Last Name (un) 6250**], has chronic dry cough, which recent became productive of green/yellow sputum. He states the shortness of breath was rapid onset while watching TV at home, persisted until given medications as OSH. No associated symptoms. Has chronic wheezing, has never used inhalers. At home minimally active [**1-10**] leg claudication which occurs after several minutes of walking, L>R. Cath showed DIAG 2 90%, calc. LAD, C 90%, RCA 100% , calcified iliacs/femorals/high grade right common iliac [**Last Name (un) 2435**]/ moderate to severe left common iliac artery [**Last Name (un) 2435**]. prox. Referred for CABG to Dr. [**Last Name (STitle) 914**]. Pre-op chest CT also showed a pulmonary nodule and patient was seen by thoracic surgery. Past Medical History: COPD last PFTs about 10 yrs ago HTN CAD, MI in [**2097**], PTCA Hyperlipidemia + tobacco use COPD Claudication/PVD s/p appendectomy Social History: Divorced, lives with significant other and her son Retired driver works part time as shuttle bus driver Tobacco: 50 pkyr, currently [**2-9**] ppd ETOH: 6 pack a day, denies any hx of DTs or other withdrawal in the past with stopping no IVDA Family History: no early CAD Father died of leukemia (late 50s or early 60s) Mother [**Age over 90 **] y/o, lives in [**Name (NI) **] Sister 73 y/o, healthy Physical Exam: Temp 96.4, BP 135-170/60s, HR 72, RR 18, O2 sat 90% on 2L NC GEN: appears older than stated age, comfortable, breathing comfortably HEENT: anicteric, OP clear NECK: JVP not elevated CV: RRR nl s1, s2, no m/r/g Lungs: diffuse expiratory wheezes, no crackles ABD: soft, ND, NT, no HSM EXT: both groins without hematoma or bruit, feet warm, pulses dopplerable Neuro: non-focal Pertinent Results: [**2104-4-11**] 04:30PM BLOOD WBC-15.4* RBC-3.84* Hgb-12.4* Hct-36.2* MCV-94 MCH-32.2* MCHC-34.2 RDW-13.3 Plt Ct-204 [**2104-4-12**] 01:12AM BLOOD WBC-17.1* RBC-4.02* Hgb-12.9* Hct-38.3* MCV-95 MCH-32.2* MCHC-33.8 RDW-13.4 Plt Ct-215 [**2104-4-12**] 06:40AM BLOOD WBC-16.5* RBC-3.90* Hgb-12.6* Hct-36.8* MCV-94 MCH-32.2* MCHC-34.2 RDW-13.2 Plt Ct-201 [**2104-4-13**] 06:55AM BLOOD WBC-14.9* RBC-3.89* Hgb-12.4* Hct-36.7* MCV-94 MCH-32.0 MCHC-33.9 RDW-13.3 Plt Ct-220 [**2104-4-14**] 07:10AM BLOOD WBC-13.0* RBC-4.04* Hgb-12.9* Hct-37.9* MCV-94 MCH-31.8 MCHC-33.9 RDW-13.2 Plt Ct-232 [**2104-4-15**] 07:30AM BLOOD WBC-14.1* RBC-4.04* Hgb-13.2* Hct-37.7* MCV-93 MCH-32.6* MCHC-34.9 RDW-13.0 Plt Ct-276 [**2104-4-16**] 06:55AM BLOOD WBC-15.3* RBC-4.28* Hgb-13.8* Hct-40.1 MCV-94 MCH-32.2* MCHC-34.3 RDW-13.3 Plt Ct-309 [**2104-4-17**] 11:57AM BLOOD WBC-18.5* RBC-3.14*# Hgb-9.8*# Hct-29.6*# MCV-94 MCH-31.4 MCHC-33.3 RDW-13.3 Plt Ct-261 [**2104-4-17**] 12:45PM BLOOD WBC-28.1*# RBC-3.56* Hgb-11.6* Hct-33.5* MCV-94 MCH-32.6* MCHC-34.7 RDW-13.5 Plt Ct-262 [**2104-4-16**] 06:55AM BLOOD Neuts-74.3* Lymphs-18.1 Monos-5.8 Eos-1.3 Baso-0.6 [**2104-4-11**] 04:30PM BLOOD PT-12.9 PTT-35.4* INR(PT)-1.1 [**2104-4-14**] 07:10AM BLOOD PT-12.1 PTT-66.1* INR(PT)-1.0 [**2104-4-17**] 11:57AM BLOOD PT-15.7* PTT-30.2 INR(PT)-1.4* [**2104-4-17**] 12:45PM BLOOD PT-15.0* PTT-35.9* INR(PT)-1.4* [**2104-4-11**] 04:30PM BLOOD Glucose-167* UreaN-8 Creat-0.6 Na-134 K-4.0 Cl-100 HCO3-27 AnGap-11 [**2104-4-16**] 06:55AM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-140 K-3.8 Cl-99 HCO3-33* AnGap-12 [**2104-4-17**] 12:45PM BLOOD UreaN-9 Creat-0.7 Cl-106 HCO3-29 [**2104-4-11**] 04:30PM BLOOD ALT-11 AST-16 AlkPhos-42 Amylase-27 TotBili-0.4 [**2104-4-12**] 06:40AM BLOOD CK(CPK)-92 [**2104-4-13**] 06:55AM BLOOD CK(CPK)-112 [**2104-4-14**] 07:10AM BLOOD CK(CPK)-104 [**2104-4-12**] 06:40AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2104-4-13**] 06:55AM BLOOD CK-MB-3 cTropnT-.12* [**2104-4-14**] 07:10AM BLOOD CK-MB-2 cTropnT-0.14* [**2104-4-12**] 06:40AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0 [**2104-4-11**] 04:30PM BLOOD Albumin-3.3* [**2104-4-11**] 04:30PM BLOOD VitB12-183* [**2104-4-11**] 04:30PM BLOOD %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE [**2104-4-17**] 07:31AM BLOOD Type-ART pO2-214* pCO2-53* pH-7.41 calHCO3-35* Base XS-7 Intubat-INTUBATED Vent-CONTROLLED [**4-27**] K 4.8 WBC 8.9 Hct 28.7 creat 0.9 . C.Cath [**4-11**]: COMMENTS: 1. Selective coronary angiography showed a right dominant system with normal LMCA but heavily calcified LAD. The LAD itself was only mildly diseased but a large twin D2 had a 90% stenosis. LCX had a proximal 90% stenosis and OM2 had a 90% stenosis at the bifurcation. The RCA was heavily calcified and chronically totally ocluded in its mid portion with very faint L-R collaterals. 2. Left ventriculography showed normal ejection fraction and wall motion without mitral regurgitation. 3. Limited hemodynamics showed mildly elevated left sided filling pressures and systemic aortic pressures. 4. Abdominal aortography showed diffuse bilateral illiac and femoral disease with calcifications. Both Right and Left iliac vessels had high grade stenosis with post-stenotic aneurysmal dilation. Access from the left femoral artery required use of JR4 catheter and angled glide wire. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Normal ventricular function. 3. Iliac peripheral vascular disease (bilateral). . [**4-14**] MRI/MRA pelvis and lower extremities: IMPRESSION: 1. Significant inflow disease with focal high-grade (90%) stenosis of the proximal right common iliac artery and 50-70% narrowing involving the proximal left common iliac artery. 2. Bilateral common iliac aneurysms, measuring up to 1.7 cm. 3. Near total occlusion vs. short segment occlusion involving the distal left common femoral artery. Collateral flow around this lesion supplies the proximal superficial and profunda femoral arteries on the left. 4. Bilateral three-vessel runoff, as described above. . [**4-14**] Carotid U/S: IMPRESSION: Less than 40% stenosis in the bilateral extracranial internal carotid arteries. . Echo [**4-14**]: Conclusions: The left atrium is elongated. The right atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild basal infero-lateral hypokinesis. Overall left ventricular systolic function is normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: Pt presented to the cathetirization lab, where after some difficulty with crossing aorta, access was obtained via L groin for cardiac catheterization, which revealed diffuse 3 vessel disease. Pt was evaluated by CardioThoracic surgery for bypass surgery. His CK's remained flat during admission, troponins trended up slightly to max of 0.14. He was continued on aspirin, metoprolol, lisinopril, heparin, and atorvastatin. Hydralazine and isosorbide were added and titrated for blood pressure control as the patient continued to have SBP in 160s. His pre-op evaluation including lower exremity MRI/MRA, carotid u/s, and echocardiography were performed. There was concern regarding his pulmonary function and the patient was noted to consistently require about 2 L of oxygen per nasal cannula. He was coninued on steroids, although these were changed to PO prednisone and titrated off by 10mg daily. He complete a 5 day course of azithromycin, but continued to have a somewhat productive cough. Levofloxacin was added empirically to cover for community acquire pneumonia. Pulmonary consult was obtained as were pulmonary function tests. These were consistant with emphysema, and the patient was thought to have long standing pulmonary disease which he has been fairly asymptomatic from. He was started on spiriva and alburol nebulizer treatments as well as fluticasone inhaler. He remained without any chest pain, or shortness of breath, but did have a productive cough with some scant blood mixed in with sputum. The patient went for his CABG x 4 on [**4-17**] and was transferred to the CSRU in stable cpndition on propofol, epinephrine and nitroglycerin drips. He developed numbness and ischemia in his left leg on [**4-18**] and underwent an aortogram and bilat. common iliac angioplasties by Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **]. Heparin drip started as well as abx and beta blockade titration. Chest tubes removed on POD #3 and transferred to the floor. Left leg still cool and the planned left femoral endartectomy was performed on [**4-22**] with bilat. common iliac stents and patch angioplasty by Dr. [**Last Name (STitle) **]. Also followed by the pulmonary service for COPD. Transferred back to the floor on [**4-23**]. Follow up arranged for pulmonary nodule with Dr. [**Last Name (STitle) **]. Over the next several days he was monitored for swelling in his left leg and pulmonary toilet as he desaturated with activity. Cleared for discharge to home with VNA on POD #[**10-13**]. Patient to return here for staple removal from groin incision on [**5-6**] and to follow up with all providers as outlined in discharge planning. Medications on Admission: MEDS on Xfer: ASA Plavix 75 Lipitor 80 Lisinopril 20 Daily Lopressor 50 [**Hospital1 **] Herpain Integrillin . Home Meds: ASA Lisinopril 20 daily Atenolol 50 daily MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks. Disp:*28 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*1* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 1 months. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: s/p cabg x4 [**2104-4-17**] s/p aortogram/ bil iliac stents [**2104-4-18**] s/p left femoral/profunda endarterectomy/patch angioplasty/aortogram [**2104-4-22**] PVD COPD MI HTN CAD/PTCA [**2097**] elev. lipids Discharge Condition: good Discharge Instructions: may shower over incisions and pat dry no lotions, creams or powders on any incision call for fever, redness or drainage no driving for one month no lifting greater than 10 pounds for 10 weeks Followup Instructions: return to [**Hospital Ward Name 121**] 2 for removal of groin staples on Tues. [**5-6**] see Dr. [**Last Name (STitle) 4797**] in [**12-10**] weeks see Dr. [**Last Name (STitle) 1295**] in [**1-11**] weeks see Dr. [**Last Name (STitle) **] in [**1-11**] weeks See Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] see Dr. [**Last Name (STitle) **] in clinic on [**5-6**] at 1:30PM [**Hospital Ward Name **] [**Hospital Ward Name 23**] 9 (thoracic surgeon) see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**] (pulmonary medicine) in 6 weeks after chest CT is done [**Telephone/Fax (1) 612**] Completed by:[**2104-4-28**]

[ "443.9", "272.0", "410.71", "303.90", "305.1", "414.01", "401.9", "491.21", "518.89", "412", "V16.6", "442.2" ]

icd9cm

[ [ [] ] ]

[ "39.50", "88.56", "88.48", "36.13", "88.53", "38.18", "36.15", "00.41", "00.46", "37.22", "39.90", "39.61", "89.60" ]

icd9pcs

[ [ [] ] ]

12485, 12547

8435, 11106

359, 526

12805, 12812

3548, 6828

13053, 13724

2995, 3138

11325, 12462

12568, 12784

11132, 11302

6845, 8412

12836, 13030

3153, 3529

282, 321

554, 2564

2586, 2720

2736, 2979

22,888

108,592

53356

Discharge summary

report

Admission Date: [**2147-8-4**] Discharge Date: [**2147-9-15**] Date of Birth: [**2102-12-7**] Sex: M Service: Vascular CHIEF COMPLAINT: Fever and hypotension. HISTORY OF PRESENT ILLNESS: The patient was seen in the Emergency Department on [**2147-8-4**] with the onset of fever and hypotension. The patient is a 44-year-old white gentleman with a past medical history of end-stage renal disease secondary to ureteral reflux nephropathy. He underwent a living-related renal transplant and has a history of mesenteric ischemia requiring a [**Doctor Last Name 4726**]-Tex superior mesenteric artery aorta bypass graft in [**2145-12-25**]. The patient now presents after a prior admission for occlusion, status post t-PA, of the superior mesenteric artery with a 24-hour to 36-hour history of increasing weakness, malaise, and fever. Temperature was 102.8. The patient admits to chills. He denies chest pain, shortness of breath, or cough. There was no bright red blood per rectum. He denies any associated symptoms or abdominal discomfort or pain. He is now admitted for further evaluation and treatment. PAST MEDICAL HISTORY: 1. History of end-stage renal disease. 2. History of peripheral vascular disease. 3. History of gastroesophageal reflux disease. 4. History of a 25-pack-year smoking history. 5. History of squamous cell carcinoma of the lower lip. 6. History of [**Doctor Last Name 15532**] esophagus. 7. History of duodenitis. PAST SURGICAL HISTORY: 1. Living-related renal transplant in [**2130-5-25**]. 2. Aorta superior mesenteric artery bypass with polytetrafluoroethylene in [**2145-11-25**]. 3. T-PA of superior mesenteric artery graft times two in [**2147**]. ALLERGIES: He has no known drug allergies. MEDICATIONS ON ADMISSION: (His medications included) 1. Coumadin 3 mg by mouth every day. 2. Imuran 50 mg by mouth once per day. 3. Prednisone 10 mg by mouth once per day. 4. Levoxyl 125 mcg by mouth once per day. 5. Furosemide 20 mg by mouth once per day. 6. Bactrim single strength by mouth every Monday, Wednesday, and Friday. SOCIAL HISTORY: The patient is divorced. He has one child. He is an electronic technician. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed vital signs with a temperature of 100.3 degrees Fahrenheit, heart rate was 108, blood pressure was 75/55, respiratory rate was 16, and oxygen saturation was 99% on 2 liters. General appearance revealed a male sitting in bed in no acute distress. Oriented times three. Lung examination revealed left inspiratory basilar crackles. Heart examination revealed distant heart sounds; regular. No murmurs, gallops, or rubs. The abdomen was slightly distended and tympanic. Diminished bowel sounds. There was no guarding. There was a right iliac fossae renal transplant noted. Rectal examination was without abscess and was guaiac-positive. Extremity examination was without edema. The feet were warm. There were no ulcerations. Pulse examination revealed intact femoral pulses and popliteal pulses bilaterally with triphasic dorsalis pedis pulse on the right and a palpable posterior tibialis pulse on the right with a triphasic dorsalis pedis pulse on the left with a palpable posterior tibialis pulse on the left. PERTINENT LABORATORY VALUES ON PRESENTATION: Admission laboratories revealed white blood cell count was 3.6 and hematocrit was 26.5 (down from 28). INR was 3. Blood urea nitrogen was 17. Creatinine was 1.2. Potassium was 3.9. PERTINENT RADIOLOGY/IMAGING: A single view chest x-ray revealed no infiltrate or effusions. Heart mediastinal shadows were okay. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was placed in the Vascular Intensive Care Unit. Linezolid, Flagyl, and Levaquin were instituted after cultures were obtained. The patient was transfused two units of packed red blood cells with a post transfusion hematocrit of 28. The Renal Transplant Service followed the patient. He another unit of packed red blood cells for his hematocrit of 28. The Endocrinology Service was consulted because of the patient's elevated thyroid-stimulating hormone of 51. Recommendations were to check FT4 and antimorph antibodies. His levothyroxine dose required adjustment. The patient remained in the Vascular Intensive Care Unit. His hematocrit after three units of packed red blood cells was 33. It was felt that he would require further evaluation for a gastrointestinal bleed. The Infectious Disease Service was consulted and the Gastrointestinal Service was consulted. The Infectious Disease Service did see the patient. They felt, in light of the patient's previous perirectal abscess, Escherichia coli to the cecum, bacteremia, and superior mesenteric artery thrombosis, he improved in house. The evaluation at this time was unrevealing for potential sources. Recurrent abscesses with computed tomography scans were negative. Clostridium difficile has been negative, but blood can interfere with Cytoxan assay. They recommended continuing current antibiotics, check transthoracic echocardiogram, repeat blood cultures if fever recurs, send stools for Clostridium difficile, Cytoxan D, and recommended change to Bactrim from single strength to double strength. These recommendations were followed through on. The echocardiogram demonstrated biventricular hypokinesis consistent with diffuse process (i.e. toxic/metabolic). There were no computed tomography or Doppler evidence of endocarditis. Blood cultures from admission were no growth but not finalized. Repeat cultures were done on [**9-8**] which were pending. Urine cultures were finalized at no growth, and repeat urine cultures on [**9-7**] had not been finalized. At the time Gastrointestinal Service saw the patient, stool culture were unremarkable except for yeast. The chest x-ray was without infiltrates or effusions. Recommendations indicated the patient would require endoscopic examination with upper and lower endoscopies to rule out ischemic colitis, but this could only be done once the patient's INR was below 1.5. Coumadin was discontinued on admission. Initial computed tomography demonstrated a hydronephrotic native atrophic left kidney of uncertain clinical significance. There were no secondary signs of inflammation. The upper left collecting system in the past has shown various decrease of dilatation and decompression. There was a diffuse large-bowel and small-bowel dilatation without evidence of obstruction. The superior mesenteric artery bypass was patent. A repeat computed tomography of the abdomen done on [**8-12**] did not reveal any source of the patient's fevers. An ultrasound of the gallbladder was negative for cholelithiasis or intrahepatic ductal dilatation. Blood cultures done on [**2147-8-12**] grew Enterococcus to the cecum. It was susceptible to streptomycin, linezolid, and methacycline. Resistant to vancomycin, penicillin, and levofloxacin, and ampicillin. All cultures were negative. The patient then underwent on [**2147-8-14**] and upper esophageal endoscopy. This showed a normal esophagus. There was localized erythema of the mucosa. No bleeding was noted in the antrum of the stomach. These findings were compatible with gastritis. There was no evidence of active bleeding. The duodenum was normal. The patient then underwent a colonoscopy. Although there was neither blood nor obvious lesions identified, the preparation was poor and small mucosal lesions might have been missed. If further bleeding occurs, it is likely to be colonic. Then it would be appropriate to do a repeat study after a better preparation. The patient underwent a white blood cell tagged study on [**2147-8-22**]. This demonstrated findings consistent with infectious or inflammatory process with increased activity in the loops of the small bowel within the upper pelvis. Recommendations included a positron emission tomography scan be considered for anatomical localization of findings if clinically warranted. On [**8-8**], there was one blood culture which grew [**Female First Name (un) 564**] parapsilosis. The patient continued to spike fevers and rigors despite antibiotics. Cultures from [**8-19**] grew 2/4 bottles of gram-negative rods on the blood cultures. On [**8-22**], the Gastrointestinal Service was consulted again, and the patient underwent an upper endoscopy the same day. It demonstrated a normal esophagus and a normal stomach. The duodenum showed gastrografin through the duodenum. There was no bleeding noted around the site of erosion. General Surgery was consulted after the endoscopic findings. Total parenteral nutrition was begun. Antibiotics were continued. On [**2147-8-26**], the patient had a drop in blood pressure and hematocrit requiring a transfusion of three units of packed red blood cells. He was transferred to the Surgical Intensive Care Unit for continued monitoring and care. The drop in the hematocrit was secondary to a spontaneous bleeding into the neck, not intra-abdominal bleeding. The patient was stabilized. The patient underwent a right axillar bifemoral bypass graft on [**2147-8-30**]. He returned to surgery on [**2147-8-31**] and underwent a repair of duodenal fistula, gastrostomy, and jejunostomy. A #14 French jejunostomy tube was placed, and a #16 French Foley gastrostomy tube was placed. The superior mesenteric artery graft was removed with a redo aorta superior mesenteric artery bypass with superficial femoral vein from the left leg. At the time of repair, antibiotics included fluconazole 400 mg intravenously q.24h. (this was day 21), linezolid 600 mg q.12h. (this was day 19), meropenem 1 g q.12h. (this was day 17). His postoperative hematocrit remained stable at 33.6. His INR was 1.3. Partial thromboplastin time was 68. Blood urea nitrogen was 9. Creatinine was 0.7. His ALT, AST, and alkaline phosphatase were unremarkable. The patient was continued on total parenteral nutrition. His protein needs were 55 to 70 of protein per kilogram with 30 to 32 calories per kilogram with a total calorie need of 1400 cc to 1500 cc. Goal rate for the total parenteral nutrition was 1200 cc per 24 hours. The patient was transferred to the Vascular Intensive Care Unit on [**2147-9-2**] for continued care. Tube feeds were started on [**2147-9-5**]. The meropenem was discontinued on [**2147-9-6**]. Cefepime 2 g was started intravenously q.12h. The Foley catheter was discontinued on [**2147-9-6**]. Physical Therapy was requested to see the patient in anticipation for discharge planning. They felt that he would be at a level that would be safe for discharge to home after two to three more sessions (and this was on [**2147-9-7**]). The patient underwent G2 study which was negative for duodenal leak. On [**2147-9-12**], the Infectious Disease Service signed off with recommendations of continuing the cefepime for a total of four weeks, the fluconazole for a total of four weeks, and we could convert him to oral agents once he was allowed to use his gastrointestinal tract. Linezolid should be continued until central venous access is discontinued. The last dose of cefepime and fluconazole will be [**2147-9-28**]. The patient was to follow up in the Infectious Disease Clinic on [**2147-9-29**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient will require monitoring of his liver function tests/renal function on a weekly basis while on fluconazole and cefepime. Total parenteral nutrition was slowly tapered, and his tube feeds were increased to meet goal at 60 cc per hour. Tube feeds were brought to goal on [**9-10**], and cycling was begun at 60 cc per hour (2 p.m. to 8 a.m.). A regular diet was instituted. Total parenteral nutrition was discontinued. The patient had a peripherally inserted central catheter line on [**9-11**] under fluoroscopy. His patient-controlled analgesia was discontinued, and he was converted to Vicodin on [**2147-9-11**]. Physical Therapy continued to work with the patient. He continued to progress in his endurance and mobility. During the remainder of his hospital course, he continued to show improvement. Reglan was begun with improvement in his oral tolerance. His central line was discontinued, and linezolid was discontinued. Case Management was in the process of screening. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. MEDICATIONS ON DISCHARGE: 1. Regular insulin sliding-scale four times per day before meals and q.h.s. as follows: glucose of less than 120 use no insulin; glucose of 121 to 160 use 2 units subcutaneously, glucose of 161 to 200 use 4 units subcutaneously, glucose of 201 to 240 use 6 units subcutaneously, glucose of 241 to 280 use 8 units subcutaneously, glucose of 281 to 320 use 10 units subcutaneously, glucose of 321 to 360 use 12 units subcutaneously, glucose of 361 to 400 use 14 units subcutaneously, glucose of greater than 400 use 16 units subcutaneously. 2. Cefepime 2 g intravenously q.12h. (to be continued until [**2147-9-28**]). 3. Dulcolax suppository per rectum at bedtime as needed. 4. Hydrocodone/acetaminophen tablets one to two tablets by mouth q.4-6h. as needed (for pain). 5. Protonix 40 mg by mouth once per day. 6. Reglan 10 mg by mouth before meals and at bedtime. 7. Bactrim single strength one tablet by mouth twice per day. 8. Levothyroxine 125 mcg by mouth every day. 9. Azathioprine 50 mg by mouth once per day. 10. Prednisone 10 mg by mouth q.48h. 11. Acetaminophen 325 mg to 650 mg by mouth q.6h. as needed. 12. Fluconazole 400 mg once per day (until [**2147-9-28**]). 13. Metoprolol 12.5 mg by mouth twice per day (hold for a systolic blood pressure of less than 80 or a heart rate of less than 60). DISCHARGE DIAGNOSES: 1. Enterococcal cecum septicemia. 2. Candidiasis septicemia. 3. Graft erosion of the duodenum. 4. Blood loss anemia; corrected. 5. Status post renal transplant (on immunosuppression). DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] status post discharge from rehabilitation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2147-9-12**] 16:19 T: [**2147-9-12**] 16:29 JOB#: [**Job Number 109763**]

[ "038.0", "998.6", "530.81", "996.1", "443.9", "996.62", "112.5", "280.0", "V42.0" ]

icd9cm

[ [ [] ] ]

[ "43.19", "45.13", "46.39", "00.14", "46.72", "39.49", "45.23", "39.29", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

13861, 14051

12510, 13840

1792, 2103

14085, 14517

1499, 1765

3691, 12418

12433, 12483

158, 182

211, 1135

1157, 1476

2120, 3662

21,276

170,954

8687+55965+55963

Discharge summary

report+addendum+addendum

Admission Date: [**2135-12-18**] Discharge Date: [**2136-1-5**] Date of Birth: [**2095-4-14**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 28789**] Chief Complaint: heartburn Major Surgical or Invasive Procedure: c-section History of Present Illness: 40 yo G2P1 @ 28 wks GA, with GI cancer (pancreatic vs duodenal), presents to triage with worsening heartburn and abd pain. No ctx/LOF/VB. Past Medical History: none Past Surgical History: none Past OB History: NSVD at term 9#, no complications (home birth) Past GYN History: cervical dysplasia s/p laser ablation Prenatal Course: EDC [**2135-3-11**] by LMP c/w 1st trimester U/S O+/Ab-/RPR NR/RI/HBsAg- AMA: declined amniocentesis, normal serum screen Social History: Lives with husband in [**Name (NI) 3844**]. Nonsmoker. No EtOH/drug use. Family History: aunt with pancreatic cancer Physical Exam: AVSS rrr ctab soft, gravid, epigastric tenderness, no r/g nt/ne no ctx fht aga Brief Hospital Course: Pt was admitted and remained NPO on tpn as she had been at home. She was given BMZ. She underwent cesarean delivery on [**2135-12-19**] so that she could pursue more aggressive treatment of her likely pancreatic cancer given her worsening symtoms and prognosis. Her postpartum course will be dictated as needed in a dictation to follow. Medications on Admission: fa pepcid morphine compazine Discharge Medications: same Discharge Disposition: Extended Care Facility: post partum service [**Hospital1 18**] Discharge Diagnosis: s/p cesarean delivery likely pancreatic cancer Discharge Condition: stable - to postpartum service Discharge Instructions: will follow in postpartum dictation Followup Instructions: to follow Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 5297**] Admission Date: [**2135-12-18**] Discharge Date: [**2136-1-5**] Date of Birth: [**2095-4-14**] Sex: F Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 48**] Addendum: pt had uncomplicated LTCS on [**12-19**] and recovered on 6S. SHe was unable to tolerate po's and a general surgery consult was obtained and the patient had an NGT placed on POST-op day #3 that drained 1500cc of bilous fluid. Her nausea resolved after this. GIven the MRI findings [**12-18**] suggestive of obstruction and the patient's post-operative course, the decision was made to transfer her to the general surgery/hepatobiliary service on [**12-26**] and to have her Whipple on [**12-27**] due to the obstruction. The patient was continued on a PCA dilaudid post-op and her lytes were followed as she continued TPN. Transfer to Dr. [**Name (NI) 5316**] service on [**2135-12-26**]. Discharge Disposition: Home Discharge Diagnosis: Cesarean delivery Cancer Discharge Condition: fair Discharge Instructions: transfer to Dr.[**Name (NI) 5317**] service [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**] Completed by:[**2135-12-31**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 5297**] Admission Date: [**2135-12-18**] Discharge Date: [**2136-1-5**] Date of Birth: [**2095-4-14**] Sex: F Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 48**] Addendum: Transplant Surgical Service addendum to follow Chief Complaint: Pancreatic/Duodenal Cancer Major Surgical or Invasive Procedure: Cesarean delivery Whipple [**2135-12-19**] Blood Patch History of Present Illness: Asked to consult on this 40yo WF for suspected pancreatic cancer. Patient presented to OSH in early [**Month (only) 5298**] with two week complaint of epigastric pain, nausea/vomiting, emesis, early satiety and reflux. Patient describes a recent 9 pound weight loss over a two month period. At OSH, patient's amylase was noted to be 1032, ALT 87, and AST of 37. On U/S patient showed RUQ GB sludge and CBD dilatation to 1.7cm. She was admitted to [**Hospital1 8**] on [**2135-11-21**], placed NPO with IVF and her GB percutaneously drained. ERCP and Bx showed adenocarcinoma at the ampulla of vater with lymphatic involvement. Patient is in for same admission after cesarean secion on [**2135-12-19**]. Patient at time of interview c/o nausea, anorexia, two small bouts of emesis, and no flatus. Past Medical History: Past Surgical History: none Past OB History: NSVD at term 9#, no complications (home birth) Past GYN History: cervical dysplasia s/p laser ablation Prenatal Course: EDC [**2135-3-11**] by LMP c/w 1st trimester U/S O+/Ab-/RPR NR/RI/HBsAg- AMA: declined amniocentesis, normal serum screen Social History: Lives with husband in [**Name (NI) 5299**]. Nonsmoker. No EtOH/drug use. Family History: aunt with pancreatic cancer Physical Exam: At time of interview: GEN: alert and oriented x 3; NAD HEENT: nonicteric, no cervical LAD CV: RRR LUNGS: CTAB ABD: Soft, nontender, moderate distension without palpable masses. Lower abdominal incision is clean, dry, and intact EXT: Patient has no clubbing, cyanosis, or edema Pertinent Results: [**2136-1-5**] 06:45AM BLOOD WBC-7.8 RBC-3.22* Hgb-9.7* Hct-28.1* MCV-87 MCH-30.2 MCHC-34.6 RDW-14.6 Plt Ct-323 [**2135-12-22**] 06:32AM BLOOD WBC-9.9 RBC-2.89* Hgb-9.1* Hct-27.3* MCV-95 MCH-31.5 MCHC-33.3 RDW-14.5 Plt Ct-237 [**2136-1-5**] 06:45AM BLOOD Plt Ct-323 [**2135-12-22**] 06:32AM BLOOD Plt Ct-237 [**2136-1-5**] 06:45AM BLOOD Glucose-91 UreaN-12 Creat-0.7 Na-140 K-4.4 Cl-102 HCO3-27 AnGap-15 [**2135-12-22**] 06:32AM BLOOD Glucose-108* UreaN-13 Creat-0.3* Na-140 K-3.9 Cl-106 HCO3-24 AnGap-14 [**2136-1-5**] 06:45AM BLOOD ALT-63* AST-28 AlkPhos-303* Amylase-22 TotBili-0.6 [**2135-12-22**] 06:32AM BLOOD ALT-71* AST-30 AlkPhos-140* Amylase-135* TotBili-1.2 [**2136-1-5**] 06:45AM BLOOD Lipase-9 [**2135-12-24**] 06:00AM BLOOD Lipase-75* [**2136-1-5**] 06:45AM BLOOD Albumin-3.3* [**2135-12-22**] 06:32AM BLOOD Albumin-2.7* Calcium-8.3* Phos-3.1 Mg-1.9 [**2135-12-22**] 06:32AM BLOOD Triglyc-127 [**12-18**] MRI: Lesion within the pancreatic head along the right, involving the ampulla and duodenal wall concerning for primary carcinoma of either the periampular region (pancreas versus duodenum) or ectopic pancreas within the duodenum. [**12-25**] CXR: No acute cardiopulmonary abnormality [**12-27**] Pathology: GB- Chronic cholecystitis, with cholesterolosis. 2. No calculi or tumor Pancreas- 1. Adenocarcinoma of the pancreatic head; see synoptic report. 2. Chronic inactive duodenitis with marked hyperplasia at the ampulla. 3. Marked dilation of the common bile duct. 4. Chronic pancreatitis with fibrosis and dilated pancreatic duct. G2: Moderately differentiated, pT3: Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery. pN1b: Metastasis in multiple regional lymph nodes. Lymph Nodes Number examined: Eight (8). Number involved: Three (3). Distant metastasis: pMX: Cannot be assessed.Margins: Margins uninvolved by invasive carcinoma: Distance from closest margin: 4 mm. Perineural, lymphatic, and venous involvement all present [**1-2**] T-tube study -Flow of contrast from the intrahepatic biliary tree into the small bowel without apparent hold up or obstruction. No contrast extravasation Brief Hospital Course: Patient care taken over from OB/Gyn service on [**2135-12-26**] after cesearean section post-op care. Patient transferred to the West [**Hospital 8**] campus and preop'ed for Whipple procedure on [**12-17**] (HD10). Patient tolerated the procedure well and was admitted to the ICU for acute post-operative care. Patient had Hct of 31.5 on POD1, but required fluid boluses to maintain urine output; patient had good pain control with epidural. Patient was transferred to the transplant surgery floor on [**2135-12-29**]. Patient developed headache on [**12-29**] while getting out of bed to a chair, APS following patient recommended caffeine and bedrest, as patient obtaining good pain relief with epidural. Routine post-op care was continued on [**12-30**], with continued HA, but good pain relief with epidural. Patient remained without flatus but appropriate urine output while remaining AF with stable VS. To prevent future HA, APS discontinued the epidural on [**12-31**] and a blood patch placed through the old epidural site. NGT was removed on the same day and patient placed on sips with good tolerance. Patient was walking on [**1-1**] and diet was advanced, with clearance by PT obtained as patient fully ambulatory. Patient obtained T-tube cholangiogram on [**1-2**] with above mentioned results and amylase of 19 obtained. Patient was advanced to full regular renal diet on [**1-3**] with capped T-tube, and JP drain removed. Patient weaned off of TPN started in prepartum period, and LFT's continued to trend downward, while patient monitored on [**1-4**] for increased PO intake. KUB was obtained to evaluate for possible obstruction or ileus, but was WNL. Patient discharged home on [**1-5**] with good PO intake, appropriate ambulation, and good PO pain control Medications on Admission: Reglan, Anzemet, Morphine, Pepcid 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. Acetaminophen-Caff-Butalbital [**Medical Record Number 5300**] mg Tablet Sig: [**2-13**] Tablets PO Q4-6H (every 4 to 6 hours) as needed: do not exceed 6 tabs per day. Disp:*56 Tablet(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed: breakthrough pain. Disp:*30 Tablet(s)* Refills:*0* 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for delayed gastric emptying. Disp:*42 Tablet(s)* Refills:*1* 6. Anzemet 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*2* 7. Ultram 50 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: cesarean delivery mechanical GI obstruction cholangiocarcinoma spinal headache Discharge Condition: stable Discharge Instructions: call [**Telephone/Fax (1) 242**] if fevers, chills, nausea,vomiting, inability to take medications, increased abdominal pain, worsening headache, jaundice, redness/pus/drainage from t.tube or any questions. Labs weekly Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**], MD, PHD[**MD Number(3) **]:[**Telephone/Fax (1) 242**] Date/Time:[**2136-1-11**] 2:00 Please call with any questions or to reschedule your appointment [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**] Completed by:[**2136-1-5**]

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Discharge summary

report

Admission Date: [**2172-12-22**] Discharge Date: [**2172-12-30**] Date of Birth: [**2101-8-23**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 19817**] Chief Complaint: MS changes Major Surgical or Invasive Procedure: Intubation/Extubation History of Present Illness: Ms. [**Known lastname 8817**] is a 71 year old female with a complicated medical course over the past year, who is being transferred from OSH on her son's request. She was transferred to the OSH from nursing home after low grade temperature and agitation. Her past medical history includes storke, seizure disorder, atrial fibrillation, type 2 diabetes mellitus, recent hospitalization for enterococcal UTI, frequent MS change, for enterococcal urinary tract infection, moraxella bacteremia, altered mental status, subdural hemorrhage, acute renal failure thought secondary to dehydration, pyelonephritis, C-diff colitis. Her baseline mental status is AOx1 per reports. She had an ICU stay for status epilepticus, requiring IV midazolam. Upon presentation to the OSH she was reported to have had low grade fevers, and vomiting. She was found to have UTI per UA, and was given Levofloxacin and Ceftriaxone. Flu swab was reportedly negative. Per notes, CT head was obtained and neg. MS difficult to assess. Unclear baseline. A+Ox0-1. Not trully verbal, alert. Uncooperative with exam. In our ED, T 95.6 150/70 88 16 100RA, CT abdomen was obtaine to work up elevated LFTs, and prelim report negative except for dilated rectum due to fecal load. Past Medical History: 1. stroke 30 years ago (? location-images not available) with residual right hemiparesis, dysarthria, and difficulty to express herself 2. Type 2 DM, insulin dependent 3. HLP 4. atrial fibrillation, not on coumadin 5. h/o recurrent UTI 6. seizure disorder, unspecified 7. h/o angina 8. PVD 9. chronic thrombocytopenia 10. anemia 11. depression 12. osteoporosis 13. dementia with delusional features 14. obesity 15. bilateral cataract surgery [**79**]. prior admit for B chronic SDH and acute parafalcine SDH. Social History: Home: Lives in nursing home. Son is HCP, niece is training to be a nurse and is involved in her care. EtOH: None Drugs: None Tobacco: None Family History: Could not obtain full family history due to patient's baseline dementia and altered mental status Physical Exam: Exam on admission to medicine service: Vitals: T: 97.4 BP: 150/70 P: 88 R: 20 O2: 94% General: lethargic, poorly arousable, responds to painful stimuly, does not follow commands HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally anteriorly 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: cold and clamy, no clubbing, cyanosis or edema Neurological exam by neurology resident: Mental status: Not alert or arousable to voice; eyes closed during exam; grimaces to noxious stimuli. Does not follow commands. Cranial Nerves: I: not tested; II: Pupiles symmetric 4mm; reactive to light. Does not blink to visual threat. III, IV, VI: gaze was upwards initially; then moved to midline; L exotropia V, VII: Right facial weakness. VIII: hearing appears intact to voice IX, X, [**Doctor First Name 81**], XII: tongue midline. Motor: Increased tone R arm and leg. No observed myoclonus or tremor ; retracts both legs and arm L>>R to noxious stimuli. Sensation: Withdraws from painful stimuli bilaterally L>>R, localizes pain by moving bilateral upper extremities, making moaning sounds. Reflexes: B T Br Pa Pl Right 1 1 1 0 0 Left 1 1 1 0 0 R upgoing toe Coordination and gait not assessed Exam at time of discharge: Pertinent Results: [**2172-12-22**] 06:15AM BLOOD WBC-5.9 RBC-3.98* Hgb-12.2 Hct-38.2 MCV-96 MCH-30.6 MCHC-31.8 RDW-14.6 Plt Ct-123* [**2172-12-22**] 06:15AM BLOOD Neuts-71* Bands-0 Lymphs-18 Monos-9 Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2172-12-22**] 06:15AM BLOOD PT-14.5* PTT-27.2 INR(PT)-1.3* [**2172-12-22**] 06:15AM BLOOD Glucose-120* UreaN-41* Creat-0.9 Na-145 K-4.8 Cl-106 HCO3-26 AnGap-18 [**2172-12-27**] 01:55AM BLOOD Glucose-145* UreaN-7 Creat-0.5 Na-140 K-3.4 Cl-109* HCO3-24 AnGap-10 [**2172-12-22**] 06:15AM BLOOD ALT-300* AST-307* CK(CPK)-59 AlkPhos-142* TotBili-0.4 [**2172-12-26**] 03:00AM BLOOD ALT-73* AST-35 AlkPhos-83 TotBili-0.2 [**2172-12-22**] 06:15AM BLOOD Lipase-33 [**2172-12-23**] 04:55AM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.5 Mg-1.7 [**2172-12-26**] 03:00AM BLOOD Albumin-3.1* Calcium-7.3* Phos-2.9 Mg-1.7 [**2172-12-22**] 06:15AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.010 [**2172-12-22**] 06:15AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD [**2172-12-22**] 06:15AM URINE RBC-0-2 WBC-[**6-24**]* Bacteri-MOD Yeast-NONE Epi-[**3-19**] Microbiology: URINE CULTURE (Final [**2172-12-25**]): OBTAINED AFTER PATIENT HAD ALREADY RECEIVED 2 DAYS OF CEFTRIAXONE ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- =>16 R C.Diff - negative x2 BCx - pending Imaging: EEG [**12-22**]: IMPRESSION: This is an abnormal portable EEG due to four non-convulsive electrographic seizures as detailed above. The interictal activity was slow and disorganized consisting of a mixed alpha/theta activity. Continuous EEG monitoring is recommended to ensure resolution of these ictal events. [**12-23**]: IMPRESSION: This telemetry captured multiple periods of activity described above without clinical correlate. The interpretation of this is unclear. It may represent electrographic seizure activity, but each event had a gradual onset and evolved gradually, with a gradual offset. The slower progression and evolution is not typical of electrographic seizures, but cannot be excluded. Patterns like this can also be seen with electrographic arousals, and the patient's known structural abnormality involving the left hemisphere (left MCA stroke,) may be the cause of the asymmetry of progression. There were no interictal discharges seen in this recording. The background activity was slow suggestive of a moderate encephalopathy. CXR [**12-22**] - IMPRESSIONS: No acute cardiopulmonary abnormality. Low lung volumes. CT abdomen/pelvis: IMPRESSION: 1. Massively fecal impacted rectum. 2. Persistent bibasilar nodular opacities and atelectasis which is again nonspecific. Continued followup is recommended. 3. 3.9cm rounded structure in the left adnexa may represent an exophytic fibroid or enlarged ovary. Recommend pelvic ultrasound after fecal disimpaction. LENIs - IMPRESSION: No evidence of deep vein thrombosis in either leg. Brief Hospital Course: This is a 71 yo female with complicated medical including a stroke ~ 30 years ago with residual aphasia and right hemiparesis, chronic SDH bilaterally, afib off AC due to SDH, seizure disorder, and recurrent cycles of UTI/urosepsis (moraxella bacterimia) and C.Diff infections, who had her dilantin discontinued on [**11-19**], and was noted to develop decreased level of alertness and confusion at her NH 2 days PTA. She was diagnosed with a UTI however did not improve after one day of treatment and was thus transferred to OSH, then [**Hospital1 18**]. She was initially admitted to the medicine service, where CFTX was stopped. A neurology service was consulted to determine whether patient was in NCSE. Her initial exam showed that she does not follow commands, eyes closed, eyes midline, mumbles with pain, and retracts both legs and arms L>R to noxious stimuli. Because the initial EEG showed signs concerning for NCSE, she was transferred to Neurology service for further monitoring and treatment on [**2172-12-24**]. Her baseline state includes (confirmed with NH staff): Awake, alert, interacting with staff (maintains eye contact) and answers in one word, often with intelligible sounds without reproducibly following directions with dense right sided hemiparesis requiring full assisstance with transfers and ADLs. # MS changes/Sz disorder: Decreased alertness and responsiveness. Etiology was felt to be most likely encephalopathy due to E.Coli UTI in setting of already compromised neuronal reserve, however, given prior hx of Sz/Status and discontinuation of dilantin on [**11-19**], NCSE evaluation was performed. Initial EEG was suggestive of NSCE, patient was restarted on Dilantin, however for multiple reasons, therapeutic levels of dilantin were not reached until [**12-24**]. Keppra was increased to 1500mg IV bid. Secondary review of EEG suggested continued NCSE thus patient was started on midazolam gtt which required temporary intubation. Once this was achieved, EEG showed no epiletiform activity. Patient was extubated on [**12-25**] and midazolam gtt weaned off. Her level of alertness improved, but she remained encephalopathic and became somewhat agitated. Dilantin levels were maintained in the 18 - 25 (corrected for alb) range. There were no further clear ictal or interictal epileptiform activity seen. Of note OSH CT head revealed no overall change from prior imaging. The following medications were discontinued Toradol, Compazine, and Methenamine, as these were not indicated and could contribute to patients current presentation. She was started on prn Zyprexa for agitation. She was changed to PO medications (passed speech as swallow for ground solids, thin liquids). Dilantin was changed to 100mg TID and Keppra to 1500mg [**Hospital1 **]. She should have a dilantin level checked 5 days after discharge and albumin corrected level's goal is [**11-3**]. This should be communicated with Dr. [**Last Name (STitle) 877**] at [**Hospital1 18**] [**Telephone/Fax (1) 41108**]. # UTI: Initially CFX was stopped due to no available UA or Cx data and a contaminated UA. Following OSH records arrival, pt was noted to have a E.Coli UTI with > 100K colonies. CFTX was restarted on [**12-25**]. Patient received a total of 7 days of IV CFTX discontinued on [**12-27**]. # Hypertension: continued outpatient BP medications. Intermittently hypertensive over [**12-29**] - [**12-30**] due to missing medications (pt refused am/pm doses of medicines). Verapamil was increased to 160mg TID. # Transaminitis. Unclear etiology but suspected due to polypharmacy, incuding use of methenamine. CT of abdomen/pelvis was obtain to evaluate for vascular and ostructive etiologies. Hepatitis panel showed negative Ab for all HBV antigens and HCV antigens. She received first immunization against HepB vaccine. On initial evaluation with CT abd/pelvis, a 3.9cm rounded structure in the left adnexa was noted that may represent an exophytic fibroid or enlarged ovary. Pelvic ultrasound ultrasound was recommended as a follow up examination. Toradol, compazine and methenamine were withheld. With this, transaminitis improved and LFTs at time of discharge are reported in pertinent results (ALT/AST 73/35). One of the reported AEs for Methanamine is AST/ALT elevation. # Type 2 DM: continued home lantus and SS. # Afib: Patient was noted to be in sinus rhythm. She was not on coumadin due to SDH. She was continued on ASA and Plavix. # Communication: #. Communication: Emergency contact [**Name (NI) **] [**Name (NI) 84805**] [**Name (NI) 8817**] [**Telephone/Fax (1) 84806**] cell # is best way to reach him, [**Telephone/Fax (1) 84807**] home #, [**Telephone/Fax (1) 84808**] work #. Medications on Admission: Actonel 35mg daily Amlodipine 10 mg daily ASA 81 mg daily Lisinopril 40 mg daily Plavix 75 mg daily Simvastatine 20 mg daily Keppra 750 mg [**Hospital1 **] Tylenol 1000 mg [**Hospital1 **] + 325 q6h prn Methenamine [**Hospital1 **] 1 tab Verapamil 240 mg ER [**Hospital1 **] Oral vancomycine 125 mg [**Hospital1 **] Neurontine 300 mg qhs Lantus 25 mg qhs Novolin prn ss Dulcolax supp 10 mg prn MOM prn Hydralazine 10 mg po q6h compazine 10 mg q6h prn Trazadone 50 -100 mg q6h prn restlessness Tramadole 50 mg q4h Albuterole q4h prn Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 2. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 3. Actonel Oral 4. Amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 5. Lisinopril 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 8. Levetiracetam 500 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2 times a day). 9. Phenytoin 125 mg/5 mL Suspension [**Hospital1 **]: One (1) PO TID (3 times a day). 10. Verapamil 80 mg Tablet [**Hospital1 **]: Two (2) Tablet PO three times a day: hold for HR < 60, BP < 100 . 11. Vancomycin 125 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q 12H (Every 12 Hours). 12. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO HS (at bedtime). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 15. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Twenty Five (25) units Subcutaneous at bedtime. 16. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: per sliding scale Subcutaneous three times a day. 17. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet, Rapid Dissolve PO BID prn as needed for agitation/distress. 18. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day. 19. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 20. Hydralazine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6) hours: hold for sbp < 100. 21. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation every 6-8 hours as needed for shortness of breath or wheezing. 22. Outpatient Lab Work Dilantin level every five days prior to AM dose until seen by Dr. [**Last Name (STitle) 877**] at [**Hospital1 18**]. Please communicate the level to Dr. [**Last Name (STitle) 877**] at [**Telephone/Fax (2) 84855**] Discharge Disposition: Extended Care Facility: [**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**] Discharge Diagnosis: Primary: Encephalopathy, urinayr tract infection, possible non-convulsive seizures Secondary: Stroke, subdural hematomas, C.diff infetion Discharge Condition: Neurological examination notable for: Awake, alert, communicating unintelligibly with examiner at most times, able to name the names of the five sons. [**Name (NI) 30983**] with motor and comprehensive aphasia. Unable to follow commands reporducibly. RUE is spastic with extensor reaction to noxious, triple flexion to noxious stimulation in RLE, while full strenght in LUE/LLE. Upgoing Right toe. Discharge Instructions: You were transferred to [**Hospital1 18**] from OSH after altered mental status. She was confirmed to have a urinary tract infection, this was treated with ceftriaxone. Her C.Diff infection was treated with vancomycin. There was some concern that she was having continuous non-convulsive seizures, and thus required re-institution of dilantin and temporary treatment with midazolam and intubation. After a dilantin was therapeutic, no more seizure activity was noted and midazolam was dicontinued, patient extubated. Her mental status improved. It is suspected that majority of her presentation was due to a urinary tract infection. The following changes were made to her medications: - Dilantin restarted at 100mg three times daily - Keppra increased to 1500mg twice daily - Verapamil increased to 160mg three times daily - Vancomycin by mouth decreased to 125mg twice daily - Zydis started on as needed basis - Toradol, Compazine, and Methenamine were discontinued - Received 1st dose of hepatitis B vaccination. She was discharged with improved mental status and motor examination back to baseline. Should she develop any further complications, or symptoms concerning to caretakers (see below), please call the responsible physician and refer patient to the emergency room. Followup Instructions: NEUROLOGY: Provider: [**First Name11 (Name Pattern1) 12562**] [**Last Name (NamePattern4) 47259**], MD Phone:[**Telephone/Fax (1) 3506**] Date/Time:[**2173-2-8**] 1:30 Completed by:[**2173-1-3**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

15283, 15386

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330, 354

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Discharge summary

report+addendum

Admission Date: [**2183-2-10**] Discharge Date: [**2183-3-3**] Date of Birth: [**2134-1-2**] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This dictation reflects the events after the patient was transferred to the medical service. The patient is a 47-year-old woman with AIDS (CD4 positive, T cell count of 3, last viral load of 66,400) and seizures, status post cerebrovascular accident, who has had a long and complicated hospital course including initial intubation in the medical intensive care unit. She was transferred to the neurosurgical intensive care unit for status epilepticus, then to the neurology service and ultimately to the medicine service. The seizures were initially difficult to control. She was placed in a phenobarbital coma and then maintained on phenobarbital afterward. She has active infectious disease issues including methicillin-resistant Staphylococcus aureus pneumonia from the ventilator, for which she was treated with linezolid ultimately; persistence of fevers despite multiple antimicrobial agents. PAST MEDICAL HISTORY: 1. HIV with several opportunistic infections including Pneumocystis carinii pneumonia and esophageal candidiasis. 2. Psoriasis. 3. Status post cerebrovascular accident in the ventral pontine area. 4. Seizure disorder. MEDICATIONS ON PRESENTATION: 1. Keppra 750 mg b.i.d. 2. [**Doctor First Name **]. 3. Azithromycin 1 gram once a week. 4. Dapsone. 5. Fioricet. 6. Kaletra. 7. Lamivudine. 8. Stavudine. 9. Variconazole. 10. Norvasc. 11. Sertraline. 12. Zoloft. ALLERGIES: The patient is allergic to sulfur-containing medicines. PHYSICAL EXAMINATION: On transfer to the medical service her temperature was 96.7 with a maximum of 100, heart rate 72, blood pressure 146/89, respiratory rate 20, oxygen saturation 100% on 12 liters. Generally she was in no acute distress. She was thin and weak appearing. Neck: The neck was slightly tender to palpation posteriorly along the band holding her sling to her right arm. Chest: The patient had a right subclavian line upon transfer to the medical service. The entry site was clean, dry and intact. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm, normal S1 and S2, no extra sounds. Abdomen: Soft, slightly decreased bowel sounds, nontender, distended. Extremities: Her right arm was in a sling. Neurologic: The patient had a waxing mental status. She would recognize occasionally the people in her room, however there were times when she did not. She had hyperprosodic speech. She was able to follow some commands. LABORATORY DATA: White blood cell count was 7.4, hematocrit 37.4, platelet count 266. Chemistry panel was sodium 133, potassium 3.8, chloride 100, bicarbonate 20, BUN 17, creatinine 0.7, glucose 107. HOSPITAL COURSE: Upon transfer to the medical service the patient was continued on the following medications: 1. Linezolid 600 mg IV every 12 hours. 2. Nystatin 5 mg t.i.d. 3. Stavudine 20. 4. Lamivudine 1 tablet q.d. 5. Ritonavir/lopinavir 3 tablets b.i.d. 6. Dapsone 100 mg daily. 7. Azithromycin 1.2 grams every week. 8. Variconazole. 1. Infectious disease: The patient was maintained on her HAART, PCP prophylaxis and [**Doctor First Name **] prophylaxis, as well as the antifungal [**Doctor Last Name 360**] and linezolid as stated above. While no new focal source of infection was identified, she had persistent blood cultures, serial blood cultures for bacteria, fungus and tuberculosis. Interval urinalysis likewise was normal. A panel of extra tests was also done revealing namely that the patient did not have C. difficile toxin present in her stool. She did not have CMV antigen in her blood. RPR and mycoplasma testing were also negative. 2. Seizure disorder: The patient was maintain on phenobarbital 50 mg IV every 12 hours and then switched to 60 mg b.i.d. p.o. For the duration of her hospital course she had no further seizure activity. 3. The patient had a right humerus fracture however she stated that the pain was mostly radiating to her neck under the area of her sling. The pain was readily controlled with occasional use of morphine sulfate solution by mouth as well as intravenously. 4. Hypertension: The patient's hypertension regimen ultimately settled on metoprolol 150 mg by mouth p.o. t.i.d. and amlodipine 5 mg daily. The patient underwent bedside speech and swallow evaluation and it was deemed safe for her to swallow, however she should receive a pureed diet with thick nectar liquids. It was also safe for her to swallow pills. On [**2183-2-28**] the patient's family stated that they wished to pursue comfort measures only. Intravenous medications were withdrawn and converted to p.o. The patient was encouraged to eat and drink ad lib. DISCHARGE DIAGNOSES: 1. AIDS. 2. Seizure disorder. 3. Hypertension. 4. Right humerus fracture. DISCHARGE MEDICATIONS: 1. Variconazole 200 mg tablets, 1 tablet every 12 hours. 2. Azithromycin 1.2 grams q. Friday. 3. Dapsone 100 mg tablet q.d. 4. Ritonavir/lopinavir 100-400/5 solution, one solution by mouth b.i.d. 5. Lamivudine 150 mg daily. 6. Stavudine 20 mg capsule once daily. 7. Acetaminophen 325 mg every 4-6 hours as needed. 8. Albuterol inhaler 1-2 puffs as needed. 9. Levetiracetam 1,000 mg b.i.d. 10. Amlodipine 5 mg daily. 11. Lorazepam 0.5 mg tablets, 1-4 tablets as needed every four to six hours. 12. Metoprolol 150 mg p.o. t.i.d. 13. Famotidine 20 mg p.o. b.i.d. 14. Phenobarbital 300 mg by mouth twice daily. 15. Morphine sulfate 0.5 to 4 mg by mouth as needed. 16. Nystatin swish and swallow as needed. 17. Ipratropium inhaler as needed. 18. Linezolid 600 mg tablets to complete a 10-day course. DISPOSITION: The patient was transferred to hospice. [**Name6 (MD) 7158**] [**Last Name (NamePattern4) 7159**], M.D. [**MD Number(1) 102966**] Dictated By:[**Name8 (MD) 7102**] MEDQUIST36 D: [**2183-3-3**] 08:02 T: [**2183-3-3**] 08:28 JOB#: [**Job Number 108869**] Name: [**Known lastname 12459**], [**Known firstname 194**] Unit No: [**Numeric Identifier 17825**] Admission Date: [**2183-2-10**] Discharge Date: [**2183-3-6**] Date of Birth: [**2134-1-2**] Sex: F Service: [**Doctor Last Name **] After further consultation with patient's family, highly active antiretroviral therapy was discontinued as well as [**Doctor First Name **] prophylaxis and PCP [**Name Initial (PRE) 2515**]. The new discharge medication list is as follows: DISCHARGE MEDICATIONS: 1. Voriconazole 200 mg tablets every 12 hours. 2. Acetaminophen 325 to 650 mg every four to six hours as needed. 3. Albuterol 90 mcg aerosol one to two puffs every six hours as needed. 4. Keppra 1000 mg b.i.d. 5. Amlodipine 5 mg daily. 6. Lorazepam 0.5 mg to 2.0 mg every four to six hours as needed. 7. Metoprolol 150 mg p.o. t.i.d. 8. Famotidine 20 mg b.i.d. 9. Phenobarbital 60 mg p.o. b.i.d. 10. Morphine sulfate 0.5 to 2 mg every four to six hour oral solution as needed. 11. Nystatin to affected areas as needed. 12. Ipratropium nebulized solution as needed. 13. Linezolid 600 mg by mouth every 12 hours for three days following discharge. [**Name6 (MD) 1662**] [**Last Name (NamePattern4) 4337**], M.D. [**MD Number(1) 4338**] Dictated By:[**Name8 (MD) 9242**] MEDQUIST36 D: [**2183-3-6**] 15:12 T: [**2183-3-6**] 14:12 JOB#: [**Job Number 17833**]

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icd9cm

[ [ [] ] ]

[ "96.04", "03.31", "00.14", "96.72" ]

icd9pcs

[ [ [] ] ]

4838, 4913

6579, 7483

2835, 4817

1664, 2817

168, 1072

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81,359

163,088

40751

Discharge summary

report

Admission Date: [**2114-7-26**] Discharge Date: [**2114-8-1**] Date of Birth: [**2066-12-25**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 896**] Chief Complaint: scrotal pain Major Surgical or Invasive Procedure: scrotal abscess I&D [**2114-7-26**] History of Present Illness: This is a 47 yo M with history of DM, MI (s/p BMS to RCA [**12/2113**]), PE (on coumadin) who presented from [**Hospital **] Hospital ER with with 1.5 weeks of increased left scrotal swelling and pain at the base of the scrotum worse over the day prior to presentation. He has a 5-year history of 12 abscesses which have drained spontaneously. At [**Hospital1 **], he had a testicular ultrasound with moderate bilateral scrotal swelling without testicular abnormalities noted and then a CT scan that showed scrotal cellulitis and a left scrotal abscess. Labs were notable for a leukocytosis to 15K and he was given Vancomycin, Piperacillin-Tazobactam, and Clindamycin. For INR of 12.2 he received 5mg IV Vitamin K. He was then transferred to [**Hospital1 18**] for urgent urology evaluation. Upon arrival to our ED, VS 96.5, 99, 116/81, 18, 95/4L. Labs were significant for creatinine 1.2, calcium 7.9, lactate 1.3, WBC 15.4 with N73.2, platelets 102. INR was 6.0. He was seem by urology and noted to have the abscess draining through a tract towards the left perirectal part of the left hemiscroton and I&D done with 300 cc of "maroon,bloody, foul-smelling pus" which was sent for culture. Urology felt this was more consistent with abscess and not suggestive of Fournier's gangrene. There was immediate pain relief with drainage of the abscess and the wound was packed. The patient's SBP's dropped to the 80s systolic on two occasions while in the ED but improved to 100s after three liters IVF. Given his recent hypotension he was triaged to the MICU for sepsis. On the floor, he denied recent fevers and endorsed scrotal pain. He had mild dyspnea, which he has had previously and relates to COPD. No other significant complaints. Past Medical History: -CAD complicated by myocardial infarction in [**2113-12-4**] with placement of bare metal stent in RCA at [**Hospital3 2358**] -Insulin dependent diabetes mellitus -COPD -OSA (not adherent to CPAP) -Pulmonary Emboli X6, last 1 year ago, on coumadin with INR 1.8 X 3 months within the past several months -Atrial flutter -HLD -Cerebrovascular disease (unclear history) Social History: Former salesman, now unemployed on disability. - Tobacco: one pack/month - Alcohol: drinks every 2-3 days, denies hx of withdrawal - Illicits: denies Family History: No history of venous thromboembolic disease. Positive for history of diabetes mellitus and atrial fibrillation. Physical Exam: Admission Exam: Vitals: 96.3, 149/84, 112, 9, 97/4L General: Alert, oriented, no acute distress, falling asleep during conversation HEENT: Sclera anicteric, MMM, oropharynx clear Neck: JVP could not be assessed Lungs: Distant heart sounds and clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic with regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present but hypoactive, no rebound tenderness or guarding, no organomegaly GU: no foley, large erythematous, tense tender scrotom with wick in place in drainage site posterior to left scrotum. Erythema/tenderness does not extend onto skin of abdomen or buttocks ext: clamy b/l feet with 1+ DP b/l, pitting edema [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]>L . Discharge Exam: Vitals: 98.3, 149/84, 89, 18, 97/2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: JVP could not be assessed Lungs: Distant heart sounds and clear to auscultation bilaterally, no wheezes, rales, ronchi CV: NSR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley, slightly enlarged, erythematous scrotum that is much improved since admission. I&D site is completely healed and is now intact without e/o infection. ext: wwp, no c/c/e Pertinent Results: [**2114-7-25**] 10:55PM BLOOD WBC-15.4* RBC-5.01 Hgb-16.3 Hct-48.0 MCV-96 MCH-32.5* MCHC-33.9 RDW-15.5 Plt Ct-102* [**2114-7-25**] 10:55PM BLOOD Neuts-73.2* Lymphs-18.0 Monos-5.1 Eos-3.0 Baso-0.8 [**2114-7-25**] 10:55PM BLOOD PT-55.8* PTT-40.0* INR(PT)-6.0* [**2114-7-25**] 10:55PM BLOOD Glucose-295* UreaN-29* Creat-1.2 Na-135 K-4.7 Cl-95* HCO3-32 AnGap-13 [**2114-7-26**] 03:50AM BLOOD ALT-42* AST-36 CK(CPK)-152 AlkPhos-101 TotBili-0.8 [**2114-7-25**] 10:55PM BLOOD CK-MB-7 cTropnT-<0.01 [**2114-7-25**] 10:55PM BLOOD Calcium-7.9* Phos-4.7* Mg-1.8 [**2114-7-27**] 08:01AM BLOOD Vanco-11.5 [**2114-7-26**] 07:20AM BLOOD Type-ART pO2-69* pCO2-63* pH-7.29* calTCO2-32* Base XS-1 . Cultures: MRSA SCREEN (Final [**2114-7-28**]): No MRSA isolated. [**2114-7-26**] 12:30 am SWAB GRAM STAIN (Final [**2114-7-26**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2114-7-30**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. DR [**First Name (STitle) **] BRUSH ([**Numeric Identifier 29614**]) REQUESTED SPECIATION OF ORGANISMS [**7-28**]. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES. PROBABLE MICROCOCCUS SPECIES. SPARSE GROWTH. NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. RARE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES. ANAEROBIC CULTURE (Final [**2114-7-30**]): NO ANAEROBES ISOLATED. Blood Culture, Routine (Final [**2114-8-2**]): NO GROWTH. . TTE [**7-26**] The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF = 75%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: dilated, hypocontractile right ventricle with at least moderate pulmonary hypertension; small, hyperdynamic left ventricle . [**7-26**] BILATERAL LOWER EXTREMITY ULTRASOUND: No deep venous thrombosis involving the right or left lower extremity. . [**7-26**] CXR: FINDINGS: An ill-defined opacity at the left lung base, likely atelectasis, could be related to a bulge to the left mediastinal contour just inferior to the aortic knob could be a left hilar or mediastinal mass or, less likely aneurysm of the descending aorta. . No pleural effusion or pneumothorax. . [**7-26**] CTA: 1. Mild septal thickening predominantly in the lung apices, consistent with mild volume overload. 2. Scattered symmetric mediastinal and hilar lymph nodes measuring up to 11 mm. Findings may be reactive secondary to mild pulmonary vascular congestion; however, the differential is broad and continues to include inflammatory and neoplastic etiologies. Therefore, follow-up chest CT in three months is recommended to evaluate for interval resolution. 3. Mild centrilobular emphysema, predominantly at the lung apices. 4. No pulmonary embolism or acute aortic syndrome. Brief Hospital Course: Primary Reason for Admission: This is a 47 yo M with history of DM, CAD/MI, PE on coumadin, presenting with scrotal abscess and fever admitted to the ICU after drainage of his abscess then downgraded to floor for discharge pending improvement in scrotal swelling. Active Problems: 1) Sepsis from scrotal abscess: Patient presented with septic physiology that improved in the setting of receiving broad spectrum antibiotics (vancomycin/piperacillin-tazobactam) and and having abscess drained by urology. Unclear what portal of entry was but given history of folliculitis in area possible this evolved into cellulitis. As of his second hospital day the patient began to manifest considerable improvement in his septic physiology in the context of antibiotic treatment. Cultures were obtained and grew out multiple bacteria as detailed in results. His antibiotics were narrowed to Levo/Flagyl and the patient's symptoms markedly improved prior to discharge. 2) Presumed Chronic Right Ventricular Failure: The patient had persistent mild hypoxia in the ICU, sinus tachycardia, and echo showing RV dilation and hypokinesis. This raised concern of acute PE (though he was supratherapeutic on coumadin at presentation). CTA without PE though did show emphysema, which along with his OSA and recurrent previous PE's are probably the etiology of his RV failure. Persistent sinus tach thought due to right ventricle being unable to augment output without tachycardia. 3) Sinus tachycardia: Worked up as described. Over the course of hospitalization this improved with adequate pain control and resolution of fever. 4) History of pulmonary embolism: Given INR of 12 at presentation and surgery his coumadin was held until INR hit 2.5 at which time it was restarted at half dose (5 mg per day). At time of discharge INR was 1.2 and the patient was bridged with Lovenox with instructions to f/u his INR with PCP. Chronic Problems: 5) Hypoxia: The patient remained mildly hypoxic over the first few days in the hospital with primary etiology thought to be his COPD and fluid shifts. This improved over the course of his time on the medical floor, but the patient was sent home with supplemental O2. 6) Diabetes: [**Last Name (un) **] was consulted and recommended changing the patient's home oral agents to long acting once daily pills due to non-compliance with twice daily dosing. Insulin teaching was done and the patient was also sent home with instruction to use insulin to supplement his oral agents. 7) CAD: He had no signs or symptoms of ACS. He had two sets of cardiac enzymes that were negative for signs of infarction. His aspirin was continued throughout the hospitalization. 8) Hyperlipidemia: He was continued on his home simvastatin 9) Hypertension: His lisinopril, Metoprolol, and furosemide were all initially held given hypotension but then restarted without incident once the patient's hemodynamic status had stabilized. Transitional Issues: Pt was discharged home with instructions to follow up with his PCP, [**Name10 (NameIs) **] to follow up the results of his chest CT that showed mediastinal LAD. Urology and Endocrinology follow up were also arranged. Medications on Admission: (confirmed with patient) glyburide 2mg [**Hospital1 **] simvastatin 80 mg daily lisinopril 5 mg daily metformin 500mg [**Hospital1 **] metoprolol succinate ER 200 mg daily Advair Diskus 500 mcg-50 mcg/dose [**Hospital1 **] Spiriva with HandiHaler 18 mcg daily ProAir HFA 90 mcg/Actuation Aerosol Every 6-8 hrs, as needed furosemide 80 mg Tab Oral daily aspirin 81 mg Tab Oral daily Coumadin 10 mg Tab Oral daily Discharge Medications: 1. nebs nebulizer machine for COPD 2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation every 6-8 hours. Disp:*qs * Refills:*2* 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheeze. Disp:*qs * Refills:*0* 5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*qs Tablet(s)* Refills:*2* 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). Disp:*qs Tablet Extended Rel 24 hr(s)* Refills:*2* 8. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*qs Tablet Extended Release 24 hr(s)* Refills:*2* 9. Outpatient Lab Work Please Have your INR Checked on [**8-3**] and [**8-7**] and faxed to Dr. [**Last Name (STitle) 34030**] at [**Telephone/Fax (1) 89095**] 10. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. 12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-4**] puffs Inhalation every 6-8 hours. 13. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day. 14. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* 15. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: take with 200mg for a total of 225mg each daily. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* 16. enoxaparin 150 mg/mL Syringe Sig: One [**Age over 90 8821**]y (140) mg Subcutaneous Q12H (every 12 hours). Disp:*14 syringes* Refills:*1* 17. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 18. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 19. Lantus 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. Disp:*360 units* Refills:*1* 20. One Touch Basic System Kit Sig: One (1) kit Miscellaneous . Disp:*1 kit* Refills:*0* 21. lancets misc. Kit Sig: One (1) lancets Miscellaneous four times a day. Disp:*100 lancets* Refills:*2* 22. insulin syringes (disposable) 1 mL Syringe Sig: One (1) Miscellaneous at bedtime: to be used w lantus. Disp:*100 syringes* Refills:*0* 23. blood glucose strip blood glucose strip dispense 100 strips 1 refill Discharge Disposition: Home Discharge Diagnosis: Primary: scrotal Abscess Secondary: COPD Diabetes Type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 89096**], It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted to the hospital with a scrotal abscess. You were evaluated by Urologists, who felt it was necessary to drain the infected fluid from your scrotum. You were given antibiotics and your condition improved. Of note, during your hospitalization your INR (couamdin level) was high. After correction your INR went too low, so you are now on coumadin and a medication called lovenox (enoxaparin) to keep your blood thin while your coumadin levels rise to appropriate levels. At discharge your INR was 1.2. You will need to have your INR checked on [**8-3**] and [**8-7**]. You had some shortness of breath during your hospital stay. There were no signs of infection or blood clot. These symptoms are likely a result of COPD. Your diabetes was poorly controlled. You were evaluated by a diabetes specialist and started on injectable insulin. Please check you blood sugar 4 times per day. Call you doctor if you sugar is less than 80. A CT scan of your chest revealed some lymph nodes in your chest, the significance of which is uncertain. You should follow up with your primary care physician regarding these findings. During your hospital stay, we made the following changes to your medications: DIABETES - STOPPED Glyburide, and STARTED Glipizide XL - STOPPED Metoformin, and STARTED Metformin XR - STARTED injectable insulin (lantus) INFECTION - STARTED Flagyl and Levofloxacin, to be continued for a total of 2 weeks BLOOD THINNING - STARTED Enoxaparin - DECREASED Coumadin BREATHING - STARTED albuterol / ipratropium nebulizers HEART - INCREASED Toprol (metoprolol) Followup Instructions: PCP [**Name Initial (PRE) **]:Thursday, [**8-9**] at 10:45am With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],MD Location: [**Hospital 17457**] MEDICAL Address: 100 [**Doctor Last Name **] CENTER STE 126Q, [**Hospital1 420**],[**Numeric Identifier 15489**] Phone: [**Telephone/Fax (1) 17458**] Urology Appointment:Wednesday,[**8-15**] at 3pm Name: [**Last Name (LF) **], [**First Name3 (LF) **] K. MD Location: [**Hospital1 **] Address: [**Location (un) **], [**Hospital Ward Name **] 3RD FL, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 921**] Endocrinology Appointment: Tuesday, [**8-28**] at 10am With: Dr. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 818**] Location:[**Last Name (un) **] Diabetes Center One [**Last Name (un) **] Place, [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2384**] ** You have been put on a wait list for a sooner appt. Also, this initial appointment can take between 2 and 3 hours.

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icd9cm

[ [ [] ] ]

[ "61.0" ]

icd9pcs

[ [ [] ] ]

14585, 14591

8284, 11234

316, 353

14693, 14693

4299, 8261

16564, 17627

2706, 2821

11938, 14562

14612, 14672

11501, 11915

14844, 16541

2836, 3655

3671, 4280

11255, 11475

264, 278

381, 2127

14708, 14820

2149, 2519

2535, 2690

80,675

158,896

55042

Discharge summary

report

Admission Date: [**2112-6-9**] Discharge Date: [**2112-6-14**] Date of Birth: [**2027-10-9**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Exertional angina Major Surgical or Invasive Procedure: Coronary Artery Bypass x 3 (LIMA-LAD, SVG-OM, SVG-PDA) [**2112-6-10**] History of Present Illness: Mr. [**Known lastname 112358**] 84 year old male with known coronary artery disease since [**2108**]. Cath in [**2108**] showed multivessel disease, not amenable to PCI and he was medically managed. Over the last several months he has noticed worsening exertional chest pain and dyspnea on exertion. He was admitted to outside hospital in [**Month (only) 116**] with congestive heart failure. He denies symptoms at rest, and currently denies orthopnea, PND, pedal edema, palpitations, syncope and pre-syncope. Given the progression of his exertional symptoms, he was referred to Dr. [**Last Name (STitle) **] for surgical revascularization. Past Medical History: Coronary artery disease, Ischemic Cardiomyopathy Atrial Fibrillation Hypertension Abdominal aortic aneurysm s/p endovascular stent Hypercholesterolemia History of atrioventricular block Osteoarthritis History of Asbestos Exposure Past Surgical History s/p Endovascular repair of AAA [**2108**] s/p Repair of Endoleak of AAA [**2109**] s/p Left Inguinal Hernia repair s/p Right Total Knee Replacement s/p Left Ankle Fusion Past Cardiac Procedures: s/p [**Company 1543**] Pacemaker [**2103**] #AEXCH282840 Social History: Lives with: Wife Cigarettes: Non-smoker ETOH: rare Illicit drug use: denies Family History: non-contributory Physical Exam: BP 106/74 HR 70 RR 16 SAT 98% HT 70 inches WT 190lbs General: Elderly male in wheelchair in no acute distress Skin: Dry [x] intact [x] - multiple bruises noted HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade soft systolic murmur noted at LLSB Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: trace edema Varicosities: GSV appeared suitable. No obvious varicosities on standing but parts of the GSV appeared mildy dilated in both lower extremities 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: none Left: none Pertinent Results: [**2112-6-14**] 06:00AM BLOOD WBC-7.5 RBC-4.00* Hgb-11.3* Hct-34.8* MCV-87 MCH-28.2 MCHC-32.4 RDW-15.9* Plt Ct-112* [**2112-6-13**] 02:14AM BLOOD WBC-8.8 RBC-4.04* Hgb-11.3* Hct-34.2* MCV-85 MCH-28.0 MCHC-33.1 RDW-16.0* Plt Ct-101*# [**2112-6-14**] 06:00AM BLOOD PT-15.1* INR(PT)-1.4* [**2112-6-13**] 02:14AM BLOOD PT-18.3* PTT-39.1* INR(PT)-1.7* [**2112-6-12**] 02:11AM BLOOD PT-20.3* PTT-42.3* INR(PT)-1.9* [**2112-6-11**] 04:37AM BLOOD PT-17.1* PTT-41.4* INR(PT)-1.6* [**2112-6-10**] 04:18PM BLOOD PT-15.7* PTT-37.1* INR(PT)-1.5* [**2112-6-10**] 01:11PM BLOOD PT-17.9* PTT-48.3* INR(PT)-1.7* [**2112-6-10**] 11:24AM BLOOD PT-20.0* PTT-47.9* INR(PT)-1.9* [**2112-6-10**] 04:10AM BLOOD PT-15.0* PTT-76.6* INR(PT)-1.4* [**2112-6-9**] 11:30AM BLOOD PT-17.2* PTT-150* INR(PT)-1.6* [**2112-6-14**] 06:00AM BLOOD Glucose-111* UreaN-36* Creat-1.2 Na-136 K-4.1 Cl-99 HCO3-26 AnGap-15 [**2112-6-13**] 02:14AM BLOOD Glucose-128* UreaN-24* Creat-1.2 Na-130* K-3.6 Cl-96 HCO3-26 AnGap-12 Brief Hospital Course: The patient was brought to the Operating Room on [**2112-6-10**] where the patient underwent CABG x 3 with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He required multiple blood products in the immediate post-op period. He had VTac in the OR and was placed on Amiodarone. Permanent Pacemaker was interrogated. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. He continued to have runs of VTac and was placed on PO Amio. Coumadin was also resumed for chronic AFib. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to LiveCare of the [**Hospital3 **] in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Metoprolol Tartrate 25 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Pravastatin 40 mg PO DAILY 4. Furosemide 20 mg PO DAILY 5. Ferrous Sulfate 325 mg PO DAILY 6. Glucosamine 1500 Complex *NF* (glucosamine-chondroit-vit C-Mn) unknown Oral daily 7. Warfarin Dose is Unknown PO DAILY16 Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Metoprolol Tartrate 25 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. 3. Pravastatin 40 mg PO DAILY 4. Warfarin MD to order daily dose PO DAILY MD to dose for goal INR [**1-1**], dx: AFib 5. Acetaminophen 650 mg PO Q4H:PRN pain/fever 6. Oxycodone-Acetaminophen (5mg-325mg) [**11-30**] TAB PO Q4H:PRN pain 7. Pantoprazole 40 mg PO Q24H 8. Furosemide 40 mg PO DAILY Duration: 10 Days 40mg daily x 10 days, then resume 20mg daily (home dose) 9. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days Hold for K > 4.5 10. Ferrous Sulfate 325 mg PO DAILY 11. Glucosamine 1500 Complex *NF* (glucosamine-chondroit-vit C-Mn) 1500 units ORAL DAILY Discharge Disposition: Extended Care Facility: Life Care Center of the [**Hospital3 **] - [**Location (un) 3493**] Discharge Diagnosis: Coronary artery disease, Ischemic Cardiomyopathy Atrial Fibrillation Hypertension Abdominal aortic aneurysm s/p endovascular stent Hypercholesterolemia History of atrioventricular block Osteoarthritis History of Asbestos Exposure Past Surgical History s/p Endovascular repair of AAA [**2108**] s/p Repair of Endoleak of AAA [**2109**] s/p Left Inguinal Hernia repair s/p Right Total Knee Replacement s/p Left Ankle Fusion Past Cardiac Procedures: s/p [**Company 1543**] Pacemaker [**2103**] #AEXCH282840 Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage 2+ LE edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: The Cardiac Surgery office will call you with the following appointments: Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**] Please call to schedule the following: Primary Care Dr. [**Doctor Last Name 72900**],THARWAT A [**Telephone/Fax (1) 63184**] in [**3-3**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR Coumadin for Afib Goal INR [**1-1**] First draw [**2112-6-15**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. **Arrange for coumadin follow-up prior to discharge from rehab** Completed by:[**2112-6-14**]

[ "997.1", "272.0", "397.0", "V58.61", "428.0", "427.31", "396.3", "443.9", "E878.2", "414.01", "V45.01", "401.9", "414.8", "428.32", "427.1" ]

icd9cm

[ [ [] ] ]

[ "37.23", "89.45", "36.15", "88.56", "36.12", "39.61" ]

icd9pcs

[ [ [] ] ]

6104, 6198

3598, 4961

328, 401

6746, 6916

2596, 3575

7703, 8514

1710, 1728

5393, 6081

6219, 6725

4987, 5370

6940, 7680

1743, 2577

270, 290

429, 1072

1094, 1600

1616, 1694

804

138,064

47997+47998+59051

Discharge summary

report+report+addendum

Admission Date: [**2154-8-26**] Discharge Date: [**2154-8-30**] Date of Birth: [**2085-5-1**] Sex: M Service: MED PRESENT ILLNESS: 1. Abdominal pain. 2. Abdominal distention. 3. Dyspnea. HISTORY OF PRESENT ILLNESS: 69-year-old male with past medical history of transient ischemic attacks, hyperlipidemia, lower gastrointestinal bleed from polypectomy (hyperplastic polyp plus adenoma) in [**2152**] negative for cancer admitted last week with history of anorexia and abdominal distention now returns with worsening abdominal pain and distention with dyspnea. Workup during last admission found mesenteric peritoneal implants with evidence of peritoneal carcinomatosis on CT abdomen. CT chest found diffuse necrotic mediastinal lymphadenopathy with two right lobe nodules (one spiculated right upper lobe nodule at 1.1 cm in its greatest dimension and one non-calcified nodule in the right lower lobe with right paratracheal precarinal and a subcarinal mass). White blood count was elevated on discharge at 19.1, which was up from prior; however, no fevers or chills or lethargy. At prior admission patient presented after working out at gym with the complaint of feeling lethargic more than usual for four days. He then lost his appetite and noticed a three- pound weight gain over four days. Patient denies melena, hematochezia, abdominal pain, chest pain, shortness of breath, nausea, vomiting, constipation. Diarrhea times one. Also states a 20-pound weight gain over the past year that was intentional. Bronchoscopy of the subcarinal lymph nodes (subcarinal mass) was postponed secondary to Plavix taken five days prior. At [**Hospital1 18**], 3300 cc of ascites fluid was drained via paracentesis. Afterwards an outpatient scheduled visit with GI performed in-house which revealed no suspicious lesions. Patient's current complaint of abdominal pain and distention with shortness of breath began acutely the day after discharge and progressively worsened in severity. His symptoms rapidly increased over Saturday and Sunday without notable exacerbating or alleviating factors. He attempted running on a treadmill Sunday without incident. Patient also mentions decreased urine output since last discharge despite continuous fluid intake. However, his food intake has decreased compared to baseline. Patient has a complaint of night sweats. Patient denies chest pain, shortness of breath, nausea, vomiting, fevers, constipation, diarrhea, dysuria, cough, hemoptysis, hematemesis, hematochezia, or melena. Dr. [**Last Name (STitle) **] from Pathology only received 25 ml of the prior 2400 cc of ascites fluid drained last week. However, stains will be ready later this day. Cytology has received the fluid from the paracentesis today done in the ED. PAST MEDICAL HISTORY: 1. Hyperlipidemia. 2. Osteoarthritis. 3. Retinal hemorrhage. 4. Small PFO. 5. Status post colonoscopy with polypectomy in [**2152**]; three sessile non-bleeding polyps (positive for adenoma) were removed, negative for cancer; diverticulosis noted throughout colon. 6. Prostate needle biopsy in [**2147**], negative for cancer. 7. Status post ASD repair with trace AI and MR [**First Name (Titles) **] [**Last Name (Titles) 113**] in [**2148**]; normal chamber size and function. 8. Status post left inguinal herniorrhaphy; repair of left inguinal hernia with Marlex mesh. OUTPATIENT MEDICATIONS: 1. Plavix 75 mg. 2. Lipitor 20 mg. 3. Celebrex p.r.n. 4. Zyrtec p.r.n. ALLERGIES: Aspirin gives rash. FAMILY HISTORY: Father died of questionable prostate cancer. One son and one daughter both healthy. Mother: [**Name (NI) **] known medical problems. SOCIAL HISTORY: Tobacco: Unknown number pack years. One alcoholic beverage per day. Lives with wife in [**Name (NI) 27532**]. Traveled to South America and Eastern Europe 20 to 30 years ago. He has had no known exposure to asbestos in his lifetime. No known exposure to TB. PHYSICAL EXAMINATION: In general, in no acute distress. Appears stated age. Is concerned about prognosis. Vital signs: T-max 96.7, T current 96.7, blood pressure 120/70, heart rate 76, respiratory rate 20, 97% on two liters oxygen via nasal cannula. Head and neck: Normocephalic, atraumatic. Pupils equal, round, and reactive to light. Extraocular movements intact. Dry mucous membranes. Oropharynx: Clear, no lymphadenopathy. Jugular venous distention flat. Cardiac exam: S1 and S2 normal, regular rate and rhythm, I/VI holosystolic ejection murmur, no rubs or gallops. Pulmonary exam: Clear to auscultation bilaterally, no rales, no wheeze. Abdomen exam: Slightly distended, nontender, negative shifting dullness, negative fluid wave, negative peritoneal signs, no inguinal lymphadenopathy, normoactive bowel sounds, liver edge palpable on inspiration. Extremities: Distal pulses +2 bilaterally. No cyanosis, clubbing, or edema. Neuro exam: Alert and oriented times three, cranial nerves II-XII intact, [**4-1**] upper and lower extremity strength bilaterally. Rectal exam: Guaiac negative, no masses, prostate is enlarged, smooth, and without nodules. LABORATORY DATA: White count was 33.5, hematocrit 37.4, platelets 450, MCV 94. Differential: Neutrophils 68%, bands 8%, lymphs 2%, monos 5%, eos 17%, elevated, basos 0%. There is 1+ oncocytosis, 1+ poikilocytosis, and 1+ ovalocytosis. PT 14.0, PTT 29.7. Chem-7 at 9 a.m. was 131, sodium and potassium 17.4, chloride 95, bicarbonate 23, BUN of 43, creatinine 1.3, glucose 119 with an anion gap of 20. The elevated potassium was thought to be due to hemolysis ............. Chem-7 was done at 10 a.m. Sodium 134, potassium 5.8, chloride 97, bicarbonate 25, BUN of 46, creatinine of 2.0, glucose 130, anion gap of 18. UA was done; yellow, clear, specific gravity of 1.015, trace protein, negative for urinary tract infection. Ascites fluid from [**2154-8-26**] at 4:30 a.m. was drawn and demonstrated white blood cells at [**Pager number **], red blood cells [**Pager number **], polys at 6%, lymphs at 14%, monos at 64%, eos at 13%, basophils at 1%, and mesothelial cells at 2% not consistent with SVP. Total protein is 4.1, glucose was 113 mg/dl. LDH was 381 units per liter, amylase 20 units per liter, albumin 2.1 g/dl. Cultures were negative for growth. Chest x-ray was done in the Emergency Department and demonstrated bilateral filler lymphadenopathy but otherwise unremarkable. SUMMARY OF HOSPITAL COURSE: Patient was admitted for malignant ascites and hyperkalemia of 5.8. Hyperkalemia was corrected via 10 units of insulin plus 50% of 50 cc of glucose solution with a resulting potassium of 4.6 at 2 a.m. the following morning. EKG done in the ED and repeat EKG done on the floor demonstrated poor R-wave progression without prior for comparison. Further analysis of the ascites drained on [**2154-8-26**] demonstrated gram stain with 2+ , no micro organisms. Cultures were negative for growth, and cytokeratin stain was positive with negative staining with TIF/1. A FENA was performed and the patient was found to be pre-renal. Patient was rehydrated with D5 normal saline at 100 cc per hour and reassessed clinically. On [**2154-8-27**] the patient's serum LDH was found to be elevated at 452. His albumin was found to be decreased at 2.2 On [**2154-8-28**] a full dermatological exam was performed and found to be negative for melanoma. A TSH was found to be elevated at 11. CEA was normal at 1.2. Serum II ascites albumin gradient was found to be 0.1, indicating no portal hypertension. On [**2154-8-29**] Interventional Radiology was again consulted, and under ultrasound, found ascites accumulation for the third time for this admission. Placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] type abdominal drain was then ordered via Interventional Radiology. Patient then developed severe constipation and was treated with Dulcolax times one, Senna times one, Lactulose times two without effect. A bisacodyl suppository times one was then tried without effect. Fleet p.o. was tried times one without effect. Fleet enema was then tried times one with good effect. Patient remained off Plavix now for nine days. As of [**2154-8-30**] pathology indicates a preliminary diagnosis of adenocarcinoma likely of lung or pancreatic source. Interventional Radiology did place [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] style abdominal pain and peripherally inserted central catheter line without complication. Hyperkalemia was noted to be corrected at 5.0. Secondary to poor p.o. intake from abdominal distention, the renal failure began to present again with a BUN of 48 and a creatinine of 2.1. Intravenous fluids were then again ordered with D5 normal saline at 100 cc per hour times one liter. Patient was then transferred to the [**Hospital1 18**] Oncology Medicine Service on the [**Hospital Ward Name 516**] for initiation of chemotherapy for the diagnosis of adenocarcinoma with unknown primary source. DISCHARGE STATUS: Fair. DISPOSITION: To Oncology Medicine Service on [**Hospital1 18**] [**Hospital Ward Name 8559**] #50. DISCHARGE DIAGNOSES: 1. Malignant metastatic ascites. 2. Adenocarcinoma of unknown origin. DISCHARGE MEDICATIONS TO ONCOLOGY MEDICINE SERVICE AT [**Hospital1 18**] [**Hospital Ward Name **]: 1. Acetaminophen 325 to 650 mg p.o. q. four to six hours p.r.n. 2. Zolpidem tartrate 5 mg p.o. h.s. 3. Heparin 5000 units subq. q. 12 hours. 4. Atorvastatin 10 mg p.o. q.d. 5. Senna one tab p.o. b.i.d. p.r.n. 6. Lactulose 30 ml p.o. q. eight hours p.r.n. 7. Lorazepam 0.5 mg IV q. four hours p.r.n. DR.[**Last Name (STitle) 313**],[**First Name3 (LF) 312**] 12-766 Dictated By:[**Last Name (NamePattern1) 101265**] MEDQUIST36 D: [**2154-8-30**] 17:30 T: [**2154-9-2**] 10:38 JOB#: [**Job Number 101267**] Admission Date: [**2154-8-26**] Discharge Date: [**2154-9-3**] Date of Birth: [**2085-5-1**] Sex: M Service: ACOVE Patient's attending was not clear as patient was transferred out of the unit and died on the same day with the attending in the unit. HISTORY OF PRESENT ILLNESS: This is a 69-year-old male with a past medical history significant for hyperlipidemia, osteoarthritis, retinal hemorrhage, small SBO status post a colonoscopy, who was admitted to the hospital on [**8-26**] for further workup and possible treatment for a metastatic adenocarcinoma of unknown primary. Briefly, the patient had been well until approximately two weeks ago when he became tired and lethargic at the gym on admission and workup at that time revealed the cancer in a metastatic stage. The patient was DR.[**First Name (STitle) **], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 11-575 Dictated By:[**Last Name (NamePattern1) 6006**] MEDQUIST36 D: [**2154-9-3**] 11:17 T: [**2154-9-4**] 10:40 JOB#: [**Job Number 101268**] Name: [**Known lastname 635**], [**Known firstname **] Unit No: [**Numeric Identifier 16265**] Admission Date: [**2154-8-26**] Discharge Date: [**2154-9-2**] Date of Birth: [**2085-5-1**] Sex: M Service: [**Hospital1 248**] I started another dictation on this patient several minutes ago, and the phone call lost. HISTORY OF PRESENT ILLNESS: This is a 69-year-old male, who was readmitted on the day of admission with known metastatic adenocarcinoma of unknown primary. The patient had been well until approximately two weeks prior to this admission when he became lethargic and fatigued at the gym. Hospital admission and workup revealed possible GI malignancy of unknown type. The patient presented with abdominal distention and ascites. Patient was also found to have pulmonary nodules and diffuse mediastinal lymphadenopathy. After these findings, the patient was readmitted for further workup and possible treatment of his metastatic cancer. HOSPITAL COURSE: On this admission, the patient was initially admitted to the floor and his condition declined, and was transferred into the Intensive Care Unit. He underwent two large volume paracenteses, one on [**2154-8-31**], which removed 3.5 liters of fluid and a peritoneal drain was placed. His condition further worsened as he went into increasing renal failure, became hypotensive, and there was substantial discomfort. The patient was thought to possibly be septic at this point, and the decision was made to make the patient comfort measures only. This decision was undertaken with full consultation of the patient's wife and family, who agreed with the decision. I spoke with the patient's wife about his condition when the patient was being transferred on [**2154-9-2**] from the Intensive Care Unit back to the floor, and she was clear about her desire for comfort measures. The patient on the floor was placed on a Morphine drip and Ativan was used prn for comfort. Respiratory rate and heart rate were monitored only as a way to assess pain. At approximately midnight between [**2154-9-2**] and [**2154-9-3**], the house officer was called by the nurse to pronounce the patient. The patient's wife had told the nurse that she believed the patient had "passed." Patient had no heart rate or respirations. Patient is found to have fixed and dilated pupils. There were no respirations or heart sounds over the course of two minutes. The time of death was noted to be 11:51 p.m. on [**2154-9-2**]. The option of an autopsy was offered to the family, but they refused. The attending physician as well as the primary care physician were notified of this death. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-766 Dictated By:[**Last Name (NamePattern1) 2223**] MEDQUIST36 D: [**2154-9-3**] 11:23 T: [**2154-9-4**] 10:44 JOB#: [**Job Number 16268**]

[ "276.7", "995.92", "276.1", "276.2", "199.1", "745.5", "584.9", "197.6", "038.9" ]

icd9cm

[ [ [] ] ]

[ "54.91", "38.93" ]

icd9pcs

[ [ [] ] ]

3546, 3682

9243, 10227

12059, 13954

6466, 9222

3420, 3529

3986, 6437

11431, 12041

2815, 3396

3699, 3963

43,003

174,006

35852

Discharge summary

report

Admission Date: [**2132-12-7**] Discharge Date: [**2132-12-11**] Date of Birth: [**2078-11-12**] Sex: M Service: MEDICINE Allergies: Tetanus / Glucophage Attending:[**First Name3 (LF) 358**] Chief Complaint: chest pain Reason for MICU Admission: Monitoring Overnight for HCT drop Major Surgical or Invasive Procedure: endoscopy colonoscopy History of Present Illness: This is a 54yoM w/h/o laparoscopic gastric bypass([**6-29**]) transferred from an OSH who p/w chest pain, HCT drop, and paricardial effusion. He notes that 2 weeks ago he picked up a fire hydrant "to get it from point A to point B." 2 days later, he had CP across his chest BL, stabbing [**8-31**] worse w/breathing. He went to a clinic(not regular PCP) where he was prescribed prednisone and lortab(vicodin) which he took for 7 days and resolved the pain. After completion, the same CP recurred but he did not take anything more for the pain. He traveled to the [**Location (un) 86**] area with his mother to visit family. Because of the severity of the CP, his family brought him to the [**Hospital1 3325**] ED. . There, he was afebrile HR 124, BP 118/88. EKG revealed sinus tachycardia w/poor R-wave progression and TWI in V4-V6. He had guiac +stools and HCT 27.9. Cardiac enzymes were negative x 1. He recieved 1L NS, 1 unit of PRBCs, Zosyn 3.375mg IV x1, protonix IV x 1, and dilaudid IV for [**10-31**] stabbing left sided CP. CT chest/abdomen/pelvis was negative for PE but revealed a 2cm pericardial effusion and bilateral pleural effusions. . He was transferred here for further evaluation of GIB. . In the ED, Tm 99.7 HR 112 BP 143/86 O2sat100%2L. He received 1 unit PRBCs at [**Hospital3 3583**]. TTE in ED revealed 2cm pericardial effusion w/o tamponade physiology. GI was consulted and Cardiology made aware; they felt that there was no need for emergent TTE. He received Morphine and Fentanyl IV for pain. . Currently, the patient endorses [**8-31**] stabbing chest pain which he describes as worst w/lying on his left side, worse w/deep breaths, and sitting up, associated w/SOB. He notes that he had an + episode of diarrhea this AM, otherwise denies melena/BRBPR/abdominal pain, or N/V. He endorses an episode of lightheadedness this AM. Able to complete 4 mets at home. He otherwise denies any fevers, chills, URI sx, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. . Past Medical History: laparascopic gastric bypass [**2132-6-28**] normal colonoscopy [**12-28**] MI at age 25years Bipolar d/o Polysubstance abuse . Social History: Lives on a farm next door to his mother. On disability due to bipolar disease, + etoh abuse 3/5s hard liquor per week up to 2 weeks ago, h/o cocaine and IV heroin use quit 35 years ago, 25 pack year smoking hx, quit 1 year ago. . Family History: colon cancers, unknown etiology Physical Exam: On Presentation: Vitals: T: 96.3 BP: 138/99 HR: 114 RR: 19 O2Sat: 99% 2LNC orthostatics lying flat: BP 125/76 HR 116, sitting BP 120/80 HR 121 No pulsus noted GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, pale anicteric sclera, no epistaxis or rhinorrhea, dry MM, 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 Rectal: melenotic stool, guiac + 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. . Discharge: AF,VSS Gen-- pleasant, NAD, ambulating Heart -- regular Lungs -- clear, Abd -- benign Pertinent Results: OSH: WBC 23.7 HCT 27.9 136 100 44 ------------< 280 4.2 26 1.05 Albumin 3.0 T. bili 0.5 CK 27 . [**2132-12-7**] 03:30PM WBC-18.2* RBC-3.12* HGB-9.2* HCT-27.2* MCV-87 MCH-29.4 MCHC-33.7 RDW-14.9 [**2132-12-7**] 03:30PM NEUTS-85.9* LYMPHS-9.9* MONOS-3.7 EOS-0.2 BASOS-0.3 [**2132-12-7**] 03:30PM PLT COUNT-451* . [**2132-12-7**] 03:30PM PT-14.1* PTT-23.2 INR(PT)-1.2* . [**2132-12-7**] 03:30PM GLUCOSE-188* UREA N-37* CREAT-1.0 SODIUM-139 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-29 ANION GAP-9 [**2132-12-7**] 03:30PM ALT(SGPT)-12 AST(SGOT)-8 CK(CPK)-20* ALK PHOS-54 TOT BILI-0.4 [**2132-12-7**] 03:30PM LIPASE-682* [**2132-12-8**] 05:59AM BLOOD Lipase-43 . [**2132-12-7**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG [**2132-12-7**] 09:42PM URINE RBC-<1 WBC-5 BACTERIA-NONE YEAST-NONE EPI-<1 . [**2132-12-7**] 03:30PM cTropnT-<0.01 [**2132-12-7**] 03:30PM CK-MB-NotDone [**2132-12-8**] 05:59AM BLOOD CK-MB-2 cTropnT-<0.01 [**2132-12-8**] 05:59AM BLOOD CK(CPK)-17* . ECG: Sinus rhythm at 117 bpm, poor R-wave progress, TWI in V4-V6, earlier EKG on day of admission from OSH the same except for HR of 129 otherwise no comparison. . OSH Imaging: OSH CT chest/abdomen/pelvis: No abnormal fluid collections/free air; no acute intra bowel abnormalities, no evidence of pancreatitis. No evidence of PE, Pericardial effusion ~2cm, subcentimeter mediastinal LNs, small left and tiny right pleural effusions. CXR: negative for acute intrathoracic pathology . Dischage: [**2132-12-11**] 06:25AM BLOOD WBC-8.2 RBC-3.45* Hgb-10.1* Hct-30.9* MCV-90 MCH-29.2 MCHC-32.6 RDW-14.3 Plt Ct-596* [**2132-12-8**] 05:59AM BLOOD PT-15.1* PTT-24.9 INR(PT)-1.3* [**2132-12-11**] 06:25AM BLOOD Glucose-133* UreaN-11 Creat-0.9 Na-139 K-4.3 Cl-102 HCO3-29 AnGap-12 [**2132-12-7**] 03:30PM BLOOD ALT-12 AST-8 CK(CPK)-20* AlkPhos-54 TotBili-0.4 [**2132-12-8**] 05:59AM BLOOD Lipase-43 [**2132-12-8**] 05:59AM BLOOD CK-MB-2 cTropnT-<0.01 [**2132-12-7**] 03:30PM BLOOD cTropnT-<0.01 [**2132-12-9**] 06:15AM BLOOD Calcium-8.2* Phos-2.4* Mg-2.2 [**2132-12-8**] 05:59AM BLOOD Triglyc-112 [**2132-12-7**] 09:42PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.032 [**2132-12-7**] 09:42PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2132-12-7**] 09:42PM URINE RBC-<1 WBC-5 Bacteri-NONE Yeast-NONE Epi-<1 ========= SPECIMEN SUBMITTED: GI BX'S, 2 JARS. Procedure date Tissue received Report Date Diagnosed by [**2132-12-10**] [**2132-12-10**] [**2132-12-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]/dsj?????? DIAGNOSIS: 1. Colon, sigmoid; polypectomy (A) Surface hyperplastic change. 2. Colon, rectum; polypectomy (B) Hyperplastic polyp. ========= UPPER GI: Initial scout image demonstrates a moderate-sized left pleural effusion, with associated atelectasis and consolidation of the left lower lobe. Anastomotic sutures are seen within the left upper quadrant of the abdomen. The patient drank Conray without difficulty, with Conray passing freely into the stomach and small bowel loops, without holdup, atony, or obstruction. No leak was identified within the gastrojejunal anastomosis. Patient subsequently drank thin barium to exclude an occult leak, and no leak was identified. Delayed images demonstrate contrast passage into small bowel loops within the lower abdomen. The afferent limb of the anastomosis is not identified on this study. IMPRESSION: No leak identified in the region of gastrojejunal anastomosis. The afferent loop of the gastric bypass is not identified. ========== Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.7 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 60% >= 55% Left Ventricle - Stroke Volume: 75 ml/beat Left Ventricle - Cardiac Output: 7.01 L/min Left Ventricle - Cardiac Index: 3.25 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 12 < 15 Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 24 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.57 Mitral Valve - E Wave deceleration time: *106 ms 140-250 ms TR Gradient (+ RA = PASP): <= 25 mm Hg <= 25 mm Hg Pericardium - Effusion Size: 1.4 cm Findings LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No MS. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: Small to moderate pericardial effusion. Stranding is visualized within the pericardial space c/w organization. No echocardiographic signs of tamponade. Conclusions The left atrium is elongated. 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 valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a small to moderate sized pericardial effusion. Stranding is visualized within the pericardial space c/w organization. There are no echocardiographic signs of tamponade. ============== CXRPortable AP chest radiograph was reviewed with no prior studies available for comparison. The heart size is enlarged but according to the clinical history, the patient has known pericardial effusion. There is left retrocardiac consolidation with accompanied pleural effusion which might represent either atelectasis or infectious process. A smaller area of involvement is seen in the right lower lobe which may represent a focus of infection as well. The upper lungs are unremarkable. No evidence of edema is seen. IMPRESSION: Mild-to-moderate cardiomegaly consistent with known pericardial effusion. Left pleural effusion, small to moderate. Left retrocardiac consolidation which may represent a combination of atelectasis and pneumonia Brief Hospital Course: This is a 54yoM w/h/o laparoscopic gastric bypass who was transferred from an OSH for evaluation of GIB and management of his pericardial effusion. # GIB: Initially thought likely related to ulcerated surgical anastamosis, in light of recent steroid use. Hct initially of 27 then dropped to 25. He was transfused 2 U PRBC and placed on IV ppi. He underwent endoscopy and colonoscopy, both of which did not show any source of possible bleeding. He did have two small polyps removed in his colon, with path showing hyperplastic polyps. The pathology returned after his discharge, so results were not discussed with him. He had no recurrent episodes of blood loss. He was advised to discuss capsule endoscopy with his providers in [**State 33977**]. . # Pleuritis and pericardial effusion: w/o evidence of tamponade physiology; most likely pericarditis ? viral. Elevated lipase which resolved within 24 hrs and no evidence of pancreatitis on CT at OSH. No h/o recent URI/viral sx but difficult to rule out. He will follow up with his cardiologists in [**State 33977**]. He was advised to return to the hospital with any recurrent pain. He was also advised not to drive while taking the Percocet prescribed. - cardiac enzymes negative x 2 - pain improved throughout hospitalizaiton - no NSAIDS due to GIB . # leukocytosis: in the setting of having been on recent steroids; he has been afebrile and w/o subjective fevers. Received Zosyn at OSH. WBC normalized prior to discharge. - blood negative, urine cx negative . # Polysubstance Abuse: last drink 10 days ago, no h/o withdrawal seizures - normal LFTs, but increased INR - SW consult, advised to abstain from alcohol. . Medications on Admission: Abilify 10 mg daily MTV Calcium/vit D Discharge Medications: 1. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for 7 days. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. pericarditis/pericardial effusion 2. acute on chronic blood loss anemia from GI bleeding Discharge Condition: Stable, Hct 30%. Discharge Instructions: You were hospitalized with chest pain and blood loss from your bowels. Your chest pain is from pericarditis, and you should follow up with a cardiologist in [**State 33977**] to repeat the heart ultrasound (echocardiogram) in a few weeks. You had an endoscopy and colonoscopy in the hospital to evaluate bleeding, and no source of blood was found. You may need to have a capsule endoscopy to visualize the rest of your bowels. Please discuss this with your doctors [**First Name (Titles) **] [**Last Name (Titles) **]. Call you primary care physician or return to the hospital if you have increasing chest pain, shortness of breath, fever greater than 101, blood in your stool, lightheadedness or any other concerns. Do not drive while taking the pain medication prescribed. Followup Instructions: See you primary care doctor and your cardiologist in TN.

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icd9cm

[ [ [] ] ]

[ "45.13", "48.36", "88.72", "45.42", "99.04" ]

icd9pcs

[ [ [] ] ]

13326, 13332

11326, 13010

354, 378

13468, 13487

3990, 11303

14316, 14376

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13099, 13303

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406, 2515

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39408

Discharge summary

report

Admission Date: [**2140-6-3**] Discharge Date: [**2140-6-16**] Date of Birth: [**2089-11-1**] Sex: M Service: SURGERY Allergies: Penicillin G Attending:[**First Name3 (LF) 1384**] Chief Complaint: ETOH cirrhosis Major Surgical or Invasive Procedure: liver transplant [**2140-6-4**] History of Present Illness: 50 y/o male who presents today for liver tansplant. Patient started evaluation in [**2139-10-23**] associated with the diagnosis of liver disease in [**2138-11-23**], when he was admitted to an OSH for edema and hernia pain and it was at this time that he learned of his liver disease diagnosis. Liver disease appears to be associated with a period of approximately 9-12 months, he was using a great deal of Tylenol and drinking alcohol to manage his pain and discomfort associated with a hernia. He was advised at that time to quit drinking alcohol and stop using Tylenol, which he did without any difficulty. He completed his workup and was listed the end of [**2140-4-22**]. Patient reports recent increas in lasix dosing which has helped with edema, and lactulose and rifaxamin have controlled encephelopathy which has been more pronounced in the past. ROS: Mouth sores have improved with clotrimazole, Denies fever, chills, chest pain, shortness of breath. Occasional tenderness over abdomen, most recent paracentesis was at [**Hospital 1474**] Hospital many months ago. Reports 3 BMs daily, soft/loose. Lower extremity edema improved recently, and no open areas on feet. c/o 2 cm open area > 1 year on left groin following hernia repair non-healing wound. . Past Medical History: Cirrhosis [**2-24**] ?EtOH (c/b portal HTN with ascites, and hepatic encephalopathy) [**2140-6-4**] liver transplant GERD OSA not on CPAP Hyponatremia Hernia CHF HTN Anemia PNA ETOH abuse Mouth Sores (5 units of plasma and 9 units of pRBC since '[**38**]) Osteoarthritis Social History: Used to work in collision repair. Lives with sister and mother, quit drinking >1 year ago, does not smoke, divorced. Has 2 healthy children. Family History: sister - SLE, DM, father - CVA, HTN mother - breast cancer, DM, CVA, CAD Physical Exam: VS - 99.5, 80, 137/65, 16, 97%, 94.1 kg GENERAL - Jaundiced, No acute distress, oriented, talkative HEENT - scleral icterus, no LAD, tongue grooved and increased redness; no lesions noted LUNGS - CTA bilaterally HEART - II/VI systolic murmur (not new) RRR ABDOMEN - Soft, mildly tender, obese, no fluid wave noted. Left groin with open area and dressing in place over 2 cm by 1/2 cm deep wound, purulent appearing material on dsg, no odor noted. No other scars noted EXTREMITIES - 1+ pitting edema bilaterally lower extremities, no open areas on feet, 2+ DPs NEURO - No asterixis, alert and oriented x 3, no focal deficit noted Pertinent Results: [**2140-6-15**] 05:49AM BLOOD WBC-3.4* RBC-3.44* Hgb-10.6* Hct-31.9* MCV-93 MCH-30.9 MCHC-33.3 RDW-17.6* Plt Ct-126* [**2140-6-10**] 04:30AM BLOOD PT-12.5 PTT-24.5 INR(PT)-1.1 [**2140-6-16**] 04:30AM BLOOD Glucose-130* UreaN-12 Creat-0.6 Na-133 K-3.3 Cl-99 HCO3-29 AnGap-8 [**2140-6-16**] 04:30AM BLOOD ALT-31 AST-16 AlkPhos-112 TotBili-1.6* [**2140-6-16**] 04:30AM BLOOD Albumin-3.1* Calcium-8.1* Phos-2.2* Mg-1.6 [**2140-6-15**] 05:49AM BLOOD tacroFK-7.9 [**2140-6-16**] 04:30AM BLOOD tacroFK-6.7 Brief Hospital Course: On [**2140-6-4**], he underwent liver transplant. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please refer to operative note for details. Postop, he was sent to the SICU for management. He was extubated. Postop hepatic duplex was unremarkable with all vessels patent. LFTs initially increased then trended down. He required blood products per protocol parameters. Hct remained stable. IV lasix was given for volume overload. He was transferred out of the SICU on [**6-8**]. Pain was initially managed with IV dilaudid. This was switched to po dilaudid once diet was advanced and tolerated. He required a fair amount of pain medication, but was very sleepy, therefore po dilaudid was decreased with improved mental status. IV lasix was continued for generalized edema with good diuresis. [**Male First Name (un) **] stockings were applied. Abdominal incision staples were intact. Incision was without redness or drainage. Two JPs had been placed. Outputs were non-bilious. Lateral JP was removed on [**6-7**]. Medial JP continued to have large output then slowly decreased to 600cc/day. LFTs started to increase. Duplex was unremarkable. An ERCP was performed on [**2140-6-3**] which demonstrated a single stricture that was 5 mm long at the choledochocholedecho anastamosis. There was a tight angulation at the area of the stricture. A 9cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed successfully in the choledochocholedocho anastamosis. LFTs trened back down and remained stable. Repeat ERCP will need to be repeated in next month. Medial JP was removed on [**6-16**]. Site was sutured. He was tolerating a regular diet. Glucoses were elevated and required sliding scale insulin. Immunosuppression was well tolerated. This consisted of Cellcept 1 gram [**Hospital1 **], solumedrol that was tapered to prednisone per protocol and prograf that was started on [**6-5**]. Prograf doses were adjusted per trough levels. Goal level was 10. He will required labs every Monday and Thursday with results fax'd to the [**Hospital1 18**] transplant office (fax [**Telephone/Fax (1) 697**]). Transplant Office should be called to make any medication adjustments ([**Telephone/Fax (1) 673**]). PT evaluated and recommended rehab for significant deconditioning. He was ambulating with a walker at time of discharge. A bed was available at [**Hospital3 **] in [**Hospital1 8**] and he was transferred there in stable condition. Immunosuppression consisted of Cellcept which was well tolerated, steroids (tapered per protocol) and prograf which was adjusted per trough levels with goal of 10. Medications on Admission: Lactulose 30 gm [**Hospital1 **], Rifaxamin 550 [**Hospital1 **], Vit D 50,000u q Tuesday, Metoprolol 25 mg [**Hospital1 **], Spironolactone 100 mg daily, Protonix 40 mg daily, Folic acid 1 mg daily, Thiamine 100 mg daily, Lasix 40 mg [**Hospital1 **], Vit B12 1000 mg daily, Ferrous Sulfate 300 mg [**Hospital1 **], Colace 100 mg [**Hospital1 **], MVI daily, Ursodiol 300 mg TID, Ultram 50 mg TID, Ambien 5 mg hs, Calcium+D daily, Clotrimazole troche 5x/day Discharge Medications: 1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): see printed taper schedule. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 7. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. valganciclovir 450 mg Tablet Sig: Two (2) 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. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain: no more than 2 grams per day. 15. tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 16. insulin lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. 17. NPH insulin human recomb 100 unit/mL Suspension Sig: Fifteen (15) units Subcutaneous once a day. 18. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continuing Medical Care-[**Hospital1 8**] Discharge Diagnosis: ETOH cirrhosis s/p liver transplant Biliary stricture 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 will be transferring to [**Hospital3 **] in [**Hospital1 8**]. Please contact [**Hospital1 18**] Transplant Office [**Telephone/Fax (1) 673**] if the patient develops fevers, chills, nausea, vomiting, inability to take any of the medications, jaundice, increased abdominal pain, incision redness/bleeding/drainage. Please have labs checked every Monday and Thursday and faxed to the transplant clinic at [**Telephone/Fax (1) 697**]. CBC, Chem 10, AST, ALT, Alk phos, T Bili, Albumin, trough Prograf level. Do not make medication changes without discussing with the transplant surgery clinic. Monitor incision for redness, drainage or bleeding. The patient may shower. No heavy lifting (nothing greater than 10 pounds)or straining Followup Instructions: -[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2140-6-23**] 2:30 -[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2140-6-30**] 1:40 -[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2140-7-7**] 2:20 Completed by:[**2140-6-16**]

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icd9cm

[ [ [] ] ]

[ "51.87", "00.93", "50.59" ]

icd9pcs

[ [ [] ] ]

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286, 320

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232, 248

348, 1615

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1925, 2068

21,293

125,616

21326+57239

Discharge summary

report+addendum

Admission Date: [**2176-11-24**] Discharge Date: [**2176-11-29**] Date of Birth: [**2101-10-21**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: s/p MVC [**2176-11-24**] Major Surgical or Invasive Procedure: Scalp Laceration repair(emergency department) [**2176-11-24**] NO neurosurgical procedures performed History of Present Illness: 70M with hx CAD s/p MI, stents, dementia, depression, CRI, was unrestrained driver in truck and hit tree in the am of [**2176-11-24**], while en route to work. He was taken to [**Hospital 1474**] Hospital and had unknown GCS or exam on arrival but was noted to be verbal. He was intubated for airway protection for transfer to [**Hospital1 18**] for definitive treatment of his injuries. Past Medical History: CAD: s/p STEMI with overlapping stents to RCA in [**6-/2171**] IDDM CHF (EF 40-45% [**6-24**] TTE) HTN s/p C3-4 laminectomy c/b dysphagia hyperlipidemia PVD: s/p left [**Month/Year (2) 1793**] stent in [**2170**] s/p stent to LRA and atherectomy of right CFA in [**9-22**] s/p PTA of left [**Date Range 1793**] in [**11-22**] GERD Asbestosis CRI b/l Cr ~1.2 Anemia PUD s/p remote partial gastrectomy Depression Dementia Social History: ex smoker, quit 3 yrs ago after 80 pack year history, denies etoh or illicit drugs, widower, semi retired, works as [**Last Name (un) **] at Stop and Shop Family History: non contributory Physical Exam: PHYSICAL EXAM(On Admission): VS; 176/90 P 90 RR 15 100% on vent Gen: intubated, sedated HEENT: large L frontal scalp laceration difficult to fully characterize as surgery team is suturing at time of encounter. dried blood on face. Neck: Supple. Lungs: CTA anteriorly Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Exam limited at time of encounter due to need for stabilization of acute issues (wound care of scalp lesion) which required patient to remain on sedation. PERRL 2mm-->1.5mm. Face appears symmetric. No spontaneous movements witnessed, however ED team states patient was moving all extremities off sedation. Pertinent Results: Labs on Admission: [**2176-11-24**] 06:56AM BLOOD WBC-14.5* RBC-4.31* Hgb-12.8* Hct-38.5* MCV-89 MCH-29.8 MCHC-33.3 RDW-14.6 Plt Ct-170 [**2176-11-24**] 06:56AM BLOOD PT-19.1* PTT-26.8 INR(PT)-1.7* [**2176-11-24**] 12:30PM BLOOD Glucose-206* UreaN-22* Creat-1.1 Na-139 K-4.3 Cl-109* HCO3-24 AnGap-10 [**2176-11-24**] 12:30PM BLOOD CK(CPK)-555* [**2176-11-24**] 06:56AM BLOOD Lipase-26 [**2176-11-24**] 12:30PM BLOOD CK-MB-12* MB Indx-2.2 cTropnT-<0.01 [**2176-11-24**] 12:30PM BLOOD Albumin-3.3* Calcium-7.0* Phos-2.7 Mg-1.5* [**2176-11-24**] 12:30PM BLOOD Phenyto-12.8 Labs on Discharge: [**2176-11-28**] 05:35AM BLOOD WBC-6.3 RBC-2.81* Hgb-8.4* Hct-24.9* MCV-89 MCH-29.8 MCHC-33.7 RDW-14.7 Plt Ct-175 [**2176-11-28**] 05:35AM BLOOD PT-11.6 PTT-23.7 INR(PT)-1.0 [**2176-11-28**] 05:35AM BLOOD Glucose-177* UreaN-24* Creat-1.3* Na-143 K-3.8 Cl-109* HCO3-22 AnGap-16 [**2176-11-28**] 05:35AM BLOOD Albumin-2.8* Calcium-7.8* Phos-1.9* Mg-2.1 [**2176-11-28**] 05:35AM BLOOD Phenyto-6.5(bolused with 500mg IV prior to discharge) Imaging: Head CT [**11-24**]: small subdural hematoma of the right frontal convexity and right parietovertex. Head CT [**11-26**]: stable appearance of small right frontal subdural hematoma. CXR [**11-27**]: without evidence of pneumonia LENIS [**11-27**]: no evidence of DVT Brief Hospital Course: This patient was transferred to [**Hospital1 18**] from [**Hospital 1474**] hospital intubated to the trauma ICU. Initially his exam was poor, but off of sedation on hospital day one he was arousable, opened his eyes and followed commands with all four extremities. He was extubated subsequent to this, and transferred to the neurosurgery stepdown on [**11-26**]. His head CT was repeated, and determined to be stable. His mental status continued to wax and wane, consistant with his history of dementia. She continued to remain neurologically stable, and was transferred from the stepdown until to the NSURG floor. He was restarted on his aspirin and sub-q heparin. He was determined to be safe to resume his coumadin on [**12-7**](to be monitored by his PCP/vs Cardiologist). On [**11-27**], he had a one-time low grade fever, cultures of urine, chest x-ray, and LE ultrasounds were performed(all determined to be negative). He continued to be seen and evaluated by PT/OT who recommended dispoisition to a rehab facility. He was then discharged on [**2176-11-28**]. Medications on Admission: -aricept 10 mg daily -metformin 1000 mg [**Hospital1 **] -skelaxin 800 mg q8h -warfarin 5 mg daily -nexium 40 mg daily -hydrocodone 7.5 mg daily -cymbalta 60 mg daily -humulin ss -levemir 37 units qhs Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: not to exceed more than 4gm apap in 24hrs. 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for hr<55, SBP<100 . 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for const. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 13. Regular Insulin sliding scale per nursing handouts 14. IV Fluids continue NS w/20MEQ K at 75cc/hr until adequate PO fluid intake 15. Telemetry continue telemetry Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Right frontal traumatic SDH Discharge Condition: 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. ?????? You may safely resume taking your Coumadin on [**2176-12-7**]. You have already been restarted on your aspirin. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **] , 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. Scalp Laceration Follow Up: Please call ([**Telephone/Fax (1) 56365**] to schedule an appointment with Dr. [**Name (NI) 56366**] office to have the staples on your scalp, as well as the sutures on your hands removed. This should be performed on or about [**12-4**]. If you are still at rehabilitation during this time, this may be performed there. Completed by:[**2176-11-28**] Name: [**Known lastname 10567**],[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Unit No: [**Numeric Identifier 10568**] Admission Date: [**2176-11-24**] Discharge Date: [**2176-11-29**] Date of Birth: [**2101-10-21**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 599**] Addendum: temperature taken immediately prior to disposition of 101.8 PO. On [**11-27**]-he also had a temperature of 100.5(axilary). Chest XR, labs, UA and LENIS were obtained. No infectious etiology of fever was identified. It was decided to continue to discharge him, with the following instruction: 1. Patient to return to [**Hospital1 8**] for additional evaluation if fever does not resove within the next 48hrs. Resolution to be considered a fever less than 101.5. Discharge Disposition: Extended Care Facility: [**Hospital3 2215**] Northeast - [**Location (un) 50**] [**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**] Completed by:[**2176-11-28**]

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icd9cm

[ [ [] ] ]

[ "86.59", "96.71" ]

icd9pcs

[ [ [] ] ]

9298, 9518

3538, 4611

347, 450

6399, 6399

2209, 2214

7648, 7997

1500, 1518

4863, 6221

6347, 6377

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283, 309

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478, 868

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1327, 1484

51,078

118,253

50558

Discharge summary

report

Admission Date: [**2191-4-12**] Discharge Date: [**2191-5-7**] Date of Birth: [**2127-5-5**] Sex: F Service: SURGERY Allergies: Penicillins / Codeine / Dilaudid / Keflex / citalopram / Erythromycin Base Attending:[**First Name3 (LF) 3223**] Chief Complaint: dyspnea,fatigue,pancytopenia Major Surgical or Invasive Procedure: Splectomy History of Present Illness: 63F with a PMH of ITP, Hypogammaglobulinemia on monthly IVIG, Colon CA, s/p resection [**4-/2190**] and 6 cycles of FOLFOX,Hypertension,DM1 with retinopathy, recurrent bronchitis with bronchiectasis, hepatic cirrhosis on recent biopsy and recent splenectomy for massive splenomegaly of unclear cause c/b shocked liver and ARF now with altered mental status in the setting of persistent significant elevated LFTs and worsening renal failure. Patient has undergone numerous bone marrow biopsies, and per report, they have shown no evidence of malignancy. Last year she was diagnosed with colonic mucinous adenocarcinoma, for which she underwent right hemicolectomy ([**Hospital1 756**], 5/[**2189**]). She completed 6 rounds of FOLFAX (last round completed [**1-/2191**]), during which time she required multiple PRBC transfusions. She was then recently admitted to the [**Hospital1 18**] Heme/Onc service for symptomatic anemia (HCT 17), for which she received several transfusions. Continued pancytopenic workup was un revealing. During that admission, CT imaging showed an increase in splenomegaly to 23.8cm, prompting concern for splenic lymphoma versus hemophagocytic lymphohistiocytosis. She was discharged home [**2191-4-3**] with surgical referral for consideration of elective splenectomy. However,she was re-admitted on the medicine service on [**2191-4-12**] with increasing dyspnea and fatigue and was found to have a pancytopenic with HCT of 13.2 WBC 1.3 and PLT 40. Bone marrow biopsy showed hypocellular marrow and MRI abdomen showed evidence of chronic liver disease with an enlarged liver and enlarged portal and splenic veins suggestive of portal hypertension and massive splenomegaly. The cause of her splenomegaly is unclear and it was wondered whether this may have been related to portal hypertension. Portal pressure measurement showed present but not severe portal hypertension and biopsy showed cirrhosis of unclear cause.Patient elected to undergoe splenectomy. Past Medical History: PMH: - ITP ([**2176**], requiring IVIG and steroids) - Hypogammaglobulinemia - managed with monthly IVIG - Pancytopenia of unclear etiology (with bone marrow biopsies reporting hypercellular marrow) - Splenomegaly of unclear etiology - Colonic mucinous adenoCA, s/p right hemicolectomy ([**4-/2190**]) and chemotherapy (FOLFOX x6 cycles, last dose [**1-/2191**]) - Hyperbilirubinemia initially suspected secondary to hemolytic anemia, however, etiology less clear currently - Recurrent bronchitis with bronchiectasis - Hypertension; Hypercholesterolemia - Type 1 DM c/b retinopathy - Hx parapsoriasis - Hx of pericardial effusion - Hx left transudative pleural effusion s/p thoracentesis ([**2191-4-2**], path: mesothelial cells, macrophages, and lymphocytes) PSH: - Right hemicolectomy for colon cancer ([**4-/2190**]) - Right chest port-a-cath placement ([**5-/2190**]) - Colonoscopy ([**2191-3-9**]) - Left thoracentesis ([**2191-4-2**]) Social History: Lives with husband in [**Name (NI) 5110**], no smoking, EtOh, IVDU, Husband [**Name (NI) **] is HCP Family History: Mother - thyroid dz - still living, father - prostate cancer and "lung dz" Physical Exam: 98.5 98.5 63 118/49 18 96%RA General: Awake, cooperative. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. Pulmonary: clear,Decreased BS left base. Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: Abdomen soft,tender, minimal ascites on percussion. Incision:steristrips in place, no erythema. Extremities: [**1-7**] + pitting edema to knees bilaterally, 2+ radial, DP pulses bilaterally Skin: Multiple bruises. Pertinent Results: Micro/Imaging: [**2191-4-29**] KUB Unremarkable bowel gas pattern [**2191-4-27**] CT A/P ? infarction L lobe liver. Large amt ascites. [**2191-4-27**] Liver duplex Vessels patent [**2191-4-26**] CT Head negative mass,infarction [**2191-4-26**] renal US no hydro or stones, diffuse enhancement, large amt free fluid [**2191-4-25**] UCx Negative [**2191-4-24**] RUE US no DVT, non-occlusive thrombus in R IJV likely from liver biopsy [**2191-4-21**] Liver bx Nodular [**Last Name (un) **] hyperplasia. Iron deposition and Kuppfer cells. [**2191-4-21**] spleen large population of CD4/CD8 negative t cells c/w autoimmune [**2191-4-20**] EGD Grade 2 esophageal varices [**2191-4-19**] chest x-ray bibasilar atelectasis [**2191-4-18**] Liver bx no cirrhosis, c/w with nodular regenerative hyperplasia. [**2191-4-16**] Bone marrow Bx pending. Aspirate hypercellular. [**2191-4-15**] TTE LVEF 50-55%. [**12-6**]+ MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Mild-mod pericardial effusion. [**2191-4-14**] MRI prelim: ?liver cirrhosis, hepatosplenamogaly, portal HTN Brief Hospital Course: Patient was taken to the operating room on [**2191-4-21**] with Dr. [**Last Name (STitle) 519**] and underwent a splenectomy (please refer to the operative note for further details).Postoperatively patient was kept intubated due to fluid administration: 3u PRBC, 2u platelets, 2 albumin. POD 1,patient was self extubated and after a short ICU stay patient was transferred to the surgical floor. Her postoperative course was complicated by altered mental status, shock liver with elevated LFTs and acute kidney injury. POD [**12-8**] the NGT was out and she was started sips. Her hematocrit was 21 and she was transfused with 1 unit RBC and post transfusion ->24 Postoperatively SBPs for the past few days (on [**4-23**] they had been in the 120's to 130's). However on POD 4 patient was noted to have brief hypotensive episodes with SBP 90s. She received albumin/blood transfusion as needed for hypovolemia. Patient was noted to have worsening renal function with rising BUN/Creatinine. Of note patient had a positive urinalysis and was currently being treated for a UTI with PO Cipro. Of note, patient had been on vancomycin cefepime pre-operatively when she was neutropenic and spiking fevers, however postoperatively she has been afebrile. Thus the vancomycin and Cefepime were subsequently discontinued. Her urine culture eventually came back and was negative. Her urine output was monitored closely and her creatinine were trended. Serial abdominal exams were performed and of note over the next several days her abdominal distention gradually worsened. POD 5([**2191-4-26**]) patient was noted to have increase lethargy and confusion and was triggered due to change in mental status. Per nursing staff, patient had intermittent episodes of hallucination. Her morphine PCA were subsequently discontinued as there were concerns of accumulation of morphine building up given ARF. Patient underwent a head CT which was negative and neurology was consulted. There was concern for hepatic encephalopathy given the acute rise in LFTs although the ammonia level was only 35. Regarless, the pt was started on rifaximin and lactulose. Neurology recommendations were to continue to correct metabolic derangements and to increase lactulose titrating to symptomatic improvement and felt no further imaging was needed at this time. Her MS cont to improve and was at baseline by the time of discharge. Nephrology was consulted for further evaluation of patient worsening renal function. Per nephrology, a renal ultrasound was obtained which showed bilateral kidneys without evidence of hydronephrosis or stones. There were large amount of free fluid is noted throughout the abdomen consistent with ascites. Given the granular casts seen on UA, likely diagnosis of ATN was presumed by renal. Patient Nadolol was discontinued due to continued bradycardia w/ episodes of hypotension. Lasix was given prn as pt appeared volume overloaded w/ some LE swellingon exam. Heme oncology continued to follow patient postoperatively and reccommended treating with blood transfusion for a hemoglobin less than 7. Hepatology continued to follow patient and recommended trending ammonia levels which was 35. Patient received 1 dose of lactulose to treat possible hepatic encephalopathy. Patient received additional Lactulose which was titrated until she had several bowel movements. In addition Rifaximin was also added. Patient underwent an abdominal/pelvis CT which showed infarction Left lobe liver. Large amount of ascites. A Doppler study was performed which showed patent portal vein. The pt's LFTs peaked and started to downtrend during her stay. The rise was likely a reflection of her acute infarction. Hepatology recommended repeating a CT scan; however, our team did not feel this was necessary as her LFTs were downtrending and the pt was asymptomatic. There was also concern for PBC given the rise in alk phos, but given a negative liver biopsy and neg autoimmune antibodies, this diagnosis is much less likely and ursodiol was not initiated. POD 7 Transfused 1u PRBC for HCT 23. TBili decreased. However her Creatinine continued to rise to 3.7. However her LFTs continued to trend downward and her mental status gradually improved. POD [**7-17**] Patient had intermittent complaints of nausea. A KUB was performed which showed an unremarkable bowel gas pattern. Patient received antiemetics as needed. the diet was advanced as tolerated and nutrition were consulted and she was started on calorie counts. She continued to have poor glycemic control (200's-300's). Her insulin sliding scale and Lantus dose were titrated. Patient BUN/creatinine however continued to rise slowly. Her fluids were subsequently discontinued and she was diuresed with several doses of Lasix IV over the next few days. Patient continued to be managed conservatively. Nephrology continued to follow and indicated that there were no immediate need for hemodialysis as creatinine will most likely peak and plateau which it eventually did.The foley catheter was discontinued and she voided without difficulty approximately 1 liter over 24 hours. POD 13 Patient Creatinine peaked at 5.3. She was diuresing well. By the time of discharge, the patient was doing well. Her Cr and LFTs were downtrending. She was ambulating, tolerating a regular diet and urinating adequately. Medications on Admission: Bupropion 150, Lispro SS, Bactrim DS, Lisinopril 40, Simvastatin 40, IVIG monthly, Iron, Vit D, Lantus 28u HS, Clobetasol cream PRN, Lorazepam 0.5'' PRN Discharge Medications: 1. Outpatient Lab Work Basic Metabolic Panel Liver Function Tests Please take this prescription to your PCP appointment with Dr. [**Last Name (STitle) **]. You should have labs drawn weekly. 2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. insulin glargine 100 unit/mL Solution Sig: One (1) 28 Subcutaneous at bedtime. 4. lactulose 20 gram/30 mL Solution Sig: One (1) PO every eight (8) hours as needed for constipation. Disp:*30 1* Refills:*2* 5. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours. Disp:*25 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: ITP Acute Tubular Necrosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], You underwent a splectomy for treatment of your refractory ITP. The procedure went well and was without complications, but you did have a few postoperative complications that kept you in the hospital. You kidney labs started to rise. Nephrology (kidney doctors) were consulted to see you. They believe your kidney took a hit from low blood pressures and this caused some damage to your kidneys. You kidney labs peaked and were trending down at the time of discharge. It is important for you to have labs drawn weekly and the results sent to your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Please take the prescription given to you for labs to your appointment with Dr. [**Last Name (STitle) **] next week. You liver function studies were also found to be elevated. This was likely due to damage to your liver. Hepatology (liver doctors) were consulted and followed you during your hospitalization. Most of your labs were trending down at the time of discharge, but some remained elevated. These labs too should be monitored weekly. If you experience any significant abdominal pain, fevers, or any other symptoms concerning to you, please call or come into the ED for further evaluation. Thank you for allowing us at the [**Hospital1 **] to participate in your care. Followup Instructions: Name: [**First Name11 (Name Pattern1) 8031**] [**Last Name (NamePattern4) 87629**], MD When: Tuesday [**5-10**] at 10am Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2261**] *Please call [**Hospital1 18**] Registration to update before your appointments, the number is [**Telephone/Fax (1) 10676**]. Thank you. Department: SURGICAL SPECIALTIES When: MONDAY [**2191-5-16**] at 10:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**Telephone/Fax (1) 6554**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST [**Hospital 2002**] CLINIC When: MONDAY [**2191-6-6**] at 4:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

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icd9cm

[ [ [] ] ]

[ "50.13", "50.12", "45.13", "41.5", "41.31" ]

icd9pcs

[ [ [] ] ]

11528, 11585

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363, 375

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4087, 5161

13156, 14349

3493, 3569

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11606, 11635

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11807, 13133

3584, 4068

293, 325

403, 2392

11671, 11783

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3375, 3477

81,443

126,426

16770

Discharge summary

report

Admission Date: [**2110-2-14**] Discharge Date: [**2110-2-18**] Date of Birth: [**2056-9-21**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2751**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: EGD [**2110-2-14**] History of Present Illness: 53M w/ EtOH cirrhosis and IDDM x-fer from [**Hospital3 **] for DKA and coffee-ground emesis. Pt reports drinking 1-1.5 pints of vodka for the past several days (previously had been sober for 4 months). Yesterday morning describes feeling "shaky" and began vomiting, then around 10am this morning developed hematemesis with about 2L of bloody vomit per his report. He reports experiencing pain all over his body, particularly in the chest and abdomen. Called EMS and was brought to [**Hospital3 **] ED for further evaluation. . No recent illnesses, denies any fever or chills. No episodes of hematemesis in past, and patient denies any previous history of liver disease. . In [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], R-IJ was placed, pt was given IVF, SC insulin and PPI bolus and was subsequently transferred to [**Hospital1 18**] ED for further mgt. In [**Hospital1 18**] ED, VS: 104 139/78 20 95% RA. Exam was notable for diffuse abdominal tenderness. He received 3L NS and 1u PRBCs. NGT was placed which drained 2 L of dark liquidy coffee ground material. GI was called who recommended admission to MICU and urgent EGD. . In the ICU, pt appears uncomfortable and is c/o generalized body weakness, aches and diffuse abdominal pain. . ROS: Shaking, nausea, vomting/hematemesis as above. Generalized CP and abdominal pain, dyspnea, palpitations. Denies HA, blurry vision, dizziness, rhinorrhea, nasal congestion, cough, diarrhea, constipation, bloody or dark tarry stools, dysuria, arthralgias or myalgias. Past Medical History: hx B/L SDHs hx EtOH w/d seizures hx EtOH cirrhosis IDDM c/b hypoglycemia HTN HLD intention tremors Social History: Mr. [**Known lastname 47374**] moved to the US from [**Location (un) 4708**] 14 years ago. He attended college but never obtained a degree and currently owns and works in a Lil Peach store. He has prior hx smoking and quit in [**2078**]. Previously he drank 3-4 beers 3-4 times a week. Has prior hx drinking daily since [**2101**]. Reports he had stopped drinking x4 months, but recently has been drinking 1-1.5L vodka daily. He has two children (daughter is [**Name (NI) **] and next of [**Doctor First Name **]) and lives with his son and wife [**Name (NI) 47375**]. Denies any illicit drug use or history of IVDU. Family History: Mr. [**Known lastname 47376**] mother had HTN and his father had DM. No family history of cancer. Physical Exam: ADMISSION EXAM: VS: T: 99.0 HR: 111 BP: 123/75 RR: 22 SaO2: 98% RA GEN: thin-appearing Trinidadian male in moderate distress, w/ NGT in place draining copious amts of black liquidy material, w/ dried blood around his nose and mouth HEENT: anicteric sclerae; EOMI, PERRLA CV: tachycardic rate, regular rhythm LUNGS: CTAB/L no w/r/r ABD: +BS soft, diffusely TTP all over EXT: no peripheral edema, 2+ distal pulses B/L NEURO: A&Ox3 Pertinent Results: ADMISSION LABS: [**2110-2-14**] 05:15PM BLOOD WBC-11.2*# RBC-3.37* Hgb-10.4* Hct-29.6* MCV-88 MCH-31.0 MCHC-35.3* RDW-14.4 Plt Ct-92* [**2110-2-14**] 05:15PM BLOOD Neuts-85.8* Bands-0 Lymphs-10.8* Monos-2.7 Eos-0.3 Baso-0.3 [**2110-2-14**] 05:15PM BLOOD PT-13.9* PTT-26.4 INR(PT)-1.2* [**2110-2-14**] 05:15PM BLOOD Glucose-424* UreaN-34* Creat-1.1 Na-121* K-4.1 Cl-80* HCO3-10* AnGap-35* [**2110-2-14**] 05:15PM BLOOD ALT-25 AST-38 AlkPhos-99 TotBili-0.5 [**2110-2-14**] 05:15PM BLOOD Albumin-3.5 [**2110-2-14**] 05:17PM BLOOD Hgb-10.6* calcHCT-32 [**2110-2-14**] 05:17PM BLOOD Glucose-407* K-4.0 MICRO: IMAGING: [**2-14**] CXR: No acute process. Right IJ central line ends at the superior cavoatrial junction. [**2-14**] RUQ US: No acute hepatobiliary process. Echogenic liver, presumed fatty liver, however more advanced forms of hepatic parenchymal disease. Patent portal vein. Brief Hospital Course: 53 M w/ ?EtOH cirrhosis, IDDM w/ recent EtOH binge in setting of unemployment, p/w large-volume UGIB and DKA, and who was found to have necrotic appearing esophagus on EGD. . ACTIVE ISSUES: #. Upper GI Bleed secondary to ischemic esophagitis: Patient reported hematemsis of approx 2L blood the morning of admission. Was initially brought to [**Hospital3 **], then transferred to [**Hospital1 18**] for urgent EGD. EGD performed the night of admission revealed a necrotic appearing esophagus with friability noted from 20 cm to GE junction. There were no clear esophageal varices noted, and no bleeding lesions. There was erythema and friability in the whole stomach compatible with gastritis, as well as small erosions in a linear pattern appear to be from NG tube. Hematin noted in duodenum. It was felt that the patient may have had a hypotensive episode prior to admission, precipitating necrosis of the esophagus. He was continued on a PPI gtt and started on sucralfate 1gm QID. His HCT was closely monitored, and an active type and screen was maintained. The patient did receive 3 units pRBCs overnight on the night of admission. On the floor, he was transitioned to PO pantoprazole [**Hospital1 **] and continued on sucralfate. Tolerating a regular diet, hematocrit was stable. . #. DKA: Patient on insulin pump at home and had not been taking insulin as directed. It was felt that medication non-adherence and decreased PO intake at home were the triggers for his DKA, though patient had an infectious work-up to pursue other causes. Sugars were >400 on transfer, and anion gap was 31 in ED. Patient was aggressively hydrated with NS, and started on an insulin gtt at 7 units per hour until the gap closed. His electrolytes were monitored closely, and potassium and phosphate were repleted as needed. Fluids were switched to D5 1/2 NS once FSBS was <250. His gap had closed by the following morning, and the patient was transitioned to 10 units glargine QAM plus a HISS. [**Last Name (un) **] was consulted and thought that his DKA was precipitated by pump failure. They recommended sending the patient out on self-administered insulin, 19 units of glargine qAM with a provided sliding scale until a [**Company 1543**] technician was able to make a house visit to evaluate the patient's insulin pump. He was set up with a follow-up appointment with the [**Hospital **] clinic. . #. ETOH ABUSE: Patient has history of withdrawal seizures, which puts him at risk for recurrent seizures. He stated he had previously been sober for 4 months, but that over the past several days he had been drinking 1-1.5 pints of vodka daily. Per his wife, trigger for heavy alcohol abuse is recent loss of job. Patient given banana bag and started on thiamine and folate once taking PO. He was monitored for signs of withdrawal per CIWA protocol. Social work consulted regarding substance abuse counseling. Patient also had RUQ to eval for possible EtOH cirrhosis, which revealed an echogenic appearing liver, which could be secondary to fatty liver. He was seen by the Alcohol Addiction specialist who recommended AA meetings. The patient was sent out with thiamine, folate, and multivitamin supplementation. There was no evidence of cirrhosis on exam, he will follow-up with GI, with Liver f/u per their discretion. . #. HTN: Restarted on discharge . Transitional Issues: - GI f/u and repeat endoscopy - ?liver follow up - AA meetings - [**Last Name (un) **] f/u and insulin pump evaluation - PCP [**Last Name (NamePattern4) 702**] Medications on Admission: insulin Humalog sliding scale Lisinopril Centrum MVI Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO once a day. 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. thiamine HCl 250 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Carafate 100 mg/mL Suspension Sig: Ten (10) mL PO four times a day. Disp:*qs * Refills:*2* 7. Lantus 100 unit/mL Solution Sig: Nineteen (19) units Subcutaneous qAM. Disp:*qs * Refills:*0* 8. Humalog 100 unit/mL Solution Sig: Per provided sliding scale Subcutaneous four times a day. Disp:*qs * Refills:*0* 9. Lancets,Ultra Thin Misc Sig: Use as directed Miscellaneous four times a day. Disp:*qs * Refills:*0* 10. Insulin Syringe Ultrafine [**12-15**] mL 29 x [**12-15**] Syringe Sig: As directed Miscellaneous four times a day. Disp:*qs * Refills:*0* 11. Glucose monitoring strips Please provide glucose monitoring test strips. Needs to be compatible with [**Company **] OneTouch Ultralink. 12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Ischemic esophagitis, Upper GI bleed, diabetic ketoacidosis, ethanol intoxication Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 47374**], It was a pleasure taking care of you during your admission. You were admitted because you were vomiting blood. You had an Upper Endoscopy which showed a "black esophagus," a condition that happens when your blood pressure is low. We monitored you and your blood levels were stable. Your blood pressure may have been low secondary to your drinking which caused you to go into a condition called diabetic ketoacidosis (DKA) which happens when your blood sugars are uncontrolled. We monitored your blood levels and they were stable. We treated you with insulin which controlled your blood sugars. The [**Last Name (un) **] doctors saw [**Name5 (PTitle) **] and thought that your pump was malfunctioning. You're pump will be examined by a technician, but in the meantime, you will need to control yourself with self-administered insulin based on the sliding scale we provided. . You were seen by an alcohol addiction specialist while here; it is VITALLY important that you stop drinking as continued drinking could be fatal either from another bleed or from liver damage. Alcoholics Anonymous (AA) may be able to help you with this goal. . We added the following medications: Pantoprazole 40mg by mouth twice daily Sucralfate 1gram by mouth four times a day Lantus 19units every morning Humalog per provided sliding scale . Please follow up with the appointments scheduled below. Followup Instructions: Department: [**Last Name (un) **] Diabetes Center When: THURSDAY [**2110-2-20**] at 2:00 PM With: Dr. [**Last Name (STitle) 3617**] [**Telephone/Fax (1) 9670**] Name: [**Doctor Last Name **], Madhvendra Location: [**Hospital3 **] MEDICAL ASSOCIATES Address: [**Street Address(2) 17502**], [**Location (un) **],[**Numeric Identifier 17464**] Phone: [**Telephone/Fax (1) 17503**] Appointment: Monday [**2-24**] at 4PM Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2110-3-4**] at 3:00 PM With: [**Name6 (MD) 11170**] [**Last Name (NamePattern4) 11171**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Completed by:[**2110-2-19**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report+addendum

Admission Date: [**2140-2-6**] Discharge Date: [**2140-3-23**] Date of Birth: [**2103-9-4**] Sex: M Service: CHIEF COMPLAINT: Heart block, anoxic brain injury, Methicillin sensitive Staphylococcus aureus bacteremia, hemothorax. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4318**] is a 36 year old male with a past medical history of endocarditis secondary to intravenous drug abuse resulting in tricuspid valve replacement that needed to be removed for infection. The patient then had complete heart block requiring a pacemaker that was removed secondary to pocket infection. The patient was maintained as an outpatient on Lasix. On [**2140-2-6**], the patient was at home with his fiance when he had a cardiac arrest. The fiance performed CPR for approximately five minutes with no return of pulse. The patient was intubated in the field and was found to be bradycardic with a heart rate in the 30s and 40s. The patient was taken to a local Emergency Room, stabilized and then transferred to [**Hospital1 1444**]. In the Emergency Room, the patient had an episode of ventricular tachycardia with prolonged QT that resolved with direct current cardioversion. PAST MEDICAL HISTORY: 1. Hepatitis C. 2. History of intravenous drug abuse on methadone. Last used intravenous drugs in [**2138-11-28**], nasal heroin. 3. Past cardiac history: In [**2132-5-28**], Methicillin sensitive Staphylococcus aureus bacteremia endocarditis, in [**2132-9-27**], tricuspid valve vegetation, Methicillin sensitive Staphylococcus aureus bacteremia; in [**2132-9-27**], septic emboli to the lungs, tricuspid valve resection, patent foramen ovale, tricuspid valve replacement, foramen ovale closure, third degree atrioventricular block, status post permanent pacemaker in [**2133-8-28**]; atrial lead placement, pacer reprogramming in [**2133-10-28**]; Methicillin sensitive Staphylococcus aureus bacteremia in [**2133-12-28**]; tricuspid valve prosthesis removed, atrial septal defect graft revision, epicardial pacemaker implanted; in [**2134-11-28**], pacemaker pocket was infected again; in [**2135-1-29**] heroin overdose, pacemaker removed; in [**2135-1-29**], cardia pacemaker wires were infected, removed through sternotomy. 4. In [**2135-8-29**], the patient had a bout of osteomyelitis. 5. In [**2136-2-26**], Methicillin sensitive Staphylococcus aureus, lung abscess. 6. In [**2136-5-28**], osteomyelitis of L4-L5 status post diskectomy. 7. The patient has had a total of three pacemakers in the past. ALLERGIES: Dicloxacillin; the patient develops a rash. MEDICATIONS ON ADMISSION: 1. Tylenol 650 mg p.o. q. six hours p.r.n. 2. Lopressor 25 mg p.o. twice a day. 3. Methadone 40 mg p.o. q. day. 4. Amiodarone 400 mg p.o. q. day. 5. Free water boluses 250 cc p.o. three times a day. 6. Vancomycin 1 gram intravenous q. 12. 7. Levofloxacin 500 mg p.o. q. day. SOCIAL HISTORY: The patient does not work. He is engaged and lives with his fiance. No tobacco, no ethanol. History of heroin abuse. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On admission, vital signs, 101.6 F.; blood pressure 130/80; heart rate 80 and paced; respiratory rate 20; 94% on room air. In general, the patient is a well developed, well nourished male in no apparent distress, somewhat confused. HEENT: Pupils equally round and reactive to light. Extraocular muscles are intact. No scleral icterus. Cardiovascular: Regular rate and rhythm, S1, S2 present. There was a right ventricular heave. Prominent neck veins secondary to lack of tricuspid valve. Lungs clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended. Positive bowel sounds. Extremities showed no cyanosis, clubbing or edema and good pulses. No signs of endocarditis. Neurologically, the patient was confused, awake, alert, oriented times two. Has difficulty with short-term memory, however, answers appropriately to all questions. LABORATORY: Values initially showed a white blood cell count of 9.7, hematocrit of 33.2, magnesium 1.8, ALT 37, AST 41, alkaline phosphatase 296, total bilirubin 1.0. Blood cultures were growing initially Methicillin sensitive Staphylococcus aureus; urine cultures showed coagulase negative Staphylococcus. HOSPITAL COURSE: 1. Cardiovascular: While in the Cardiac Care Unit, the patient had a transvenous pacer placed for his complete heart block. The patient was treated initially for Methicillin sensitive Staphylococcus aureus, however, subsequent blood cultures showed that the patient was growing Methicillin resistant Staphylococcus aureus and the patient had to have his transvenous pacer wire removed. It was felt that it was the source of his infection. The patient had an echocardiogram on the [**6-21**] which showed left ventricular wall thickness was normal. Left ventricular systolic function was minimally depressed. Right ventricular wall thickness was normal. Right ventricular cavity was markedly dilated. Right ventricular systolic function appeared to be depressed and there was abnormal diastolic septal motion position consistent with right ventricular volume overload; abnormal septal wall motion. The aortic root was normal. Aortic valve leaflets were normal with no masses or vegetatives. Mitral valve was normal with trivial mitral regurgitation. There was severe four plus tricuspid regurgitation because of the lack of a tricuspid valve. Because the patient had the episode of torsade de pointes, the patient was given a transvenous pacer and was told to keep the pacemaker at a rate of 80. Throughout the hospital course, the patient had episodes of non-sustained ventricular tachycardia for which he was started on Amiodarone 400 mg p.o. q. day for a total of three months which will end on [**2140-5-18**]. On that date, the Amiodarone should be changed to 200 mg p.o. q. day. The patient is to have repeat permanent pacemaker placed by the Electrophysiology Service once the course of antibiotics has continued and has finished and subsequent surveillance blood cultures have been negative by the Electrophysiology Service at [**Hospital1 69**]. With the history of complete heart block, the patient had a transvenous pacer in place at a heart rate to be left at a heart rate of 80. The patient will be re-evaluated by Electrophysiology as stated earlier. The patient has no history of coronary artery disease. He had a clean catheterization at [**Hospital6 **] last year. 2. Infectious Disease: The patient was found to have Methicillin resistant Staphylococcus aureus bacteremia secondary to transvenous pacer wire infection. After the pacer wire was removed, the patient had surveillance blood cultures done which were no longer positive for Methicillin resistant Staphylococcus aureus. The patient was treated with Vancomycin for the Methicillin resistant Staphylococcus aureus. The patient is to have a total of 30 days of Vancomycin. Currently, the patient is on day 15 of Vancomycin. He currently gets one gram intravenously q. 18. Vancomycin level needs to be checked and dosed accordingly. The patient was also on Toprol XL 50 mg p.o. q. day. In order to look for sources of infection initially, a CT scan of the abdomen was done which was negative. The patient had negative blood cultures after the new pacer wire was placed. The patient also had a neck ultrasound done which was negative for any sort of pus pockets. Throughout the hospital course, the patient developed mild myelosuppression while on the Vancomycin, however, prior to discharge, the patient's white blood cell count had gone up to about 3 or 4 which was felt to be normal for him and the patient's white blood cell count was stable while on the Vancomycin. The patient also had some issues with his creatinine being slightly elevated during the hospital course to a maximum of 1.4, however, this was felt to be prerenal and the patient was encouraged to take good p.o. intake. Urine eosinophils were negative. There were also some issues with the patient possibly being HIV infected given the lowering blood counts, however, the patient was found to be HIV negative and it was felt that the low blood counts were probably from the myelosuppression on the Vancomycin. Initially, when they were looking for a source of infection, the patient had a tagged white blood cell scan to find out what exactly was the source. This had showed uptake in the lungs. The patient also had a Panorex of the mouth to look for any sort of dental abscesses, but this was all negative and it was felt that the patient was infected from the transvenous pacer wire. The patient also received a PICC line on the day prior to discharge for long-term antibiotics. DISCHARGE DIAGNOSES: 1. Transvenous pacer wire infection. 2. Complete heart block. 3. Torsade de pointes. 4. Cardiac arrest. 5. Tricuspid valve removal. 6. History of endocarditis. 7. History of osteomyelitis. 8. Intravenous drug abuse with heroin. 9. Methicillin resistant Staphylococcus aureus bacteremia. DISCHARGE INSTRUCTIONS: 1. The patient is to have follow-up with the Electrophysiology Service after the completion of the full 30 days of Vancomycin. Surveillance blood cultures need to be done after the Vancomycin course is completed. 2. The patient will return to the Electrophysiology Service for a permanent pacemaker placement. 3. Check white blood cell count as well as Vancomycin levels as well as BUN and creatinine while the patient is in rehabilitation to make sure the patient is not having any more myelosuppression or renal toxicity from the Vancomycin or is not getting prerenal. Vancomycin levels also needs to be checked as the Vancomycin dose may need to be adjusted. 4. The patient is to be switched to amiodarone 200 once a day on [**2140-5-18**], if the patient is still at rehabilitation at that point. DISPOSITION: To Rehabilitation. CONDITION AT DISCHARGE: Fair. NOTE: The patient had a prolonged hospital course of approximately two months and none of the interns (they know who they are), did not do their parts of the dictation. If you have any further questions, please call [**Hospital1 188**]. [**Last Name (LF) **],[**Name8 (MD) **] M.D. [**MD Number(1) 9783**] Dictated By:[**Name8 (MD) 9784**] MEDQUIST36 D: [**2140-3-23**] 09:36 T: [**2140-3-23**] 09:49 JOB#: [**Job Number 9785**] 1 1 1 OMR Name: [**Known lastname 1323**], [**Known firstname 63**] Unit No: [**Numeric Identifier 1324**] Admission Date: [**2140-2-6**] Discharge Date: [**2140-3-23**] Date of Birth: [**2103-9-4**] Sex: M Service: ADDENDUM: This addendum covers the [**Hospital 1325**] hospital course from [**2-26**] to [**2140-3-11**]. INFECTIOUS DISEASE: Investigation for a source of the patient's Methicillin resistant Staphylococcus aureus bacteremia lead to tagged white blood cell scan, which showed an enlarged spleen and diffuse uptake in the lungs. However, the patient has had an enlarged spleen in the past. Followup chest x-ray did no show any focal areas of pneumonia. CT of the abdomen showed no focal source of infection and it was consistent with diffusely mottled liver with marked prominence of IVC filter mild splenomegaly. There were no focal splenic abnormalities. There were no significant MR vegetations. On further review of the patient's chart, it was found that the patient became Methicillin resistant Staphylococcus aureus positive after the transvenous pacer was placed in the Coronary Care Unit. In light of no other clear source of the patient's bacteremia, the patient's transvenous pacer was changed by the EP laboratory. The tip of the wire was sent for culture and positive for Methicillin resistant Staphylococcus aureus. The patient continued to received IV Vancomycin throughout the course. The patient's followup blood cultures remained negative. CARDIOVASCULAR: The patient continued to be on "Amio" for his history of nonsustained ventricular tachycardia and transvenous pacer for complete heart block and history of torsade. As outlined in the Infectious Disease section, the patient's transvenous pacer was changed in light of no other clear-cut source of his Methicillin resistant Staphylococcus aureus bacteremia. HEMATOLOGY: The patient's white blood cell count and platelet count remained low, but stable throughout the course of two weeks. It was felt to be secondary to myelosuppression perhaps from Vancomycin. The patient's CBC was monitored throughout the course of the two weeks. NEUROLOGICAL: The patient's mental status remained at baseline. DR.[**Last Name (STitle) 1326**],[**First Name3 (LF) 1327**] 12-983 Dictated By:[**Name8 (MD) 1328**] MEDQUIST36 D: [**2140-3-23**] 09:04 T: [**2140-3-23**] 09:40 JOB#: [**Job Number 1329**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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37439

Discharge summary

report

Admission Date: [**2112-11-10**] Discharge Date: [**2112-11-29**] Date of Birth: [**2056-11-26**] Sex: F Service: MEDICINE Allergies: Morphine / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 5893**] Chief Complaint: transfer for radiation oncology evaluation Major Surgical or Invasive Procedure: intubation PICC placement [**2112-11-21**] tracheostomy, PEG, thoracentesis History of Present Illness: 55 yo female with history of tobacco abuse and chronic back pain transferred from [**Hospital6 33**] for Oncology and Radiation Oncology evaluation. The patient initially presented to [**Hospital 7912**] on [**2112-11-5**] following an evaluation by ENT for sinus congestion. Per the patient's family, she had been complaining of upper respiratory symptoms including nasal congestion, drainage, cough for approximately 2 months. She had been evaluated in [**State 108**] by her PCP and ENT. She was treated with antibiotics and antihistamines without relief. She came to [**Location (un) 86**] to visit her family for [**Holiday 1451**]. Her daughter was concerned with facial and neck swelling. She noticed that her neck veins were engorged. Her daughter referred her to her own ENT who ordered a CT chest to evaluate for SVC syndrome. The CT showed RUL and RML collapse due to a central obstructing lesion as well as bulky lymphadenopathy. The patient was referred to the [**Hospital3 **] ED, and admitted for malignancy evaluation. On admission she had a thoracentesis which did not show evidence of malignancy. She was transferred to the ICU on [**2112-11-6**] for respiratory decompensation. On [**2112-11-8**], thoracic surgery performed a rigid bronchoscopy with biopsy which showed non-small cell lung cancer. The patient was intubated initially for this procedure, extubated, but then developed respiratory failure 20 min later requiring reintubation. She self extubated on [**2112-11-9**], was in respiratory extremis and required reintubation. The patient was transferred to [**Hospital1 18**] for further evaluation. Her sedation medications have included propofol, precedex, fentanyl and ativan. On arrival to the [**Hospital Unit Name 153**], the patient is intubated and sedated. The patient's husband, daughter and son are present. They are concerned for her comfort. They feel she has been very uncomfortable on the ventilator, without adequate sedation. They report she has chronic severe back pain from scoliosis which is likely contributing to her discomfort. Unable to obtain review of systems secondary to intubation. Past Medical History: Non-small cell lung cancer diagnosed [**10-17**], SVC syndrome Scoliosis, chronic back pain s/p cholecystectomy s/p hysterectomy Social History: The patient lives in [**State 108**] with her husband. [**Name (NI) **] daughter and son are very supportive and live here in Mass. She has smoked a pack of cigarettes per day since she was 18 years old (37 pack year history). Denies alcohol or illicit drug use. Family History: NC, no known lung cancer Physical Exam: GENERAL: Intubated sedated in NAD HEENT: neck has dilated veins, plethoric, normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MM dry. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: Rhonchi bilaterally, decreased air movement on right upper, no wheezes or crackles. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: BL UE edema, no LE edema, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: Unable to assess given sedation PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: From [**Hospital6 33**] CT Chest [**2112-11-2**]: RUL and RML collapse, central obstructing mass, large right pleural effusion, bulky right paratracheal, subcarinal, precarinal and lateral vascular adenopathy. MRI head [**2112-11-6**]: Nonspecific small foci of increased T2 and Flair signal in the subcortical white matter likely represent small vessel ischemic change. No mass or metastatic disease. CT Abd/pelvis [**2112-11-6**]: Large right pleural effusion, compressive atelecatsis, no liver lesions, no abdominal mass or adenopathy, 3mm right renal calculus, edema in the subcutaneous fat of the anterior chest wall as well as the right and left breast. no pelvic mass Brief Hospital Course: #. Respiratory Failure: She was intubated at an OSH for respiratory distress. She had a high a-A gradient throughout admission that was felt to be secondary to shunt physiology with collapse of her right upper and right middle lobe. She had an initial bronchoscopy the day after admission which showed a large tumor burden obstructing the airways. She had a stent placed by IP on [**11-13**] to the right main stem bronchus to prevent further collapse. She then had a tracheostomy/PEG placed on [**11-21**] as well as a thoracentesis of 1.2 L of pleural fluid. The fluid was negative for malignant cells. On [**2112-11-22**], she was liberated from the ventilator but required further ventilatory support overnight on several instances. Ms. [**Known lastname **] continued to do well, spending most of her time on trache-mask. Repeat CXR showed slow reaccumulation of pleural effusion, but her respiratory function remained stable with attempts to diurese her further. If her respiratory function acutely worsens, would consider CXR to assess fluid status, diuresis with prn lasix and/or thoracentesis to drain pleural fluid. She also likely may require ventilatory support to rest overnight occasionally. She was on this at discharge at night. Her settings were Volume Control TV 450, RR 16, PEEP 5, Fi02 50%. #. Non-Small Cell Lung Cancer: This was a new diagnosis immediately prior to admission. Radiation oncology was consulted. She completed 4 doses of palliative XRT (400 cGy x 5 fractions) which was completed [**11-16**]. Medical oncology was consulted as well and offered chemotherapy as a possible option for the future. Initial metastatic workup has been negative with negative abdominal and brain imaging. She was followed by palliative care. #. SVC Syndrome: She initiallly presented to the OSH with facial swelling secondary to SVC sydrome due to her lung mass and bulky lymphadenopathy. She was started on IV steroids which were tapered gradually. She was also started on a Heparin gtt due to an SVC and IVC clot which was transitioned to Lovenox on [**11-22**]. Her neck and facial swelling worsened from [**Date range (1) 84136**], and she was restarted on dexamethasone 4 mg [**Hospital1 **] with a plan to slowly taper down to a low dose (4 mg [**Hospital1 **] x 2 days then decrease to 2 mg [**Hospital1 **] (on [**12-1**]) and assess response. If pt continues to have better controlled edema and no vomiting, it can eventually be decreased to 2 mg qd. If she has more symptoms may need to go up on dose to 2 mg tid or 4 mg [**Hospital1 **]. Goal is smallest dose possible to keep symptoms under control and to allow of increase in dose if symptoms reoccur. #. Bleeding: On [**11-23**], she had an episode of bleeding from her PEG tube, increasing abdominal pain, and a hematocrit drop. She was given a total of 2 units of blood and her bleeding stopped. Her anticoagulation was initially held. GI did an endoscopy on [**11-25**] and found an ulcer which was injected with epinephrine and her hematocrit remained stable, although dropped slightly (2 points of the day of discharge). Her hematocrit should be checked daily for 2-3 days to ensure stability after discharge. #. Chronic Back pain: She has chronic pain secondary to scoliosis. She was continued on fentanyl initially and was transitioned to Dilaudid IV as needed however this caused delerium so she was changed back to oxycodone on [**11-26**]. She was also started on Methadone, but felt that this precipitated nausea and made her somnolent. Consequently, she was changed to oxycodone 30mg PGT q4 standing, with oxycodone 30-60 mg PGT q2 prn. The patient was only requiring 30mg Q2-4H at discharge and was tolerating this regimen well. #. Anxiety: She had substantial anxiety and was managed with benzodiazepines scheduled and as needed. There was some concern that she had some confusion with ativan, but it was felt that the anxiolytic benefits outweighed the possible confusion. At the time of discharge, the patient was maintained on standing klonopin with ativan prn for anxiolysis as needed. The team felt that much of her pain was being relieved by treating this anxiety. #. Vomiting/Nutrition: Patient had multiple episodes of vomiting without nausea during her radiation therapy. This resolved and was thought to be due to esophagitis. Patient then re-developed vomiting on [**2115-11-28**]. This was initially instigated by suctioning but was then spontaneous. It was of unclear etiology though the patient thought it was due to Methadone. As the steroids had been recently stopped, and there was increased neck swelling, there was concern for worsening SVC syndrome, brain edema, and/or anxiety causing the vomiting. However, the patient felt this vomiting was due to Methadone so it was stopped. The patient had no vomiting since [**11-28**]. She had a video swallow study on the day of discharge which showed that she could not take po without aspirating and she chose to remain NPO except for ice chips. However, if she decides that she would like to eat or drink for comfort, she can do this in the future knowing the risk of aspirating. #. Tobacco Abuse: Her nicotine patch was discontinued prior to discharge. #. Code Status: She was made DNR during this hospitalization. #. Communication: Husband, HCP [**Name (NI) **] [**Name (NI) **] [**0-0-**], [**First Name4 (NamePattern1) 2270**] [**Known lastname **] (daughter) [**Telephone/Fax (1) 84137**], [**Telephone/Fax (1) 84138**] Medications on Admission: Home MEDICATIONS: Oxycodone PRN Avelox and Z-pak x2 MEDICIATIONS on Transfer: Combivent 10puffs every 4 hours Fentanyl 25mcg Q2H PRN Propofol gtt Precedex gtt Oxycodone 30mg Q6H PRN Pantoprazole 40mg IV QD SS Insulin Lorazepam 0.5mg Q4H PRN Methylprednisolone 40mg IV Q8H Nicotine patch Flexeril 10mg TID PRN Senna 1 tab PRN ALLERGIES: Sulfa/Morphine Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Polyethylene Glycol 3350 17 gram/dose Powder [**Telephone/Fax (1) **]: One (1) Dose PO DAILY (Daily) as needed for constipation. 3. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 4. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: Ten (10) mL PO BID (2 times a day). 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Telephone/Fax (1) **]: 6 (six) Puffs Inhalation Q3H (every 3 hours) as needed for wheezing. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: 6 (six) Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Telephone/Fax (1) **]: 4-8 mg Injection Q8H (every 8 hours) as needed for nausea. 8. Enoxaparin 60 mg/0.6 mL Syringe [**Telephone/Fax (1) **]: Fifty (50) mg Subcutaneous Q12H (every 12 hours). 9. Lorazepam 0.5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO every four (4) hours as needed for anxiety. 10. Metoclopramide 10 mg Tablet [**Telephone/Fax (1) **]: 0.5 Tablet PO TID (3 times a day). 11. Sucralfate 1 gram Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q6H (every 6 hours). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 13. Dexamethasone 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12 hours): Please give 4mg [**Hospital1 **] x 2 days, then 2mg [**Hospital1 **] x 2 days (starting [**12-1**]), and assess her facial/neck swelling. 14. Oxycodone 15 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q4H (every 4 hours). 15. Oxycodone 15 mg Tablet [**Month/Year (2) **]: 2-4 Tablets PO Q2H (every 2 hours) as needed for pain. 16. Clonazepam 0.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times a day): Please hold for sedation or RR<12. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnosis: Non-small cell lung cancer Superior vena cava syndrome Secondary Diagnosis: Venous thrombosis Discharge Condition: Ambulating only with physical therapy present, vital signs stable, requiring intermittent ventilatory support Discharge Instructions: You were admitted to [**Hospital1 18**] with respiratory failure on an ventilator. You were diagnosed with lung cancer, which was causing compression of the veins in your chest and causing your face and arms to swell. You had blood clots in the veins in your neck and chest and were started on blood thinners to treat these blood clots. You had a tracheostomy and PEG tube placed to help you breathe and help you get nutrition. You also had the fluid around your lung drained with a needle. You should have your hematocrit and Na checked after discharge daily for 2-3 days to ensure stability. At the time of discharge, your hematocrit was 27.3 and your sodium level was 131. You should also continue dexamethasone at the following dose: 4mg by mouth twice daily x 2 days, then 2mg by mouth twice daily x 2 days (starting [**12-1**]), and assess her facial/neck swelling. If you continue to have better controlled swelling and no vomiting, it can eventually be decreased to 2 mg daily. If you have more symptoms, you may need to go up on dose to 2 mg three times daily or 4 mg twice daily. The goal is to give the smallest dose possible to keep symptoms under control. Followup Instructions: You are being discharged to a long term acute care facility. You were followed by the oncology team while you were in the hospital, and chemotherapy was discussed as a possibility in the future if you were doing well and feeling up to it. If you would like to discuss this possibility further, please contact the [**Hospital1 18**] oncology team for an appointment. You were seen by Dr. [**Last Name (STitle) **] and his clinic phone number is ([**Telephone/Fax (1) 21188**]. You should have your hematocrit and Na checked after discharge daily for 2-3 days to ensure stability. At the time of discharge, your hematocrit was 27.3 and your sodium level was 131. You should also continue dexamethasone at the following dose: 4mg by mouth twice daily x 2 days, then 2mg by mouth twice daily x 2 days (starting [**12-1**]), and assess her facial/neck swelling. If you continue to have better controlled swelling and no vomiting, it can eventually be decreased to 2 mg daily. If you have more symptoms, you may need to go up on dose to 2 mg three times daily or 4 mg twice daily. The goal is to give the smallest dose possible to keep symptoms under control.

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icd9cm

[ [ [] ] ]

[ "43.11", "31.1", "96.6", "38.93", "96.05", "44.43", "34.91", "92.29", "33.22", "96.72" ]

icd9pcs

[ [ [] ] ]

12536, 12608

4506, 10050

349, 426

12766, 12878

3799, 4483

14105, 15270

3069, 3095

10455, 12513

12629, 12629

10076, 10076

12902, 14082

3110, 3780

10094, 10432

267, 311

454, 2616

12725, 12745

12648, 12704

2638, 2769

2785, 3053

13,791

147,883

28366

Discharge summary

report

Admission Date: [**2106-11-6**] Discharge Date: [**2106-11-23**] Service: SURGERY Allergies: Tetracycline Attending:[**First Name3 (LF) 7760**] Chief Complaint: abdominal distention Major Surgical or Invasive Procedure: sigmoid colectomy, end descending colostomy History of Present Illness: 86 M who presented with worsening abdominal distention to [**Hospital1 18**] [**Location (un) **] on [**2106-11-6**]. Past Medical History: gout restrictive lung disease CRI (baseline 1.6) ataxia htn hearing impairment s/p appy s/p laparotomy-lysis of adhesions for small bowel obstruction age 40s hypercholesteremia Social History: lives at [**Hospital **] nursing home Physical Exam: on admission to [**Hospital1 18**] [**Location (un) **]- AVSS gen-NAD cor-RRR lungs-CTA abd-soft, non-tender, significantly distended Pertinent Results: [**2106-11-6**] 10:15PM PT-13.4* PTT-44.1* INR(PT)-1.2* [**2106-11-6**] 08:41PM GLUCOSE-114* UREA N-40* CREAT-2.2* SODIUM-140 POTASSIUM-3.3 CHLORIDE-111* TOTAL CO2-20* ANION GAP-12 [**2106-11-6**] 08:41PM ALT(SGPT)-11 AST(SGOT)-13 ALK PHOS-205* AMYLASE-38 TOT BILI-0.3 [**2106-11-6**] 08:41PM LIPASE-23 [**2106-11-6**] 08:41PM ALBUMIN-2.1* CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-2.2 IRON-29* [**2106-11-6**] 08:41PM calTIBC-104* FERRITIN-730* TRF-80* [**2106-11-6**] 08:41PM WBC-8.0 RBC-2.68* HGB-8.6* HCT-25.7* MCV-96 MCH-32.2* MCHC-33.6 RDW-16.3* [**2106-11-6**] 08:41PM PLT COUNT-173 [**2106-11-6**] 08:41PM PT-13.7* PTT-64.7* INR(PT)-1.2* Brief Hospital Course: Patient was admitted and had a CT scan which showed a sigmoid colon dilated to 18 cm. Also had acute renal failue with a creatinine of 3.1. Patient had a V/Q scan which was done and showed some perfusion defects suspicious for pulmonary embolus and a Left groin DVT therefore he was started on heparin. He was also initiated on TPN. In consultation with the GI service, it was decided the patient had a rectosigmoid motility disorder and needed a sigmoid colectomy. Patient underwent a sigmoid colectomy with end colostomy on [**11-12**]. Overall, the patient did well postoperatively. His diest was gradually advanced, and his ostomy began to function well. He was transitionned to coumadin and his TPN was discontinued. His INR need to be followed to keep it from 2.0-2.5. Medications on Admission: colace, sinvastatin 20, mirtazinpine 45, omeprazole 20, prn lasix, atrovent nebs prn, mvi Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. 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* 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*40 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7.coumadin to keep INR 2.0-2.5 Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Colonic obstruction. Discharge Condition: Good. Discharge Instructions: Please keep INR from 2.0-2.5, check INR daily until this goal is reached. Dhcec electrolytes since patient on lasix. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 6633**] ([**Telephone/Fax (1) 39468**] in clinic within 1-2 weeks.

[ "276.52", "564.7", "415.19", "585.3", "389.9", "568.0", "518.89", "584.9", "786.2", "427.89", "401.9", "274.9", "453.41", "729.73" ]

icd9cm

[ [ [] ] ]

[ "45.76", "96.09", "99.15", "89.39", "38.93", "46.11", "54.59", "45.24" ]

icd9pcs

[ [ [] ] ]

3241, 3307

1540, 2323

241, 287

3372, 3380

858, 1517

3545, 3663

2463, 3218

3328, 3351

2349, 2440

3404, 3522

704, 839

181, 203

315, 434

456, 634

650, 689

70,131

146,957

54881

Discharge summary

report

Admission Date: [**2134-6-15**] Discharge Date: [**2134-6-29**] Date of Birth: [**2079-4-10**] Sex: M Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 2641**] Chief Complaint: Right upper extremity infection. Major Surgical or Invasive Procedure: Debridement [**2134-6-15**], [**2134-6-17**], [**2134-6-19**], [**2134-6-21**], [**2134-6-23**] Skin graft [**2134-6-25**] History of Present Illness: 55 yo M with PMH HTN, HLD, hypothyroidism, depression, psoriatic arthritis on enbrel, and borderline DM currently undergoing work up for undiagnosed bleeding disorder who presented to OSH for pain and swelling in his right hand. Pt states that he had some cuts on his hand and wrist (which he alternately attributed to gardening, grilling, and unknown causes). He was asymptomatic until he went swimming in a freshwater [**Doctor Last Name **], after which he noticed pain and swelling at site of one of the cuts. he went to the OSH ED where he was noted to be febrile and [**1-31**] BCx bottles grew group A strep. He was started on IV abx. The swelling has since progressed and moved down his arm, where he subsequently developed swelling and redness around the cut on his wrist. Redness and swelling has continued to progress up his arm to the interior of upper arm. Arm and hand are painful. No numbness or tingling in hand. Area of cut around finger developed large blister which drained and then filled again. He c/o fevers and nausea and vomiting, which have become more frequent. He is not sure of his last tetanus booster. Animals at home: dog, cat, and [**Country 22647**] pig. Of note, pt says he was scheduled to see heme/onc today for evaluation of bleeding problems, which have been new since [**Name (NI) **]. He was told his blood counts were "all out of whack." On review of OSH records, above noted coagulopathies were seen on day of transfer. In addition, labs from [**2134-4-30**] include abnormal LFTs of Alb 3.1, Tbili 2.6, AST 89, ALT 32. Pt also states he had a RLE cellulitis recently and is concerned about why he is getting frequent infections. At OSH he was febrile to 102 but VSS. WBC 7.0 with 91% PMN. Hct 33.6, plats 50, Na 127, K 3.2, Cr 0.7, PT 19.4, PTT 50, INR 2.3. He was evaluated by ID and surgery at OSH and both were concern for necrotizing fasciitis, so he was transferred to [**Hospital1 18**] for further eval. On transfer he was on vanc/meropenem/doxycycline/tigecycline. On arrival to the floor, VS 99.3, 146/72, 92, 18, 95% RA. He currently c/o feeling nauseous, and ROS was positive for dizziness, dark urine. Past Medical History: HTN HLD hypothyroidism depression psoriatic arthritis vitiligo "thin blood" since [**2133-7-30**] gallbladder sludge borderline DM Social History: Unemployed. Drinks 3-4 drinks of hard liquor per day per wife. Family History: Brother and 2 uncles with DM. Physical Exam: ADMISSION PHYSICAL EXAM: 99.7 142/78 HR 95 18 98% RA GENERAL: Alert, jaundiced Caucasian male in mild distress. Looks uncomfortable. SKIN: Diffuse erythema and induration of volar aspect of R wrist. 1 cm hemorrhagic bullae present on wrist and 5th finger. Hand is edematous and painful to touch. Area of erythema extends up R forearm to elbow, within margins that were marked in the ED. No crepitus appreciated. Pt. also has areas of hypopigmentation on both hands, knees and extensor surfaces of lower extremities. Area of erythema and scaling on R shin c/w area of healing infection. HEENT: PERRL, sclerae icteric, MMM, OP clear HEART: RRR, nl S1-S2, no MRG LUNGS: CTAB, no wheezes, rales or rhonchi. ABDOMEN: NABS, soft/NT/ND, no masses or HSM EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses NEURO: awake, A&Ox3, CNs II-XII grossly intact DISCHARGE PHYSICAL EXAM: GENERAL: Alert, oriented, in no distress, dressing on entire right forearm to fingertips HEENT: PERRL, sclerae icteric, MMM, OP clear HEART: RRR, nl S1-S2, no MRG LUNGS: CTAB, no wheezes, rales or rhonchi. ABDOMEN: NABS, soft/NT/ND, no masses or HSM EXTREMITIES: RUE WWP, fingertips warm without cyanosis or tenderness or erythema. Right elbow warm, without erythema or swelling, 2+ peripheral pulses NEURO: awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: ADMISSION LABS: [**2134-6-15**] 06:00AM BLOOD WBC-8.0 RBC-3.68* Hgb-12.9* Hct-36.2* MCV-98 MCH-35.0* MCHC-35.6* RDW-14.8 Plt Ct-53* [**2134-6-15**] 06:00AM BLOOD PT-29.6* PTT-49.0* INR(PT)-2.9* [**2134-6-15**] 05:15PM BLOOD Glucose-188* UreaN-10 Creat-0.6 Na-128* K-2.9* Cl-96 HCO3-22 AnGap-13 [**2134-6-15**] 06:00AM BLOOD ALT-36 AST-109* LD(LDH)-379* CK(CPK)-308 AlkPhos-53 TotBili-4.4* DirBili-1.5* IndBili-2.9 [**2134-6-15**] 05:15PM BLOOD Calcium-7.2* Phos-2.0* Mg-1.8 [**2134-6-15**] 06:00AM BLOOD Albumin-3.2* Calcium-7.8* Phos-1.6* Mg-1.2* Iron-19* [**2134-6-15**] 06:00AM BLOOD calTIBC-192* VitB12-1183* Hapto-35 Ferritn-283 TRF-148* MICRO: [**2134-6-15**] BCx: No growth x 2 [**2134-6-15**] Swab R finger: GRAM STAIN (Final [**2134-6-15**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [**2134-6-21**]): BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH. ANAEROBIC CULTURE (Final [**2134-6-21**]): NO ANAEROBES ISOLATED. [**2134-6-15**] R forearm: BETA STREPTOCOCCUS GROUP A: SPARSE GROWTH. STAPH AUREUS COAG +. RARE GROWTH. [**2134-6-16**] MRSA Screen: No MRSA isolated [**2134-6-17**] R forearm: GRAM STAIN (Final [**2134-6-17**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. SINGLY AND IN PAIRS. TISSUE (Final [**2134-6-20**]): BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH. ANAEROBIC CULTURE (Final [**2134-6-21**]): NO ANAEROBES ISOLATED. NOTABLE LABS DURING ADMISSION: [**2134-6-18**] 02:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ [**2134-6-18**] 02:00PM BLOOD ALT-23 AST-43* LD(LDH)-203 CK(CPK)-26* AlkPhos-56 TotBili-5.8* DirBili-2.8* IndBili-3.0 [**2134-6-16**] 05:53AM BLOOD Albumin-2.8* Calcium-7.4* Phos-1.9* Mg-2.4 [**2134-6-16**] 12:01AM BLOOD Cortsol-21.5* [**2134-6-15**] 06:00AM BLOOD T4-4.7 [**2134-6-15**] 06:00AM BLOOD TSH-3.1 [**2134-6-19**] 05:25PM BLOOD Ammonia-35 [**2134-6-15**] 05:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2134-6-15**] 05:36PM BLOOD Lactate-1.9 STUDIES: [**2134-6-15**] X-ray R wrist and hand: Subcutaneous edema without emphysema [**2134-6-15**] RUQ US: 1. Diffusely echogenic and coarse liver. In association with moderate splenomegaly, findings are highly concerning for cirrhosis. 2. Enlarged spleen measuring 15 cm 3. No ascites 4. Sludge-filled gallbladder with possible small adherent stones. No signs of acute inflammation. [**2134-6-16**] ECHO: The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic 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. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. No outflow tract obstruction, intracardiac shunt, or significant valvular disease seen. DISCHARGE LABS: [**2134-6-29**] 08:30AM BLOOD WBC-5.4 RBC-2.55* Hgb-8.4* Hct-26.8* MCV-105* MCH-33.2* MCHC-31.6 RDW-15.4 Plt Ct-153 [**2134-6-29**] 08:30AM BLOOD Glucose-106* UreaN-6 Creat-0.7 Na-135 K-3.8 Cl-102 HCO3-29 AnGap-8 [**2134-6-29**] 08:30AM BLOOD ALT-28 AST-58* AlkPhos-80 TotBili-2.3* [**2134-6-29**] 08:30AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.6 Brief Hospital Course: 55 yo M with PMH HTN, HLD, hypothyroidism, depression, psoriatic arthritis on enbrel, and borderline DM currently undergoing work up for undiagnosed bleeding disorder who presented to OSH with bullous cellulitis, found to have [**1-31**] BCx bottles positive for Group A Strep and necrotizing fasciitis of R hand and forearm. ACTIVE ISSUES: 1. Necrotizing Fasciitis- Area of erythema, hemorrhagic bullae concerning in an immunosuppressed patient for infection atypical pathogens. The patient was transferred from an OSH on vancomycin, meropenem, doxycycline and tigecycline. He was seen by infectious disease who recommended discontinuing the doxycycline and tigecyline, increasing the dose of vancomycin and adding clindamycin to empirically cover necrotizing fasciitis. Blood culture results from the OSH showed two sets of blood cultures positive for GAS. The patient was evaluated by plastic surgery and plain films were obtained. Though no gas was seen in the soft tissues on x-ray, because the patient is immunosuppressed and the cellulitis was actively expanding outside the previously marked margins, the patient was taken to the OR on [**6-15**] for debridement. This procedure confirmed necrotizing fasciitis. Patient was treated with Vancomycin, Meropenem, and Clindamycin. Margins initially continued to expand, with erythema and induration reaching R axilla, and patient had repeat debridements on [**6-15**], [**6-21**], and [**6-23**]. Gram stain from wound swab with GNRs and GPCs in pairs, speciated as Group A Strep. Second swab grew GAS and coag + staph. When GNR's didn't speciate and fevers improved, patient was transitioned from Vanc/[**Last Name (un) **]/Clinda to Zosyn. He subsequently developed hives and pruritis and visual hallucinations of bugs biting him. Zosyn was discontinued and patient was restarted on Vanc and Meropenem. He was later transitioned to Ceftriaxone 2g q24H, and will complete a 3 week course upon discharge. He received a PICC line on [**6-29**]. He went back to the OR on [**6-25**] for skin grafting. 2. Group A Strep Septicemia: Started on Clindamycin 900mg Q6 hours, Meropenem 1G Q8 hours, and Vancomycin 1.5G Q 12 hours, ultimately narrowed to Ceftriaxone 2gm IV daily, for a total duration of Abx coverage 24 days. 3. Coagulopathy: The patient stated that he had been undergoing workup for a bleeding diathesis as an outpatient. He was found to be thrombocytopenic with elevated LFTs and an elevated INR at 2.9 which went up to 4.1. RUQ highly suggestive of cirrhosis. He was given FFP and vitamin K for his initial surgical procedure. 4. Electrolyte abbormalities: The patient's phosphate was 1.6 on admission and magnesium was 1.2. His electrolytes were repleted, an EKG was checked which was normal, and he was placed on telemetry for monitoring. He required frequent electrolyte repletions throughout admission. 5. Pain- Patient's pain was controlled with narcotic analgesics. He received an aggressive bowel regimen. 6. Liver Cirrhosis- Patient's LFT's were up and down throughout admission and he was markedly jaundiced at times, with Tbili's as high as 5.8. He was also noted to have several episodes of delirium concerning for encephalopathy. These episodes spontaneously resolved and patient did not require starting lactulose. He will need close outpatient hepatology follow up. 7. EtOH hx- Patient has a history of heavy alcohol, with 3-4 liquor drinks/day per wife. [**Name (NI) **] was maintained on CIWA scale and treated with thiamine, folic acid, and multivitamin. Please continue to encourage alcohol cessation as outpatient and AA. 8. Psoriatic arthritis- Patient's psoriasis flared in setting of holding Enbrel, and he had worsening knee pain. Dermatology was consulted and recommended topical triamcinalone, with good effect. Patient should not restart systemic immunosuppressants after discharge unless cleared to do so by ID. 9. Hypertension- Patient had an episode of hypotension and was transferred to the MICU early in hospitalization. His antihypertensives were held and his blood pressure continued to run low to normal throughout admission. 10. Anemia- Patient was found to be anemic before 4th washout, with Hgb in low 8's. He was guiaic negative and labs showed no sign of hemolysis, so oozing from open wound was determined to be most likely etiology. An active type & screen was maintained but patient's Hgb remained stable. At time of discharge, Hgb was 8.4 with MCV 105. CHRONIC ISSUES: 1. Hypothryoidism- A TSH was WNL and patient was continued on Synthroid 2. Depression- Patient was continued on Fluoxetine. 3. HLD- Patient was continued on simvastatin TRANSITIONAL ISSUES: - Must establish with hepatologist as soon as possible for management of cirrhosis - Complete 10 days of outpatient IV Ceftriaxone - Avoid systemic immunosuppressants - AA referral Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from Patient. 1. Hydrochlorothiazide 37.5 mg PO DAILY 2. Fluoxetine 20 mg PO DAILY 3. Enalapril Maleate 20 mg PO DAILY 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Simvastatin 20 mg PO DAILY *ID Rejected* 6. Enbrel *NF* (etanercept) 50 mg/mL (0.98 mL) Subcutaneous twice a week 7. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain 8. Klor-Con *NF* (potassium chloride) 20 mEq Oral [**Hospital1 **] Discharge Medications: 1. Fluoxetine 20 mg PO DAILY 2. Levothyroxine Sodium 100 mcg PO DAILY 3. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain 4. Artificial Tear Ointment 1 Appl BOTH EYES [**Hospital1 **] 5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **] Duration: 1 Weeks Please apply to psoriatic areas. RX *triamcinolone acetonide 0.1 % Apply as needed for psoriatic rash Disp #*2 Container Refills:*4 6. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg 1 tablet(s) by mouth once daily Disp #*60 Tablet Refills:*5 7. Enalapril Maleate 20 mg PO DAILY 8. Hydrochlorothiazide 37.5 mg PO DAILY 9. Klor-Con *NF* (potassium chloride) 20 mEq Oral [**Hospital1 **] 10. CeftriaXONE 2 gm IV Q24H RX *ceftriaxone 2 gram once daily Disp #*8 Vial Refills:*0 11. Multivitamins 1 TAB PO DAILY RX *Chewable Multi Vitamin 1 tablet(s) by mouth once daily Disp #*30 Tablet Refills:*2 12. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. RX *heparin lock flush 10 unit/mL daily Disp #*16 Syringe Refills:*1 Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Necrotizing fasciitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 112116**], It was a pleasure taking care of you during your stay at [**Hospital1 18**]. You were admitted for an infection of your upper arm and were seen by the infectious disease team. You were evaluated by surgery and taken to the operating room for exploration and debridement of your wound. Dear Mr. [**Known lastname 112116**], It was a pleasure taking care of you during your stay at [**Hospital1 18**]. You were admitted for an infection of your upper arm and were seen by the infectious disease team. You were evaluated by surgery and taken to the operating room for exploration and debridement of your wound. You were found to have a severe infection called necrotizing fasciitis. During your hospitalization, you received broad spectrum antibiotics and had a total of 5 surgeries to remove infected and dead tissue from your right hand and arm. You then had another surgery to place a skin graft. Your fevers improved throughout hospitalization, and your pain was controlled with narcotics. After discharge, you will take ____________XX COURSE OF ANTIBIOTICS____________________. Because of your acute infection, we discontinued your Enbrel. Your psoriasis lesions worsened and you were seen by Dermatology, who recommended triamcinalone. Please do not restart Enbrel or any other systemic immunosuppressants until directed to do so by your doctor. During your hospitalization, you were also found to have worsening liver function. After discharge, it is very important that you establish care with a liver doctor for long-term management. Once again, it was a pleasure participating in your care and we wish you the best. Sincerely, Followup Instructions: Name: [**Last Name (un) **],[**Last Name (un) 75760**] A. Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Apartment Address(1) 86648**], [**Location (un) **],[**Numeric Identifier 32948**] Phone: [**Telephone/Fax (1) 75761**] Appointment: Thursday [**2134-7-8**] 4:15pm Department: ORTHOPEDICS When: TUESDAY [**2134-7-6**] at 8:40 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2134-7-6**] at 9:00 AM With: HAND CLINIC [**Telephone/Fax (1) 3009**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital3 **]GASTROENTEROLOGY Address: [**Street Address(2) 75551**], [**Apartment Address(1) 12841**], [**Location (un) **],[**Numeric Identifier 75553**] Phone: [**Telephone/Fax (1) 112117**] Appointment: Thursday [**2134-7-15**] 3:30pm

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icd9cm

[ [ [] ] ]

[ "04.43", "82.36", "38.97", "82.35", "86.69", "82.21", "86.62", "86.22", "39.31", "83.45", "83.44" ]

icd9pcs

[ [ [] ] ]

14991, 15074

8332, 8659

299, 424

15140, 15140

4255, 4255

16995, 18173

2867, 2899

13758, 14968

15095, 15119

13225, 13735

15291, 16972

7967, 8309

2939, 3762

13017, 13199

227, 261

8675, 12807

452, 2615

4272, 7950

15155, 15267

12824, 12996

2637, 2770

2786, 2851

3787, 4236

1,574

118,935

22554

Discharge summary

report

Admission Date: [**2143-6-20**] Discharge Date: [**2143-6-24**] Date of Birth: [**2071-10-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2698**] Chief Complaint: Lack of energy Major Surgical or Invasive Procedure: none History of Present Illness: pt is 71 yo male with h/o coronary artery disease, status post MI, three-vessel disease, CABG [**2137**], Afib, atrial tachydysrrhytmias, ischemic CM with an EF of 10%, 3+MR, 3+TR, s/p biventricular pacemaker defibrillator implantation in [**9-22**] who presents with decompensated CHF. He is followed by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 58514**] (NH) for CHF management and is noted to have mult recent admission to OSH for CHF decompensation and tx with intermittent milrinone. Patient was most recently seen at the OSH on [**2143-6-14**] where he was given 3 days of milrinone and discharged because the patient felt better. At that admission patient's leg were swollen and improved after a few days of milrinone. After his discharge he has been gradually feeling worse for the next few days up until this admission. Patient states that he does not have an appettite and has not been eating for the past few days. He states that he has not been drinking more than 2000ml a day. He recently was told by his doctor at the OSH to increase his lasix dose because he again started to get swelling in his legs after his recent discharge. He states that he has not been urinating much and increasing his lasix dose did not really increase his urine output. Patient feels that ever since he was started on amiodarone in [**Month (only) 547**] that he has been gradually been getting worse. Patient states that his breathing has been stable and he requires oxygen at home(X2wks). Patient denies any recent fever or chills or illness. He states that he has been constipated but no BRBPR or melena. His wife notes 4lb wt gain over 24 hrs(224, dry wt 208lb), inc fatigue, and LE edema. Of note, pt was seen by Dr. [**Last Name (STitle) **] [**4-23**] at which time interegotion of pacemaker revealed asx episode of vfib w/ shock and that pt in Afib10% of time. Pt on the floor initially upon presentation to the hospital, but was transferred to the CCU for persistent hypotension and tachycardia. Milrinone drip continued, but after adequate diuresis (-3 L on HD#2) blood pressures remained stable. Pt was called out to floors feeling much improved, with no complaints other than mild upper extremity swelling. Some SOB, but improved. Past Medical History: 1.CAD- s/p myocardial infarction on [**2137-12-25**]. peak CK was 7,766. Cardiac catheterization 3VD w/ CABG: LIMA to the LAD, sequential SVG to the RPDA/LPL, and separate SAG to the D1 jump to the OM1. 2. CHF: LVEF of 10% from echo [**12-22**] 3. Gout 4. Dyslipidemia 5. Chronic R. pleural effusion: thought [**2-20**] CABG related lung injury 6. Tonsillectomy 7. GallStones 8. Dylipidemia 9. HTN Social History: He is married and lives with his wife. [**Name (NI) **] has four grown children. He is now retired but owned an insurance company. He smoked cigars for more than 20 years. He drinks socially. Family History: Both parents died from heart disease as did two brothers. One brother had an ICD placed. Two other sisters are alive but also have heart problems. . Physical Exam: BP 98/46 27 95% 3L NC 97.4 Gen: Patient sitting up in bed using arm to keep himself up hunched over Heent: PERRL, EOMI, sclera anicteric, MMM, OP clear Neck: Supple, JVD 16cm, No LAD Lungs: Decreased BS at right, no crackles Cardiac: RRR, Grade [**3-24**] holosystolic murmur at apex Abd: Distended, soft, NT, decreased breath sounds Ext: +3 pitting edema upto knees b/l; Distal pulses +2 Neuro: AAOx2, MS [**5-23**] UE and LE, Pertinent Results: [**2143-6-20**] 11:50AM PT-31.3* PTT-34.2 INR(PT)-6.5 [**2143-6-20**] 11:50AM PLT COUNT-416 [**2143-6-20**] 11:50AM WBC-14.7*# RBC-3.96* HGB-11.5* HCT-35.4* MCV-89 MCH-28.9 MCHC-32.4 RDW-16.5* [**2143-6-20**] 05:14PM PT-44.8* PTT-40.3* INR(PT)-13.3 [**2143-6-20**] 05:14PM PLT COUNT-406 [**2143-6-20**] 05:14PM WBC-18.9* RBC-3.87* HGB-11.4* HCT-34.8* MCV-90 MCH-29.3 MCHC-32.6 RDW-16.6* [**2143-6-20**] 05:14PM DIGOXIN-1.1 [**2143-6-20**] 05:14PM ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-6.5*# MAGNESIUM-3.1* URIC ACID-10.9* [**2143-6-20**] 05:14PM ALT(SGPT)-1754* AST(SGOT)-1433* ALK PHOS-135* TOT BILI-1.5 [**2143-6-20**] 05:14PM GLUCOSE-136* UREA N-82* CREAT-2.8*# SODIUM-120* POTASSIUM-6.5* CHLORIDE-76* TOTAL CO2-27 ANION GAP-24* [**2143-6-20**] 07:25PM LACTATE-2.5* [**2143-6-20**] 07:25PM TYPE-ART PO2-93 PCO2-43 PH-7.51* TOTAL CO2-36* BASE XS-9 [**2143-6-20**] 08:48PM PT-39.9* PTT-38.0* INR(PT)-10.5 [**2143-6-20**] 08:48PM PLT COUNT-331 [**2143-6-20**] 08:48PM WBC-17.0* RBC-3.84* HGB-11.2* HCT-34.2* MCV-89 MCH-29.2 MCHC-32.8 RDW-16.8* [**2143-6-20**] 08:48PM CALCIUM-9.2 PHOSPHATE-5.6* MAGNESIUM-3.1* [**2143-6-20**] 08:48PM GLUCOSE-185* UREA N-85* CREAT-3.0* SODIUM-127* POTASSIUM-4.4 CHLORIDE-78* TOTAL CO2-30* ANION GAP-23* Brief Hospital Course: Shortly after patient arrived at [**Hospital1 18**] his blood pressure was low with SBP 80s and patient with high oxygen demand. He was started on milrinone the floor and was transferred to the CCU as patient did not seem to improve while on the floor on milrinone. In the CCU the patient was diuresed 3L and improved so was transferred back out to the floor. Once on the floor patient was still on milrinone and again started to decompensate from a respiratory standpoint. After discussion with the patient about his condition and prognosis patient decided that he wanted to be DNI/DNR. While on the floor his breathing continued to worsen and was given morphine for comfort to help his breathing. Patient passed away shortly therafter. Medications on Admission: Coreg 3.125 [**Hospital1 **] Lasix 80 [**Hospital1 **] Aldactone 25 qd Amiodarone 200 qhs Allopurinol Lipitor 20 Aspirin 325 qd Coumadin qhs Epogen qMon Oxygen 2L Discharge Medications: Patient passed away Discharge Disposition: Expired Discharge Diagnosis: Patient passed away Discharge Condition: Patient passed away Discharge Instructions: Patient passed away Followup Instructions: Patient passed away

[ "427.31", "424.0", "397.0", "584.9", "412", "V45.02", "428.0", "414.8", "276.7", "274.9", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "38.93", "00.17", "89.49" ]

icd9pcs

[ [ [] ] ]

6192, 6201

5191, 5935

331, 337

6264, 6285

3901, 5168

6353, 6375

3282, 3433

6148, 6169

6222, 6243

5961, 6125

6309, 6330

3448, 3882

277, 293

365, 2632

2654, 3056

3072, 3266

101

175,533

15782

Discharge summary

report

Admission Date: [**2196-9-26**] Discharge Date: [**2196-10-12**] Service: Medicine HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 724**] is an 82 year-old Asian male with a history of dementia, who was transferred from the MICU to the floor following a long stay for respiratory failure, complicated by fevers and complicated by bilateral iatrogenic pneumothoraces requiring chest tube placement. Briefly the patient was admitted on [**2196-9-26**] following a respiratory and cardiac arrest after choking on food. The patient was resuscitated and intubated in the field by EMS. Estimated total time of arrest (cardiac and respiratory) was 5 to 15 minutes including 5 to 10 minutes of CPR. In the Emergency Department the patient received a left pneumothorax following an attempted left subclavian line placement. This left pneumothorax required a chest tube. The Emergency Department course is also notable for hypotension requiring Levophed, as well as witnessed aspiration event. Upon arrival to the [**Hospital Unit Name 153**] complications of the left chest tube resulted in a left tented pneumothorax as well as a right sided pneumothorax presumed secondary to high PIPs in the 90s. The cardiac surgery was consulted and bilateral chest tubes were placed. The patient was initially begun on Levofloxacin/Flagyl for presumed aspiration pneumonia with bilateral infiltrates on chest x-ray. The patient intermittently spiked fevers in the [**Hospital Unit Name 153**] for which Vancomycin was added on [**2196-9-30**]. In addition, the patient had episodes of supraventricular tachycardia, which was responsive to Adenosine and vagal maneuvers. A neurology consult was obtained who felt that anoxic brain injury was highly unlikely and his prognosis for recovery was poor. After an extensive discussion with the patient's family the patient's code status was changed to DNR/DNI. On [**2197-10-5**] the patient was extubated and bilateral chest tubes were discontinued. Since [**2197-10-5**] the patient remained hemodynamically stable and the patient was transferred to the floor on [**2196-10-6**]. PAST MEDICAL HISTORY: 1. Dementia of Alzheimer's type. 2. Prior CEAs. ALLERGIES: Bacitracin and Neosporin. MEDICATIONS AT HOME: 1. Aricept 10 mg po q.d. 2. Zyprexa 25 mg po q.d. 3. Prevacid 30 mg po q.d. 4. Tube feeds. ANTIBIOTICS WHILE INPATIENT: 1. Levofloxacin 500 mg q.d. 2. Vancomycin 500 mg q 24. 3. Flagyl 500 mg q 8 hours. 4. Subcutaneous heparin. SOCIAL HISTORY: The patient is a resident of the [**Hospital3 45444**] facility). The patient's son [**Name (NI) **] is health care proxy. The patient's daughter [**Name (NI) **] is power of attorney. The patient's wife is living in she lives at home in [**Location (un) 86**]. The patient has five children, four of whom who live locally and one who is in route to the hospital. PHYSICAL EXAMINATION ON TRANSFER: Temperature 97.3. Temperature max 99.6. Heart rate 57. Blood pressure 95 to 130/35 to 60. Respiratory rate 12 to 14. O2 saturation 100%. In general, the patient is unresponsive to verbal stimuli, but responsive to pain. Coarse upper airway sounds are audible. Cardiovascular distal heart sounds without murmurs. Lungs very coarse breath sounds, positive upper airway noise, positive rhonchi. Abdomen soft, nontender, nondistended. No masses, bowel sounds are positive. Extremities bilateral upper extremities and bilateral lower extremities with marked edema. LABORATORY DATA ON [**2196-10-5**]: White blood cell count 10.4, hematocrit 28.3, sodium 141, potassium 4, chloride 106, bicarb 27, BUN 22, creatinine 0.5, albumin 2.3, calcium 7.6, magnesium 1.9. RADIOLOGY: Chest x-ray on [**10-6**] bilateral basilar lower lobe opacities right greater then left increasing over the past few days. MICROBIOLOGY: [**10-1**] blood cultures times two, sputum is negative. Urine is negative. [**9-29**] blood cultures times two are negative. Urine is with positive coag negative staph. Electrocardiogram on [**9-26**] normal sinus rhythm at 94 beats per minute, right bundle branch block, low limb voltage. IMPRESSION: The patient is an 82 year-old Asian male with baseline dementia who is initially admitted after a prolonged cardiac/respiratory arrest. He was admitted to the Medical Intensive Care Unit with anoxic brain injury secondary to prolonged cardiac and respiratory arrest. In addition his hospital course was complicated by pneumothoraces as well as continued aspiration. A neurology consult was obtained to evaluate the patient and their overall consensus was that this patient's prognosis was very poor. Upon transfer to the floor the patient was currently aspirating with worsening bilateral lower lobe infiltrates, and the risk of recurrent arrest or decompensation was high. HOSPITAL COURSE: 1. Pulmonary: The patient continued aspirating. He remained on high oxygen flow by shovel mask. The was continued with supplemental oxygen with suctioning prn. 2. Cardiovascular: The patient is hemodynamically stable, blood pressure in the 90 to 120 range. 3. Infectious disease: Afebrile times 48 hours with negative culture workup thus far. His fevers are likely secondary to aspiration pneumonitis/pneumonia versus central in origin. Because of worsening infiltrates the patient was continued on aspiration coverage with Levofloxacin/Flagyl. 4. Renal: The patient's BUN to creatinine ratio was steadily increasing. This increasing ratio is likely indicated of a prerenal insufficiency. Intravenous fluids were given to the patient to assist with the prerenal condition. 5. Neurology: As per the neurological evaluation significant neurological recovery was very unlikely and the and patient's prognosis was poor. 6. FEN: The patient's tube feeds were continued initially. 7. Prophylaxis: The patient was kept on a PPI and subcutaneous heparin. 8. Code status: A family meeting was carried out with the [**Hospital 228**] health care proxy, son [**Name (NI) **] and power of attorney daughter [**Name (NI) **]. The [**Hospital 228**] medical condition was discussed and at the patient's current state he was at extremely high risk of decompensation and another cardiopulmonary arrest. The patient on transfer to the floor was DNR/DNI. A family meeting on [**2196-10-7**] with the son [**Name (NI) **] and daughter [**Name (NI) **] to represent the family. The [**Hospital 228**] medical condition and treatment were discussed in depth regarding DNR/DNI, intravenous fluids, antibiotics, deep oropharyngeal suction, laboratory draws, chest x-rays and blood cultures. [**Doctor Last Name **] stated that the family had already made peace with their father's health condition and he voiced the preference that the patient be kept comfortable. [**Doctor Last Name **] also stated that he wished that his father would "go peacefully" with no intervention. [**Doctor Last Name **] and [**Location (un) **] stated that they did not want any intravenous fluids or any pressors. It was decided by the family to discontinue all lines, intravenous fluids, with prn morphine given for comfort. In addition, the family declined deep oropharyngeal suctioning and laboratory draws. Regarding feedings, daughter felt that the nasogastric tube feedings "would not change anything" and they opted to have the nasogastric tube feeds discontinued as well. The patient's family stressed that the primary role is that the patient is to be kept comfortable and peaceful. A plan was made that the patient would be kept on supplemental oxygen for comfort, given prn morphine, oral suctioning as needed for comfort, as well as Scopolamine patches to decrease secretions. From [**10-8**] through [**2196-10-12**] the patient was kept comfortable with oxygen, morphine and prn Tylenol. Throughout his course the patient remained unresponsive, though the patient did once open his eyes to touch. The patient's course continued to decline from [**10-7**] through [**10-12**] and he was without spontaneous movement. On [**10-10**] the patient began having increased secretions, increased gurgling and his respiratory status became more labored. In addition, the patient began to have increased work of breathing. Supplemental oxygen, Scopolamine patches to decrease secretions and morphine GTT were continued for comfort. On [**2196-10-12**] at 12:17 p.m. the patient expired. DISCHARGE DIAGNOSES: 1. Dementia secondary to Alzheimer's disease. 2. Aspiration of food causing cardiac arrest. 3. Anoxic brain damage secondary to prolonged cardiopulmonary resuscitation. 4. Continued aspiration pneumonitis/pneumonia. 5. Iatrogenic pneumothorax status post subclavian line attempt. 6. Left tension pneumothorax, secondary to displacement of left sided chest tube, which also resulted in a small right pneumothorax. 7. Status post placement of bilateral chest tubes and removal of bilateral chest tubes. 8. Acute respiratory failure, requiring ventilator support while in the Medical Intensive Care Unit. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAD Dictated By:[**Numeric Identifier 45445**] MEDQUIST36 D: [**2197-5-13**] 02:19 T: [**2197-5-16**] 12:43 JOB#: [**Job Number 45446**]

[ "427.5", "276.2", "482.40", "512.1", "780.03", "507.0", "518.81", "348.1", "518.5" ]

icd9cm

[ [ [] ] ]

[ "96.72", "34.04", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

8460, 9301

4845, 8439

2261, 2499

121, 2128

2150, 2240

2516, 4827

25,218

118,792

1533

Discharge summary

report

Admission Date: [**2109-4-16**] Discharge Date: [**2109-4-21**] Date of Birth: [**2078-8-26**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: Morbid obestiy Major Surgical or Invasive Procedure: open roux en Y bypass, open cholecystectomy History of Present Illness: 30 y/o female with sever obesity (BMI of 79) with other medical problems secondary to her weight. Past Medical History: HTN sleep apnea restrictive lung dz (home pCO2 51) GERD Social History: unknown Family History: unknown Physical Exam: Patient resting comforably in bed. No respiratory distress. RRR s1/s2. No murmor/rubs/gallops CTABL Abd obese/soft/nt/nd. Abdominal binder in place. Wounds clean/dry/intact. A/O x3 Pertinent Results: [**2109-4-20**] 02:17AM BLOOD WBC-5.9 RBC-3.90* Hgb-10.8* Hct-32.9* MCV-85 MCH-27.8 MCHC-32.9 RDW-14.9 Plt Ct-283 [**2109-4-19**] 01:05AM BLOOD WBC-8.3 RBC-3.82* Hgb-10.8* Hct-31.9* MCV-84 MCH-28.4 MCHC-33.9 RDW-15.0 Plt Ct-267 [**2109-4-18**] 12:36AM BLOOD WBC-11.2* RBC-3.80* Hgb-10.7* Hct-31.9* MCV-84 MCH-28.1 MCHC-33.5 RDW-15.2 Plt Ct-250 [**2109-4-17**] 04:46AM BLOOD WBC-11.9*# RBC-4.05* Hgb-11.2* Hct-34.3* MCV-85 MCH-27.7 MCHC-32.7 RDW-15.2 Plt Ct-314 [**2109-4-20**] 02:17AM BLOOD Plt Ct-283 [**2109-4-21**] 05:25AM BLOOD Glucose-91 UreaN-15 Creat-0.7 Na-140 K-3.6 Cl-100 HCO3-32 AnGap-12 [**2109-4-20**] 02:17AM BLOOD Glucose-106* UreaN-11 Creat-0.7 Na-140 K-4.0 Cl-100 HCO3-33* AnGap-11 [**2109-4-19**] 01:05AM BLOOD Glucose-109* UreaN-9 Creat-0.7 Na-137 K-4.3 Cl-101 HCO3-30 AnGap-10 [**2109-4-18**] 12:36AM BLOOD Glucose-97 UreaN-11 Creat-0.9 Na-140 K-4.2 Cl-105 HCO3-29 AnGap-10 [**2109-4-17**] 04:46AM BLOOD Glucose-112* UreaN-11 Creat-1.0 Na-138 K-4.4 Cl-105 HCO3-27 AnGap-10 [**2109-4-18**] 10:36AM BLOOD CK(CPK)-2700* [**2109-4-17**] 12:47PM BLOOD CK(CPK)-1592* [**2109-4-17**] 04:46AM BLOOD CK(CPK)-692* [**2109-4-18**] 10:36AM BLOOD CK-MB-5 cTropnT-<0.01 [**2109-4-17**] 12:47PM BLOOD CK-MB-8 cTropnT-<0.01 [**2109-4-17**] 04:46AM BLOOD CK-MB-5 cTropnT-<0.01 [**2109-4-21**] 05:25AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1 [**2109-4-20**] 02:17AM BLOOD Calcium-8.7 Phos-2.5* Mg-2.1 [**2109-4-19**] 01:05AM BLOOD Calcium-8.7 Phos-1.9*# Mg-2.1 [**2109-4-18**] 12:36AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.0 [**2109-4-17**] 04:46AM BLOOD Calcium-8.3* Phos-4.7* Mg-1.9 [**2109-4-21**] 05:46AM BLOOD Type-ART pO2-261* pCO2-51* pH-7.46* calTCO2-37* Base XS-11 Comment-GREEN TOP [**2109-4-20**] 02:36AM BLOOD Type-ART pO2-61* pCO2-57* pH-7.42 calTCO2-38* Base XS-9 [**2109-4-16**] 08:30PM BLOOD Type-ART pO2-95 pCO2-62* pH-7.25* calTCO2-28 Base XS--1 Intubat-NOT INTUBA [**2109-4-16**] 10:51PM BLOOD Type-ART pO2-82* pCO2-61* pH-7.28* calTCO2-30 Base XS-0 [**2109-4-19**] 02:10PM BLOOD Lactate-0.7 Brief Hospital Course: [**2109-4-16**]: 30 y/o female s/p open [**Last Name (un) **] bypass & choly with Dr. [**Last Name (STitle) **]. There were no intraoperative complications, but the patient had difficulties ventilating due to her obsturctive breathing pattern. Instead of nasal positve pressure, she was put on a full mask for pressure support which she tolerated after getting some ativan. She had no other issues over night. [**4-17**]: On pod 1, she spent the night in the PACU and was transferred to the TSICU for her ventilation status. Pulmonary medicine was consulted for any additional recommendations on how to better optimize her her pulmonary status. She was kept on postive pressure support for her ventilation status and was kept in the icu. [**4-18**]: On pod 2, there were no overnight issues. She was hep locked and was started on a stage I-II diet. For pain managment, we continued the PCA and the epidural catheter. [**4-19**]: On pod 3, she continued her bipap overnight and tolerated a stage III diet with no issues. The pain service d/c her epidural catheter as well. [**4-20**]: On pod 4, there were no issues overnight. She was transferred from the unit to [**Hospital Ward Name 121**] 9 where she did very well. [**4-21**]: On pod 5, there were no overnight issues. Both the foley catheter and jp drain were removed in anticipation of her discharge later in the day. She was kept on antihypertensive medicaition for 2 weeks after discharge and was instructed to follow up with her primary care md to see if she needs a longer course of these medications. Additionally, she was kept on a stage 3 diet. Dr. [**Last Name (STitle) **] saw her prior to discharge and agreed with the decision to send her home. Medications on Admission: none Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for 3 weeks. Disp:*200 ML(s)* Refills:*1* 2. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) PO BID (2 times a day) for 6 weeks. Disp:*280 ml* Refills:*2* 3. Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 2 weeks: Please take this medication for 2 weeks. Make an appointment with your primary care physician to see if you need to be on this medication for a longer period of time. Please crush this medication in order to take it. Disp:*42 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day) for 2 weeks: Please take this medication for 2 weeks. Make an appointment with your primary care physician to see if you need to be on this medication for a longer period of time. Please crush this medication in order to take it. . Disp:*126 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: obesity Discharge Condition: good Discharge Instructions: You are now safe to go home. Please [**Name8 (MD) 138**] MD if you have any of the following. Fever >101.5 Bleeding Shortness of breath Chest pain loss of consciousness pain in your lower legs redness around your incision site leaking of more fluid than usual from your incision site decreased/no urine production/pain while urinating any other new symptom that concerns you. **Please take any new medications as prescribed. **Please resume all your medications you were on prior to this hospital admission. **Do not drink alcohol or drive a car while taking prescribed narcotic pain medications **Please crush all pills. Do not swallow them whole. **You need to be on a stage 3 diet. Followup Instructions: Please call Dr.[**Name (NI) 8999**] office for a follow up appointment next week. His office phone number is: ([**Telephone/Fax (1) 9000**] Completed by:[**2109-4-21**]

[ "401.9", "327.23", "530.81", "V85.4", "276.6", "278.01", "799.02", "575.11" ]

icd9cm

[ [ [] ] ]

[ "44.31", "51.22" ]

icd9pcs

[ [ [] ] ]

5608, 5614

2871, 4603

328, 374

5666, 5673

846, 2848

6410, 6582

621, 630

4658, 5585

5635, 5645

4629, 4635

5697, 6387

645, 827

274, 290

402, 501

523, 580

596, 605

61,924

105,561

41281

Discharge summary

report

Admission Date: [**2153-4-10**] Discharge Date: [**2153-5-2**] Date of Birth: [**2103-7-8**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 12174**] Chief Complaint: Worsening liver failure, AMS Major Surgical or Invasive Procedure: EGD with PPFT placement ERCP PICC placement History of Present Illness: Please see MICU admission note for details. In brief, this is a 49 yo M with a history of ESRD, HTN, DM2, and chronic hepatitis B (untreated) who presented to OSH ED with mental status changes on [**2153-4-9**]. . Notably he had a recent admission from [**Date range (1) 89889**] for worsening liver failure. He was evaluated by GI, and had a liver biopsy on [**2153-3-29**] that suggested cholestatic jaundice (though final result pending and pathology slides sent to [**Hospital1 2025**]). His bilirubin was noted to be as high as 18. However 5 days after discharge he was noted to be confused with visual hallucinations, and "chronic diarrhea" at rehab. . At the OSH, he was complaining of feeling weak and lethargic. He was unable to ambulate, and was more jaundiced. He was treated with rifaximin. Lactulose was avoided given his chronic diarrhea and incontinence. At the time of transfer, he was reported to have waxing and [**Doctor Last Name 688**] mental status with asterixis. During his hospital stay, he was noted to have a bilirubin of 30.1. RUQ US showed trace ascites and cholelithiasis, but no obstruction of the biliary tract. . In the MICU, he was briefly hypotensive to the 80s systolic upon admission but quickly improved to the 90s-110s systolic overnight after 2L of NS. His MICU course was notable for some confusion thinking he was in Domincan Republic and some asterixis, which persists today. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. Chronic hepatitis B -never treated 2. ESRD on HD MWF 3. HTN 4. DM2 5. Inguinal candidiasis 6. Traumatic brain injury from MVA 10 years ago Social History: Lives in [**Hospital 31183**] Rehabilitation. - Tobacco: None - Alcohol: Heavy drinker until 11-12 years ago. Stopped drinking at that time. - Illicits: None Family History: No family history of liver disease. Heavy family history of diabetes. Physical Exam: VS - Temp 98F, BP 97/61, HR 62, R 20, O2-sat 100% RA GENERAL - jaundiced, thin, chronically ill appearing man in NAD, AOx2 (thinks he's in [**Country 13622**] Republic in a place of business, but states [**2153-4-17**] is the date) HEENT - NC/AT, PERRLA, EOMI, sclerae markedly icteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT, mildly distended, no masses or HSM, no rebound/guarding EXTREMITIES - atrophied lower extremities, WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-10**] throughout, sensation grossly intact throughout, + asterixis Pertinent Results: [**2153-4-10**] 08:29PM BLOOD WBC-9.6 RBC-3.05* Hgb-8.6* Hct-30.5* MCV-100* MCH-28.0 MCHC-28.1* RDW-18.8* Plt Ct-335 [**2153-4-29**] 04:53AM BLOOD WBC-14.3* RBC-2.91* Hgb-8.9* Hct-28.7* MCV-99* MCH-30.5 MCHC-30.9* RDW-20.6* Plt Ct-446* [**2153-4-10**] 08:29PM BLOOD PT-17.8* PTT-36.1* INR(PT)-1.6* [**2153-4-29**] 04:53AM BLOOD PT-18.3* PTT-40.2* INR(PT)-1.6* [**2153-4-10**] 08:29PM BLOOD Glucose-153* UreaN-47* Creat-4.2* Na-128* K-4.4 Cl-92* HCO3-23 AnGap-17 [**2153-4-29**] 04:53AM BLOOD Glucose-171* UreaN-60* Creat-3.3*# Na-127* K-5.4* Cl-89* HCO3-23 [**2153-4-10**] 08:29PM BLOOD ALT-41* AST-93* LD(LDH)-190 AlkPhos-2052* TotBili-30.6* [**2153-4-29**] 04:53AM BLOOD ALT-58* AST-149* LD(LDH)-429* AlkPhos-1486* TotBili-24.3* [**2153-4-10**] 08:29PM BLOOD Albumin-2.9* Calcium-8.8 Phos-5.2* Mg-2.2 [**2153-4-29**] 04:53AM BLOOD Albumin-3.0* Calcium-10.1 Phos-2.2* Mg-2.3 [**2153-4-12**] 05:10AM BLOOD calTIBC-138* Ferritn-3039* TRF-106* [**2153-4-13**] 03:53PM BLOOD Triglyc-376* [**2153-4-20**] 08:47AM BLOOD PTH-73* [**2153-4-11**] 03:25AM BLOOD [**Doctor First Name **]-NEGATIVE [**2153-4-11**] 03:25AM BLOOD AMA-NEGATIVE [**2153-4-11**] 07:20PM BLOOD PEP-NO SPECIFI IgG-1727* IgA-538* IgM-133 [**2153-4-12**] 04:05PM BLOOD HIV Ab-NEGATIVE [**2153-4-11**] 03:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2153-4-12**] 06:07PM BLOOD Glucose-74 Lactate-0.8 Na-140 K-4.1 Cl-101 . EGD [**2153-4-24**] Impression: Esophagitis Did not proceed further after close examination of the esophagus as did not want to dislodge the feeding tube. Otherwise normal EGD to fundus Recommendations: Grade 3 esophagitis as seen on previous upper endoscopy. Feeding tube visualized. No mass lesion or adherent clot visualized as was on previous endoscopy. Continue PPI. Further recommendations to be relayed to the inpatient team. Brief Hospital Course: MICU Course: The patient was transferred from an OSH to [**Hospital1 18**] overnight and was accepted to the MICU given concern for worsening encephalopathy. He was protecting his airway at admission. He received 2L IVF boluses for hypotension with good response. He was started on lactulose. He was transferred to the floor <12 hours after admission to the MICU. Floor course: Mr. [**Known lastname 89890**] was a 49-year-old male with history history ESRD that presented with subacute liver failure (started in late [**2152**]) with predominant cholestatic picture. # Cholestatic hepatitis He was found to have elevated ALP ~ 200s in [**9-15**] and ALT/AST in 40-50s. He had acute decline in [**Month (only) 956**] with bili 4, ALT/AST in 1000s suggestive of viral, toxic, shock, or vascular etiology. He was discharged for follow-up with GI and missed all appointments on four occasions. Several times throughout the year he left the country without notifying dialysis and other doctors. He was also diagnosed with hepatitis B in [**2153-2-6**] (VL 7500). Hepatitis C negative. HIV negative. Bili 18 in [**Month (only) 958**]. He was discharged to rehab where he had diarrhea and encephalopathy in early [**Month (only) 547**]. Admission labs significant for bili 30 at OSH and transferred for further management. Biopsy suggestive of hepatitis B as etiology. Labs not suggestive of autoimmune cause. ERCP not suggestive of extrahepatic anatomical causes. Biopsy from OSH read by [**Hospital1 18**] pathology showing cholestatic hepatitis with prominent sinusoidal and portal-portal bridging fibrosis consistent with fibrosing cholestatic hepatitis although precise etiology of cirrhosis remained unclear. Treatment for hepatitis B was started with entecavir 1 mg PO weekly with recent viral load of 83,400. Hepatitis D not present. He was started on lactulose and rifaximin for hepatic encephalopathy. He was started on vitamin K for coagulopathy. Urosidol and vitamin D/multivitamins were started for cholestasis. His discharge labs showed reduced T bili 24.4 from peak of 31.2. While he was admitted, liver transplant was considered a possible endpoint for his disease, and the transplant medical and surgical evaluation was initiated. At the time of discharge, he had not undergone pulmonary function testing. It is likely that his general functional status and inparticular pulmonary function will continue to improve as his malnutrition and deconditioning are addressed at rehab. Pulmonary function testing should be sought as an outpatient. # Toxic-metabolic encephalopathy Patient triggered on [**2153-4-13**] for altered mental status secondary to anesthesia and lack of lactulose administration during ERCP peri-procedural period. He was subsequently stablized on a regimen that consisted of rifaximin alone with preservation of mental status. At the time of discharge, he was discharged on lactulose and rifaximin with clear mentation. On the day of discharge he was A&Ox3. # Thrush with esophagitis Patient had candidal thrush based on EGD and pathology and was started on 20-day course of micafungin given fluconazole was not a good option in setting of hepatic dysfunction. Micagungin therapy with be completed on [**5-7**]. # Severe malnutrition with refeeding syndrome Patient has very poor nutrition secondary to underlying disease and poor PO intake. Tube feeds were started during hospitalization with resultant hypophosphatemia suggestive of re-feeding syndrome. Electrolytes were monitored twice daily with repletion. Additionally, his subsequent diarrhea was also partly attributable to refeeding syndrome which resolved fully by the time of discharge. # Esophageal lesion Patient noted to have esophageal lesion on endoscopy with resultant chest CT suggestive of lesion arising from esophagus. Repeat EGD revelaed no evidence of esophageal lesion with apparent complete resolution. # ESRD He was maintained on dialysis throguhout admission and will continue as an outpatient. # DM2 He was well controlled on his current regimen and will continue current regimen as an outpatient. # Communication: Patient's family: [**Telephone/Fax (1) 89891**] [**First Name9 (NamePattern2) 89892**] [**Last Name (un) 72481**] (ex-wife), [**Name (NI) **] [**Name (NI) 89890**] (son) [**Telephone/Fax (1) 89893**], primary contact, eldest son and next of [**Doctor First Name **]. [**Name (NI) 9771**] [**Name (NI) 89890**] - Mother and [**Name (NI) 5321**] [**Name (NI) 89890**] - Sister [**Telephone/Fax (1) 89894**] Medications on Admission: 1. Norvasc 10mg po daily 2. Hydralazine 100mg po bid -held at OSH 3. Labetalol 600mg po bid -held at OSH 4. Nephrocaps 1 capsule daily 5. Rifaximin 550mg po bid 6. Oxycodone 5mg po q4-6h PRN pain 7. Lactulose 20mg po q4-6h 8. SSI Discharge Medications: 1. labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. micafungin 100 mg Recon Soln Sig: One (1) Intravenous once a day for 8 days: Complete 20 day course on [**2153-5-7**]. 5. insulin lispro 100 unit/mL Solution Sig: 1-8 units Subcutaneous ASDIR (AS DIRECTED). 6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 11. entecavir 1 mg Tablet Sig: One (1) Tablet PO 1X/WEEK (FR). 12. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). 13. bismuth subsalicylate 262 mg/15 mL Suspension Sig: Fifteen (15) ML PO QID (4 times a day) as needed for GI upset, diarrhea. 14. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 16. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: cholestatic hepatitis, toxic-metabolic encephalopathy, diarrhea Secondary: End-stage renal disease, candidal esophagitis, severe malnutrition, refeeding syndrome, hepatitis B, diabetes Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [**Known lastname 89890**], Your were transferred to [**Hospital1 18**] for worsening liver disease and confusion. Your liver disease was evaluated, and you were placed on medications to help this. You also have not been eating well, so a feeding tube was placed to help you with nutrition. You also received medication for diarrhea that improved. You will be evaluated by transplant service to consider liver transplantation. Please take your medication as prescribed and keep your outpatient appointments. . The following changes have been made to your home medciations. 1. You have been STARTED on Micafungin 100 mg IV daily until [**2153-5-7**] 2. You have been STARTED on Ursodiol 300 mg 2 times a day 3. CHANGED Multivitamin to Nephrocaps 4. You have been STARTED on Cholecalciferol (vitamin D3) 400 unit Tablet daily 5. You have been STARTED on Phytonadione 5 mg Tablet Daily 6. You have been STARTED on Pantoprazole 40 mg Tablet 2 time daily 7. You have been STARTED on Sucralfate 1 gram Tablet 4 times a day 8. You have been STARTED in Entecavir 1 mg Tablet once weekly 9. You have been STARTED on Cholestyramine-sucrose 4 gram Packet 2 times a day 10. You have been STARTED on bismuth subsalicylate 262 mg 4 times a day as needed for GI upset or diarrhea . No other changes have been made to your home medications. Followup Instructions: Department: TRANSPLANT When: THURSDAY [**2153-5-10**] at 10:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: TUESDAY [**2153-6-19**] at 2:40 PM With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "285.9", "349.82", "261", "250.40", "583.81", "585.6", "573.8", "276.1", "537.89", "787.91", "070.22", "403.91", "780.60", "V15.52", "276.9", "276.0", "112.0", "V45.11", "112.84", "458.8", "782.4", "572.3", "275.3", "427.89" ]

icd9cm

[ [ [] ] ]

[ "39.95", "96.6", "45.13", "38.93", "42.24", "51.10" ]

icd9pcs

[ [ [] ] ]

11648, 11714

5448, 9991

332, 378

11953, 11953

3570, 5425

13493, 14038

2580, 2651

10271, 11625

11735, 11932

10017, 10248

12138, 13470

2666, 3551

264, 294

1845, 2224

406, 1827

11968, 12114

2246, 2389

2405, 2564

71,837

106,987

46496

Discharge summary

report

Admission Date: [**2178-1-1**] Discharge Date: [**2178-1-6**] Date of Birth: [**2102-6-17**] Sex: F Service: NEUROLOGY Allergies: Percocet / Codeine Attending:[**First Name3 (LF) 2569**] Chief Complaint: Left hemiparesis, decreased level of consciousness Major Surgical or Invasive Procedure: Right hemicraniectomy Intubation History of Present Illness: 75 year old right handed woman with a history of CAD, HTN, obesity, hyperlipidemia, atrial fibrillation, currently off coumadin due to GI bleeds, Sytolic CHF (LVEF 40-45%) was last seen well when she went to bed last night. This morning at 9:30 am she was found was on the floor by her mother, mumbling a few words and not being able to move the left side of her body. They immediately called EMS who brought her here. Of note, patient has a history of colonic AVM that has led her to several hospitalizations due to GI bleed. In [**2175**] she developed atrial fibrillation and was started on coumadin by her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2450**]. As another gastrointestinal hemorrhage occured one year ago([**2176-12-31**]), it was decided to stop coumadin. Past Medical History: -Hypertension -Coronary artery disease: s/p MI X 2 ([**2142**] and [**2159**]) s/p LCX stent ([**2159**])--complicated by pericarditis, pleural effusion. Last cath [**2173**] with LCX 80% restenosis treated with angioplasty and placement of cypher DES. -DVT s/p IVC filter and completed course of coumadin -High cholesterol -Atrial fibrillation -Osteoarthritis -GIB: recurrent LGIB. Last colonoscopy [**3-30**] with AVMs--treated -s/p bilateral rotator cuff surgery -s/p hysterectomy Social History: Divorced mother of 2 children (son, daughter). Quit tob [**2159**] (smoked [**12-26**] ppd x 40 years). Occasional alcohol, no drugs. Retired inspector. Lives in Mission [**Doctor Last Name **]. She lives with her mother, brother, son, cousin, and granddaughter. Family History: There is no family history of premature coronary artery disease or sudden death Physical Exam: T-96 BP-166/68 HR-73 RR-15 100O2Sat Gen: Lying in bed, obese HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: irregular, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and alert, partly cooperative with exam, She can mumble a few words, however, it is difficult to understant.She was oriented to place, and date, nodding confirming them. Speech is nonfluent; normal comprehension (she followed commands such as pointing to the ceiling, squeezing the hand, repetition is impaired. Patient would tend to look to the left side of the room and she made a few mistakes when I tested touching one or two arms and asking how many arms I was touching. with some evidence of left sided neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are not able to test. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3. Left UMN facial weakness. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Increased tone on left leg. No observed myoclonus or tremor No pronator drift [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 L 0 0 0 0 0 0 1 3 2 2 2 3 2 3 Sensation: Intact to light touch, pinprick, vibration and proprioception throughout. No extinction to DSS Reflexes: Biceps 2+ BL; Triceps 2+ BL; Brachrad. 3+ BL, patellar trace BL; Achilles 0 BL Upgoing left toe Coordination: Finger tap normal on right side; could not perform on the right side due to weakness. Gait: not tested Brief Hospital Course: The patient is a 75 year old woman with a history of atrial fibrillation off Coumadin given history of GI bleeds related to colonic AVM, hypertension, and hyperlipidemia who presented after being found down with left hemiparesis and decreased level of consciousness. Physical exam on admission was significant for being awake but somnolent, dysarthria, left sided neglect, left hemiparesis, and upgoing toe on the left. CT Head showed an acute right MCA territorial infarct. Given her somnolence and size of her right MCA infarct with potential to swell, she was admitted to the NeuroICU. She was continued on an ASA 325 mg daily, and her blood pressure was allowed to auto-regulate (and ranged 130-180 overnight). MRI/MRA brain/neck performed at approximately [**9-3**] pm on the day of admission ([**1-1**]) showed acute right MCA infarct with no hemorrhage or shift of midline structure and decreased flow in the right ICA and complete occlusion of the right MCA at its M1 segment. The patient's GCS began to decrease at approximately 3 am on Day 2 of admission ([**1-2**]), with decreased responsiveness. This was initially thought to be due to her respiratory status. At 4:40 am, she was reevaluated by neurology and found to have a fixed and dilated R pupil at 6 mm, no corneal reflex on the right, and no gag. Repeat Head CT at 5:19 am showed showed new hemorrhagic conversion within the extensive, virtual-complete right MCA territorial infarction, which, along with worsening cytotoxic edema, caused significantly increased mass effect, with severe leftward subfalcine and right uncal and impending downward transtentorial herniation. She was thought to have a malignant MCA infarct due to recanalization and reperfusion causing hemorrhage. She was intubated and given Mannitol 20% 150 g IV x1. Her son was notified, and neurosurgery was consulted who performed an emergent right hemicraniectomy on the morning of [**1-2**]. She was hypotensive during the hemicraniectomy requiring pressors. A repeat head CT/CTA after the hemicraniectomy showed continued midline shift and increased size of the hemorrhage. She was started on Dilantin after the procedure, and her ASA was discontinued. A family meeting was held with the patient's son (who was present) and daughter (via the telephone), and they were informed about the patient's grim prognosis. The patient's daughter wanted to continue care until she was able to come to [**Location (un) 86**] from [**State 3908**]. The patient was started on Mannitol IV q6 hr. The patient was made CMO after family meeting and expired a few hours later. Medications on Admission: pantoprazole 40mg lisinoprol 40mg colchicine 0.6 mg isosorbide mononitrate 30mg senna docusate allopurinol 100mg furosemide 80mg [**Hospital1 **] Hydralizine 25mg [**Hospital1 **] crestor 40mg aspirin 325mg Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2178-1-20**]

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icd9cm

[ [ [] ] ]

[ "99.07", "01.39", "38.91", "87.03", "96.04", "99.21", "01.53", "96.6", "99.04", "96.72" ]

icd9pcs

[ [ [] ] ]

6922, 6931

4030, 6633

329, 363

6982, 6991

7047, 7196

1985, 2067

6890, 6899

6952, 6961

6659, 6867

7015, 7024

2082, 2431

239, 291

391, 1182

3011, 4007

2470, 2995

2455, 2455

1204, 1689

1705, 1969

30,228

194,954

34068

Discharge summary

report

Admission Date: [**2129-6-22**] Discharge Date: [**2129-6-22**] Date of Birth: [**2079-9-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5893**] Chief Complaint: unresponsive Major Surgical or Invasive Procedure: none. History of Present Illness: 49M h/o stage IV esophageal cancer (treated at [**Company 2860**]), DVT found by wife unresponsive earlier today taken to [**Location (un) 1468**] OSH where initially rec'd narcan for possible narcotic OD but no improvement, ?witnessed seizure (shaking of extremities) for which he was intubated and loaded with dilantin, also tachycardic and hypertensive transferred to [**Hospital1 18**] ED for further care. Per the wife, the patient was feeling fatigued and having some "congestion" prior to this presentation but was otherwise in his USOH this AM before she left for work. She then tried to call him but did not get a response so she went home and found him in a chair with his head back unresponsive. EMS was called and he was taken to OSH as above. She says that her husband was not having any fevers or chills, no dyuria, change in bowel habits, no shortness of breath but +chest pains over the last several days with upper airway congestion. She says that he never had any seizure activity at home. His other past medical history is signficant for a h/o West [**Doctor First Name **] infection c/b VRE, ?MRSA infections at [**Hospital1 112**] last year. . Here the patient is no responsive, not following commands, not responding to sternal rub, pupils sluggish but reaction. Per neuro eval in the ED, patient has intact brain stem reflexes (incl reactive pupils, corneals, dolls, grimace to nasal tickle, swallow), withdraws arms symmetrically to noxious stim and symmetric DTRs. [**Name (NI) 72787**] from OSH negative for bleed or obvious mass. Upon arrival here, patient given 2L NS, levo/vanco/flagyl for bandemia. CT torso showing preliminarily no PE, ?aspiration pnemonia and pericolic fluid. . Past Medical History: - Stage IV esophageal cancer - DVT of LE - h/o West Nile Virus - h/o VRE/?MRSA infections Social History: Has smoked 1ppd x many years, recently cut back, used to drink beer socially, lives with wife, works in sales, no children. Family History: NC Physical Exam: VS: 99.5 121 130/93 29 100% AC 550/16/5/100% --------------- General Appearance: Well nourished Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Rhonchorous: ) Abdominal: Soft, decreased BS Skin: Not assessed Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed Pertinent Results: [**2129-6-21**] 07:00PM BLOOD WBC-6.8 RBC-3.40* Hgb-10.8* Hct-32.8* MCV-96 MCH-31.7 MCHC-32.9 RDW-19.5* Plt Ct-92* [**2129-6-22**] 05:08AM BLOOD WBC-5.0 RBC-3.14* Hgb-9.6* Hct-30.2* MCV-96 MCH-30.7 MCHC-31.9 RDW-18.9* Plt Ct-54* [**2129-6-22**] 05:08AM BLOOD Neuts-78* Bands-3 Lymphs-9* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-3* [**2129-6-21**] 06:35PM BLOOD PT-14.5* PTT-23.7 INR(PT)-1.3* [**2129-6-22**] 05:08AM BLOOD PT-16.1* PTT-24.8 INR(PT)-1.4* [**2129-6-22**] 05:08AM BLOOD Glucose-110* UreaN-83* Creat-3.7* Na-128* K-4.4 Cl-90* HCO3-24 AnGap-18 [**2129-6-21**] 06:35PM BLOOD ALT-29 AST-54* CK(CPK)-210* AlkPhos-109 Amylase-115* TotBili-0.9 [**2129-6-22**] 05:08AM BLOOD LD(LDH)-300* CK(CPK)-114 [**2129-6-21**] 06:35PM BLOOD Albumin-2.4* [**2129-6-22**] 05:08AM BLOOD Calcium-8.1* Phos-4.6* Mg-1.9 [**2129-6-21**] 06:35PM BLOOD CK-MB-2 cTropnT-0.06* [**2129-6-22**] 05:08AM BLOOD CK-MB-2 cTropnT-0.06* [**2129-6-21**] 06:35PM BLOOD Phenyto-8.7* [**2129-6-22**] 05:08AM BLOOD Vanco-20.2* [**2129-6-22**] 05:08AM BLOOD Hapto-358* [**2129-6-21**] 06:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2129-6-21**] 06:35PM BLOOD Type-ART Temp-38.1 Rates-16/8 Tidal V-600 PEEP-5 FiO2-100 pO2-110* pCO2-43 pH-7.40 calTCO2-28 Base XS-0 AADO2-562 REQ O2-93 -ASSIST/CON Intubat-INTUBATED [**2129-6-21**] 11:12PM BLOOD Type-ART PEEP-5 pO2-228* pCO2-36 pH-7.47* calTCO2-27 Base XS-3 Intubat-INTUBATED [**2129-6-21**] 06:35PM BLOOD freeCa-1.07* [**2129-6-21**] 06:35PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2129-6-21**] 06:35PM URINE RBC-0 WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0 [**2129-6-22**] 10:57AM URINE Hours-RANDOM UreaN-PND Creat-PND Na-PND K-PND Cl-PND [**2129-6-21**] 06:35PM URINE AmorphX-MOD [**2129-6-21**] 7:00 pm BLOOD CULTURE #1. Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Preliminary): REPORTED BY PHONE TO ED READON @ 5:29A [**2129-6-22**]. GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. Anaerobic Bottle Gram Stain (Preliminary): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. [**2129-6-21**] 7:00 pm BLOOD CULTURE #2. Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Preliminary): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. Anaerobic Bottle Gram Stain (Preliminary): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. Blood/Urine Cultures from [**6-22**]: Pending, NGTD CT Chest/Abd/Pelvis [**6-21**] IMPRESSION: 1. Extremely limited study secondary to patient motion and lack of intravenous contrast. 2. Abnormally dilated loops of small bowel, some demonstrating wall thickening. Findings could represent proximal obstruction. 3. Left lower lobe consolidation concerning for pneumonia. 4. Multiple pulmonary nodules and small cystic lesions seen within the lungs, concerning for metastatic disease. Short interval followup within three months is recommended given patient's history of malignancy. 5. Nodular peritoneal implants with diffuse mesenteric stranding concerning for metastatic disease. Comparison with prior outside images is recommended to evaluate for change. CT Head [**6-21**]: IMPRESSION: 1. No acute intracranial hemorrhage. 2. Small area of low attenuation in the right frontal lobe, without significant mass effect or loss of [**Doctor Last Name 352**]-white differentiation. Consider MRI for further assessment. CXR [**6-21**]: IMPRESSION: ET tube in satisfactory position, with very low lung volumes. Brief Hospital Course: 50 M with advanced esophageal CA found unresponsive, with question of observed activity. . Patient was briefly admitted to the ICU for management prior to transfer to [**Hospital1 4601**] Oncology where patient receives majority of his care. . On Admission: . # Altered MS. [**Name13 (STitle) **] found unresponsive. Differential is broad, toxic metabolic, ?narcotics related although minimal/no response to narcan. ?seizure although no clear brain metastases. Patient now intubated and sedated for airway protection. ?atypical or viral source. Mental status on admission showed intact brain stem reflexes w/ reactive pupils, corneal blink, and no acute change in underlying mental status was observed during his ICU stay. On admission to ICU, patient was initially covered with vancomycin and zosyn, but given concern for CNS infection was broadened to vancomycin, ceftriaxone, acyclovir, ampicillin and flagyl at appropriate doses. Plan was for urgent LP/MRI/EEG but work-up was interrupted by request of family and primary oncologist to have transfer to [**Hospital3 328**] for further care. EEG was performed and demonstrated no focal seizure activity with moderate global encephalopathy c/w toxic/metabolic process. Plan at the time of discharge is for: - LP (plts marginal, will need plts pre LP), would send infectious/viral studies in addition to routine labwork. - MRI/MRA/MRV w/&w/o contrast brain when able. - continue dilantin for now, 100mg IV TID, check albumin and dilantin trough in am goal level (adj for hypoalb [**11-21**]). trend LFTs. - EEG as above - TSH: Pending - Neurology consulted and agrees with above plan. - Check peripheral smear for evaluation of TTP. . # Resp. Airway protection given MS. [**First Name (Titles) **] [**Last Name (Titles) 78607**] well, unable to extubate given altered mental status. CT scan of the chest demonstates left lower lobe consolidation. Blood cultures from admission growing 4/4 bottles of gram positive cocci in pairs/chains - likely strep pneumo. Patient initially covered with vanc/zosyn but after culture data returned, and given ? of CNS infection, patient changed to ceftriaxone in addition to vanc/flagyl/acyclovir/ampicillin. - ABG stable, wean O2 as tolerated. Extubation pending recovery of mental status. - mild sedation - wean qAM - sputum cultures . # Tachycardia. ECG sinus tachy. h/o DVT, no PE on CTA. Likely related to underlying infection, fevers, ?pain. Volume status appears adequate. - mild sedation - monitor on tele . # Seizure Activity. No h/o seizure. ?in setting of Narcan (patient seizured after receiving this at OSH). Per above, neuro w/up. EEG unremarkable. Continue anti-epileptics and monitor levels. - Lesion on CT unlikely seizure focus as per neurology - MRA/MRV/EEG - consider LP for infection, toxic-metabolic w/up . # Bandemia. Likely related to infection, ? contribution of malignancy. . # Stranding on Abd CT: appears c/w peritoneal mets from esophageal Ca. ?Gut ischemia vs. infection. Belly soft on exam, evidence of dilated loops of small bowel with surrounding fluid/stranding. Cover broadly for now. - consider surgical eval - serial abd exams - follow lactate . # Hyponatremia: Worsened with 2L NS on admission suggesting SIADH. Appears euvolemic on exam so would continue to monitor HR, UOP. - Immediately prior to discharge: - Urine lytes -> Osm's 313 suggesting presence of ADH w/ FeNa < 1% suggesting may be pre-renal. Continue hydration as tolerated given concern for SIADH. . #Acute Renal Failure: Likely pre-renal but ATN concern given possibility of hypotension. CK not elevated. Urine lytes c/w pre-renal. Possibly some component of contrast nephropathy and but Cr elevated on admit. Would monitor as given ARF and contrast load is high risk for contrast nephropathy. - Mucomyst 600mg [**Hospital1 **] x4 doses - Bicarbonate with IVF's. . # Esophageal CA. Followed at [**Company 2860**]. Contact primary onc team in AM. Last chemo was ~ 2 weeks ago. . #DVT: Held lovenox given thrombocytopenia and ARF. LENI's pending. . # FEN. NPO, replete lytes prn, maintenance fluids . # PPx. PPI, pneumoboots, bowel reg . # Full code presumed . # Comm: Family . # Access: PIVs Medications on Admission: MEDICATIONS: will confirm with pharmacy (wife to bring in list in AM) Unknown exactly per family Lovenox Morphine Percocet Prevacid HTN medication Mouth ulcer medication Chemo 2 weeks ago Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 4. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily). 5. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) 20% solutions for total 600mg Miscellaneous [**Hospital1 **] (2 times a day) for 4 doses. 6. Fentanyl Citrate (PF) 50 mcg/mL Solution Sig: 25-100 ucg q6H IV Injection Q6H (every 6 hours) as needed. 7. Phenytoin Sodium 50 mg/mL Solution Sig: One (1) Intravenous Q8H (every 8 hours). 8. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours). 9. Acyclovir Sodium 500 mg Recon Soln Sig: Six Hundred (600) mg Intravenous Q24H (every 24 hours). 10. Ampicillin Sodium 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours). 11. Ceftriaxone-Dextrose (Iso-osm) 2 gram/50 mL Piggyback Sig: Two (2) gram Intravenous Q12H (every 12 hours). 12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 13753**] - [**Location (un) 86**] Discharge Diagnosis: Pneumonia Bacteremia Altered Mental Status Acute Renal Failure Hyponatremia Discharge Condition: Critical. Discharge Instructions: Patient admitted after being found unresponsive. See discharge summary for complete details. Transferred to [**Hospital1 112**]/[**Hospital3 328**] where patient receives majority of his care. Followup Instructions: As per [**Hospital1 112**].

[ "584.9", "276.2", "486", "349.82", "197.0", "197.6", "150.8", "253.6", "518.81", "790.7", "780.39" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

12317, 12390

6681, 6925

328, 336

12510, 12522

2987, 4842

12765, 12796

2348, 2352

11122, 12294

12411, 12489

10909, 11099

12546, 12742

2367, 2968

5296, 6658

276, 290

364, 2077

6939, 10883

2099, 2191

2207, 2332

863

194,975

9923

Discharge summary

report

Admission Date: [**2117-10-10**] Discharge Date: [**2117-11-2**] Date of Birth: [**2053-9-24**] Sex: M Service: Surgery HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 1124**] is a 64 year old man with a past medical history of coronary artery disease, status post coronary artery bypass grafting times two with mitral valve replacement with a St. Jude valve in [**2117-6-1**], who presented to the Emergency Room on [**2117-10-10**] complaining of abdominal pain which he had been having since his heart surgery in [**Month (only) 116**]. The patient reported that his abdominal pain was increasing in severity, persisting for a longer amount of time and was more intense. It was postprandial. He reported diarrhea. He reported that the pain was associated with bowel movements. PHYSICAL EXAMINATION: On physical examination, the patient had a temperature of 97.9, heart rate 77, blood pressure 144/78, respiratory rate 18 and oxygen saturation 99%. Head, eyes, ears, nose and throat: Unremarkable. Neck: Supple without lymphadenopathy. Cardiovascular: Irregular with a loud S1 and II/VI systolic ejection murmur. Lungs: Clear to auscultation bilaterally. Abdomen: Diffusely tender with diminished bowel sounds. Neurologic: Nonfocal. PAST MEDICAL HISTORY: 1. Atrial fibrillation for years, resistant to cardioversion. 2. [**2108**], inferior myocardial infarction with angioplasty time two. 3. [**2114**], cerebrovascular accident times two. 4. Congestive heart failure. 5. Asthma. 6. [**2117-5-2**], myocardial infarction, congestive heart failure and rib fractures. 7. [**2117-6-1**], coronary artery bypass grafting times two, mitral valve replacement with St. Jude valve and dual pacemaker. 8. [**2117-9-1**], cardioversion. 9. [**2117-8-1**], cholecystectomy. 10. [**2117-5-2**], patient found to have a solitary lung nodule. ALLERGIES: The patient is allergic to benzodiazepines, which cause a paradoxical reaction. MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o.q.d., lisinopril 10 mg p.o.q.d., Lopressor 12.5 mg p.o.b.i.d., amiodarone 200 mg p.o.q.d., Coumadin 2.5 alternating with 5 mg p.o.q.h.s., Ambien p.o.q.h.s.p.r.n., albuterol meter dose inhaler two puffs b.i.d. LABORATORY DATA: A KUB demonstrated dilated loops of bowel. An abdominal CT showed no bowel wall thickening; it did show dilated loops of bowel and no diverticulosis. HOSPITAL COURSE: The patient was admitted to the vascular service with a presumptive diagnosis of mesenteric ischemia. He underwent an abdomen angiogram on [**2117-10-10**] and had angioplasty of his superior mesenteric artery, with decreased abdominal pain. On [**2117-10-12**], the patient was seen by the thoracic surgery service because he had been previously noted to have a left upper lobe lesion by chest x-ray in [**2117-5-2**]. A CT scan revealed a T2N2 left upper lobe lesion and possible right rib metastases on recent bone scan. Thoracic surgery recommended consulting medical oncology. On [**2117-10-14**], the patient complained of increasing abdominal pain and was found to have evidence of obstruction. He underwent an [**Year (4 digits) 33270**] by Dr. [**Last Name (STitle) **] on [**2117-10-14**], with pathology results confirming a carcinoid tumor. On postoperative days two through four, the patient was noted to be doing well, with an oxygen saturation of 99% on three liters nasal cannula. However, some rales were noted on examination. On [**2117-10-19**], the patient was noted to have an increased respiratory rate to 30 and rales on examination, which was treated with albuterol nebulizers with some relief. A chest x-ray revealed mild congestive heart failure. His oxygen saturation decreased to 87% to 91% on three liters and respiratory rate was in the 30s to 40s. He was treated with Lasix with some improvement. He was ruled out with cyclic cardiac enzymes. On [**10-20**] and 20, [**2117**], the patient was not noted to improve. He was transferred to the Surgical Intensive Care Unit on [**2117-10-21**] and treated with clindamycin and ciprofloxacin as per infectious disease on [**2117-10-22**]. On [**2117-10-24**], the patient was started on vancomycin and, by [**2117-10-25**], the patient was noted to be much improved, feeling well, with decreased shortness of breath. He still had a cough which was productive of clear sputum. He denied fever, chills, chest pain, nausea, vomiting or diarrhea. He was tolerating a small amount of oral intake, but this was limited secondary to his oxygen needs. On a 15 liter nonrebreather mask, the patient's oxygen saturations were 91% to 96%. Please note that the [**Hospital 228**] transfer to the Surgical Intensive Care Unit was in order to allow utilizing continuous positive airway pressure to improve oxygenation and gain alveolar recruitment. On [**2117-10-26**], the patient was found to have a systolic blood pressure in the 70s to 80s. This responded to gentle hydration and return to 104/40. His oxygen saturation was 92% to 96% on high flow humidified oxygen at 15 liters per minute. His heart rate was 85 in atrial fibrillation. At this time, the patient was transferred to the Vascular Intensive Care Unit. On [**2117-10-26**], the patient was postoperative day 12, hospital day 16. He reported that he felt okay, although he appeared to be in mild respiratory distress. He was able to speak in full sentences. He was afebrile with stable vital signs. His oxygen saturation was 86% to 94% on 15 liters high flow humidified oxygen. Cardiology was consulted regarding the pulmonary consultation's recommendation of discontinuing amiodarone. This was recommended secondary to a rare occurrence of amiodarone causing pulmonary infiltrates in an acute manner. On [**2117-10-27**], the patient was postoperative day 13 and hospital day 17. He reported that he had had a good previous night, with no complaints. His oxygen saturation was 95% on 60% oxygen by face mask. His blood pressure range was 88/46 to 110/56. His examination demonstrated an irregularly irregular heart rhythm with an S1 present. His lungs were clear on the right with some end-expiratory rhonchi on the left. His sputum culture had grown out Hemophilus influenzae, beta lactamase negative. It was decided to continue the amiodarone at this time. The patient's liver function tests, which had been previously elevated, were trending down, with his AST at 124, down from 352, ALT 148, down from 265, alkaline phosphatase 161, down from 177 and total bilirubin 0.4, down from 1.1. His pneumonia appeared to be clinically improving and he had a decreased oxygen requirement. On [**2117-10-29**], postoperative day 15 and hospital day 19, the patient was doing very well, with no complaints. He was afebrile and his vital signs were stable. His oxygen saturation was 95% on three to four liters by nasal cannula. His lungs were clear to auscultation bilaterally. On [**2117-10-29**], the patient's antibiotic regimen was changed to oral Levaquin 500 mg daily after pulmonary recommended this change. On postoperative day 17, hospital day 21, the patient was doing well, with no complaints. He was able to walk with assistance. He was afebrile with stable vital signs. His respiratory rate was 18 and he was breathing at 97% on three liters nasal cannula. His prothrombin time was 13.3, partial thromboplastin time 58.8, INR 1.2, sodium 134, potassium 4.6, chloride 102, bicarbonate 25, BUN 15, creatinine 0.8 and glucose 118. His heparin drip was increased at this time to 1,200 units/hour. His Coumadin dose was increased to 7.5 mg at bedtime. On [**2117-11-1**], the patient was doing well, with no complaints. He was postoperative day 18, Levaquin day four. He was afebrile with stable vital signs. His oxygen saturation was 98% on two liters per nasal cannula. His heart was irregular. His lungs had an occasional crackle but were otherwise clear. His abdomen was soft, nontender, nondistended, with normal active bowel sounds. His incision was clean, dry and intact with Steri-Strips. His appropriate was 13.8, partial thromboplastin time 79.2 on 1,200 units/hour of heparin and INR was 1.3. DISCHARGE MEDICATIONS: Levaquin 500 mg p.o.q.d. times nine days. Lopressor 12.5 mg p.o.b.i.d. Zantac 150 mg p.o.b.i.d. Coumadin 7.5 mg p.o.q.h.s. Heparin 1,200 units/hour. Enteric coated aspirin 325 mg p.o.q.d. Percocet one to two tablets p.o.q.4-6h.p.r.n. pain. DISCHARGE DIET: Low sodium with three cans of Boost Plus per day. CONDITION AT DISCHARGE: Fair. DISCHARGE STATUS: To rehabilitation. DISCHARGE DIAGNOSIS: Status post [**Last Name (LF) 33270**], [**2117-10-14**], of carcinoid tumor. Pneumonia, resolving. Coronary artery disease, status post coronary artery bypass grafting times two and St. [**Male First Name (un) 923**] mitral valve replacement in [**2117-6-1**]. Atrial fibrillation, chronic, with pacemaker. Cerebrovascular accident times two in [**2114**], symptoms have resolved. Asthma. Mild chronic obstructive pulmonary disease. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Last Name (NamePattern1) 23443**] MEDQUIST36 D: [**2117-11-1**] 13:55 T: [**2117-11-1**] 13:46 JOB#: [**Job Number 33271**]

[ "V45.81", "486", "560.9", "493.20", "152.2", "428.0", "447.1", "162.8", "427.31" ]

icd9cm

[ [ [] ] ]

[ "45.93", "39.50", "45.73" ]

icd9pcs

[ [ [] ] ]

8268, 8587

8669, 9379

2036, 2433

2451, 8245

854, 1300

8602, 8648

170, 831

1323, 2009

29,426

157,345

34369

Discharge summary

report

Admission Date: [**2125-12-27**] Discharge Date: [**2126-1-1**] Date of Birth: [**2064-1-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: fever, lethargy and hypotension Major Surgical or Invasive Procedure: suprpubic catheter changed History of Present Illness: 61 year-old male with a history of obstructing left renal stone, suprapubic catheter (neurogenic bladder s/p CVA), numerous UTIs who presents from day care center with fever, lethargy and hypotension. . In the ED, T 104.8, BP 74/44 HR 110 97%/2l. He recd 2 L of IVF and the SBP came up to 110s but dropped again to 80s. Total he recd 8 L of IVF and after placement of RIJ, was started on neosynephrine. He also recd vanc/ctx/levoflox initially. After noting that his last Ucx grew psudomonas which was not susceptible to CTX/levoflox, he recd zosyn x 1. . Currently, pt alert but not oriented. follows commands. denies pain, headache, CP/SOB/dizzy, abd pain/N/V. Past Medical History: s/p CVA Neurogenic bladder s/p suprapubic cath Recurrent UTIs with Klebsiella/Pseudomonas Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03 (s/p R-CHOP x 6 cycles) Bells Palsy BPH Hypertension Partial Bowel obstruction s/p colostomy Hepatitis C Cryoglobulinemia SLE with transverse myelitis, anti-dsDNA Ab+ Insulin Dependant Diabetic Fungal Esophagitis Stage IV? Urinary Tract Infections-pseudomonas & enterococcus Social History: Lives in a nursing home since [**3-9**]. Denies smoking, ETOH, drug use. Has sister close by ([**Name (NI) 79061**]) who he is close to. Is a Jehova's Witness and does not agree to blood transfusions. Family History: Non-Contributory Physical Exam: General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Breath Sounds: Crackles : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent Skin: Cool Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Movement: Not assessed, Tone: Not assessed Pertinent Results: MICROBIOLOGY: From last admit: UCx negative X2 on [**11-27**] Ucx [**11-14**]: psudomonas and providencia stuartii UCx [**11-18**] pseudomonas and NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. suprapubic UCx [**11-22**] wth 3,000-5,000 GNR (suggestive of pseudomonas) . STUDIES: CXR: RIJ in place. L pl effusion unchanged form previous on [**11-27**] . EKG: sinus tach. no sig ST-T changes. no sg changes from previous [**2125-12-27**] 09:33AM URINE BLOOD-LG NITRITE-NEG PROTEIN->300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0 LEUK-LG [**2125-12-27**] 10:53AM LACTATE-1.3 [**2125-12-27**] 05:16PM CK-MB-5 cTropnT-0.06* [**2125-12-27**] 05:16PM GLUCOSE-238* UREA N-22* CREAT-2.3*# SODIUM-140 POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-20* ANION GAP-15 [**2125-12-27**] 05:37PM LACTATE-1.4 [**2125-12-27**] 09:24AM ALBUMIN-3.4 CALCIUM-8.6 [**2125-12-27**] 09:24AM WBC-27.0*# RBC-4.58* HGB-11.8* HCT-36.2* MCV-79* MCH-25.8* MCHC-32.7 RDW-15.5 Brief Hospital Course: 61 y.o. M with h/o obstructing left renal stone, suprapubic cathether [**2-3**] neurogenic bladder after CVA, and numerous UTIs (klebsiella and pseudomonas) and hospitalizations for urosepsis, presents from [**Hospital **] Health Care Center for lethargy, fever, and hypotension, likely secondary to urosepsis. . UROSEPSIS: Likely source thought to be UTI. He had 2 L IVF on admission that led to resolution of hypotension. Pressors were discontinued on HD1. He was initially on Vanc and zosyn. Has been hemodynamically stable and off pressors since discharge from MICU on [**12-29**]. UA grossly positive in ED, but UCx with contaminant. However, given his history and no other source, UTI is likely source. WBC has been improving and he remains afebrile. He should continue meropenem for 10 days, started [**12-27**]. A PICC was placed. - PICC needs to be removed following antibiotic course. . NEUROGENIC BLADDER: Patient has a nephrostomy tube. Replaced by [**Month/Year (2) **] [**12-28**] after found to be in ureter. - Patient will need follow up in 2 weeks with [**Month/Year (2) **]. They will change tube and request that it not be changed except by them. . ACUTE RENAL FAILURE: Cr 3.6 on admission, 1.3 on transfer and back to normal range prior to discharge. Elevation likely secondary to nephrostomy tube in uritor causeing hydronephrosis vs. hydrouretonephrosis or prerenal. No stones seen on CT scan. . DIABETES TYPE I: He will continue home dose lantus, lispro. Lispro sliding scale for added coverage with QIDACHS FS. . HYPERLIPIDEMIA: continue outpatient simvastatin . DEPRESSION: continue Celexa . PAIN: continue outpatient Oxycodone prn . FEN: no IVFs / replete lytes prn / diabetic diet . PPX: HSQ, PPI, bowel regimen . ACCESS: PIV . CODE: FULL Medications on Admission: -Senna 8.6 -Docusate -Citalopram 20 mg qd -Folic Acid 1 mg qd - Simvastatin 10 mg qd -Multivitamin qd -Omeprazole 20 mg qd -Gabapentin 300 mg tid -Simethicone 80 mg Tablet -Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day): for oral thrush. -Zolpidem 5 mg qhs -Acetaminophen 325 mg -Oxycodone 5 mg Tablet Q4H prn -Lantus 18 units Subcutaneous at bedtime. -Insulin Lispro Four (4) Units Subcutaneous TID before meals: Also sliding scale. -Miconazole Nitrate 2 % Topical TID -CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1) Tablet PO at bedtime. -Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day): If not ambulating. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) U Subcutaneous at bedtime. U 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO Q8H (every 8 hours). 12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for bladder spasm. 15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 16. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 6 days: 10 day course from [**2125-12-27**] to [**2126-1-6**]. 17. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 18. Insulin Lispro 100 unit/mL Solution Sig: Four (4) U Subcutaneous three times a day: Prior to meals. 19. Calcarb 600 With Vitamin D 600-400 mg-unit Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Discharge Diagnosis: Primary: - UTI with sepsis - Acute renal failure - Post-obstructive diuresis Secondary: - Prior stroke - Neurogenic bladder s/p suprapubic cath - Recurrent MDR urinary tract infection - UPJ stone s/p perc. drain c/b perinephric bleed - NHL-Marginal Zone Lymphoma of the left orbit(R-CHOP x 6 cycles) - Bells Palsy - Hypertension - Sigmoid volvulus s/p sigmoid colectomy [**2120**] - Bleeding rectal ulcer s/p resection - Colostomy [**2124**] - Gastric ulcer with partial gastrectomy - Hepatitis C - Cryoglobulinemia - SLE with transverse myelitis - DM I - Jehovah's witness, no transfusions Discharge Condition: stable vital signs Discharge Instructions: You were admitted with a severe infection likely from your bladder. You were in the intensive care unit for two days. You should continue antibiotics for a total of 10 days to treat this infection. The PICC line should be removed once the antibiotics are done. [**Year (4 digits) 159**] changed your suprapubic catheter. You should follow up with them as an outpatient. They request that they be the ones to change your catherter next. Take all of your medications as prescribed. Please call your PCP or go to the ED if you have fevers over 102, chills, extensive nausea, vomiting, chest pain, trouble breathing or any other symptoms which are concerning to you. Followup Instructions: Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2126-1-16**] 10:00 Provider: [**Name10 (NameIs) 454**],TWO [**Name10 (NameIs) 454**] Date/Time:[**2126-2-20**] 9:00 Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 8243**] Date/Time:[**2126-2-20**] 10:30 Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 6019**] Completed by:[**2126-1-1**]

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icd9cm

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274, 308

402, 1069

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40,277

127,703

36586

Discharge summary

report

Admission Date: [**2151-8-13**] Discharge Date: [**2151-8-17**] Date of Birth: [**2070-10-11**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins / Tetracycline / Amoxicillin Attending:[**First Name3 (LF) 22864**] Chief Complaint: Syncope, fall, SAH Hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: 80F with hyponatremia transferred from OSH for unwitnessed fall from standing with subarachnoid hemorrhage. Pt got up to go to the bathroom, woke up on the floor. On asa. Recent uti on cipro. Daughter brought her to the hospital because she felt that the patient was more lethargic. Pt denies any lighheadedness, chest pain, palpitations prior to the fall. Pt also notes left collar bone pain. . In the ED, initial vitals 99 130/80 16 98%RA. Neuor exam reported as completely unremarkable. Seen by neurosurgery, who recommended repeat imaging and work-up of syncope. Got 1L NS, nebs and ativan. Head CT showed b/l frontal and left temporal subarachnoid hemmorhage, intraventricular hemmorhage (b/l), hemmorhage within the interventricular septum and small left epidural hematoma. Labs notable for a Na of 123 which was reported as chronic. EKG sinus with PACs, poor R wave progression, diffuse T wave flattening. C-Spine CT reported as negative at OSH. Cardiac enzymes negative x3. . Cough, gagging and dry heaves every morning for the last several months, 40lb unintentional weight loss over the last few years Past Medical History: Hypertension Anxiety COPD Chronic UTI Hyponatremia s/p Hysterectomy s/p Ankle repair Social History: Lives at home alone. Has 3 children. Smoked 1.5 ppd for 15-20 years. No EtOH. No illicit drug use. Family History: Sisters with CAD, DM. No h/o CVA or intracranial pathology. No h/o malignancy. Physical Exam: On transfer to MICU: Vitals: T 96.4, BP 134/71, HR 83, RR 22, O2sat 93% RA Gen: NAD although mildly anxious HEENT: NCAT, MMM, EOMI, mucous membranes mildly dry Neck: No carotid bruit, no JVD RESP: CTAB, no wheezes, rhonchi, or rales CV: RRR, S1-S2 nl, no MRG ABD: Soft, NT, ND, BS+, no hepatosplenomegaly EXT: No edema, DP 2+ b/l, bruises on arms NEURO: AAO x 3, CN II-XII grossly intact, strength 5/5, sensory function intact, no pronator drift, finger to nose intact, [**First Name3 (LF) 5348**] b/l UE tremor, DTR symmetric, toes downgoing on Babinski, gait not assessed . Vitals: 95.2 151/90 87 22 96%RA Gen: NAD, seems slightly spacey, audibly wheexy HEENT: NC, AT, MMM, EOMI RESP: CTAB, moving air well, expiratory wheeze CV: RRR, no MRG ABD: soft, NT, ND, BS+ EXT: no edema, DP's 2+, no babinski NEURO: Cranial Nerves II-XII intact, A&Ox3, muscle strength 5/5, no pronator drift, finger to nose intact Pertinent Results: [**2151-8-12**] 09:30PM BLOOD WBC-6.0 RBC-3.77* Hgb-12.1 Hct-34.5* MCV-92 MCH-32.1* MCHC-35.0 RDW-13.5 Plt Ct-191 [**2151-8-12**] 09:30PM BLOOD Neuts-72.3* Lymphs-19.2 Monos-6.4 Eos-1.9 Baso-0.3 [**2151-8-12**] 09:30PM BLOOD PT-13.2 PTT-25.6 INR(PT)-1.1 [**2151-8-12**] 09:30PM BLOOD Glucose-115* UreaN-14 Creat-1.1 Na-123* K-3.5 Cl-86* HCO3-25 AnGap-16 [**2151-8-13**] 08:40AM BLOOD Albumin-3.7 Calcium-8.8 Phos-2.4* Mg-1.6 [**2151-8-12**] 09:30PM BLOOD CK(CPK)-222* CK-MB-7 cTropnT-0.03* [**2151-8-13**] 03:17AM BLOOD CK(CPK)-206* CK-MB-6 cTropnT-0.03* . [**2151-8-13**] 08:40AM BLOOD Osmolal-245* [**2151-8-13**] 11:07AM URINE Osmolal-302 . [**2151-8-13**] 11:07AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008 [**2151-8-13**] 11:07AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2151-8-13**] 11:07AM URINE Hours-RANDOM Creat-49 Na-58 . [**2151-8-13**] 01:54PM TSH 2.7 . ---------- COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2151-8-17**] 06:20AM 5.3 3.28* 10.7* 30.2* 92 32.5* 35.2* 13.5 185 [**2151-8-16**] 06:30AM 5.6 3.25* 10.6* 30.5* 94 32.7* 34.9 13.6 176 [**2151-8-15**] 07:45AM 5.3 3.36* 10.8* 30.8* 92 32.3* 35.2* 13.6 187 ---------- RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2151-8-17**] 06:20AM 91 17 1.0 130* 3.8 96 27 11 [**2151-8-16**] 06:30AM 95 18 0.9 130* 3.9 96 24 14 [**2151-8-15**] 07:45AM 100 16 1.0 128* 3.7 94* 25 13 ---------- Radiology Report CT TRACHEA W/O C W/3D REND Study Date of [**2151-8-16**] 3:24 PM IMPRESSION: No evidence of tracheobronchomalacia. ---------- Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [**2151-8-13**] 3:35 PM IMPRESSION: 1. No interval change to bilateral subarachnoid, intraventricular, and left parietal extra-axial hemorrhages. No significant midline shift. 2. Normal-appearing CTA without evidence of AV malformation or aneurysm. ---------- Radiology Report CT HEAD W/O CONTRAST Study Date of [**2151-8-12**] 10:26 PM IMPRESSION: 1. Bilateral frontal and left temporal subarachnoid hemorrhage. 2. Hemorrhage within the ventricles as well as within the interventricular septum. 3. Small left posterior parietal epidural hematoma. No significant shift of normally midline structures. NOTE ADDED IN ATTENDING REVIEW: The lentiform extra-axial hematoma demonstrates internal low-attenuation, which may represent acute non- clotted blood ("swirl sign") and, given the overall appearance of the brain with multi-compartmental hemorrhage, may warrant close imaging follow-up. ---------- CT C-Spine: Negative for fracture per OSH record. Brief Hospital Course: 80 yo female transferred from OSH s/p unwitnessed fall with subarachnoid and epidural hemorrhages admitted to medicine for syncope work-up and transferred to ICU for management of hyponatremia. . # Hyponatremia: Per PCP, [**Name10 (NameIs) 5348**] hyponatremia in 130s; Na in 120s on admission. Most likely etiology is worsening SIADH in setting of psychiatric medications, subarachnoid hemorrhage. Also given smoking history and unintentional weight loss neoplasm is of concern. Urine osms are inappropriately elevated consistent with SIADH. Mental status is at [**Name10 (NameIs) 5348**]. Sodium checks at discharge was consistently at [**Name10 (NameIs) 5348**] in 130s. Patient alert and oriented x 3. Fluid restriction should be continued. Patient's diazide was discontinued and should likely not be restarted. . # Subarachnoid hemorrhage/epidural hematoma: No evidence of mass effect or shift. Coags nl. Neuro exam intact with deterioration >24 hours s/p fall unlikely per Neurosurg. Repeat CT head without progression. Patient will f/u with neurosurgery on an outpatient basis. . # Altered mental status: Reportedly with subtle changes from [**Name10 (NameIs) 5348**] although mentating at [**Name10 (NameIs) 5348**] currently per family; neuro exam nonfocal other than reported instability in setting of subarrachnoid hemorrhage. [**Month (only) 116**] be also from component from hyponatremia. Being treated for UTI with no fevers or leukocytosis to suggest active infection. Resolved by discharge. . # Syncope: Hemorrhage presumably due to rather than cause of syncope/fall. Pt was orthostatic on floor. Ddx includes vasovagal, seizure. Cardiac enzymes negative. No arrhythmia on EKG other than PACs. Bedside TTE in [**Hospital1 2436**] and our ED reportedly unremarakable. Formal TTE here without etiology of syncope. . # Hypertension: BP elevated after stopping dyazide, started metoprolol and this should be uptitrated as an outpatient. She has a pcp appt scheduled next week. . # Anxiety: Continue home ativan with additional doses prn . # UTI: On methanamine for suppressive therapy but started on cipro for UTI. Will continue cipro on discharge. . # Stridor: Chronic per report and related with anxiety and COPD. ENT was c/s for evaluation and they felt that there was no surgical issue or paradoxical vocal cord dysfunction or paralysis. CT neck was also negative for pathology. Medications on Admission: Ativan 0.5mg tid Dyazide 37.5/25 qd Thioridazine 25 tid Cipro 250 qid Citalopram 40mg daily ASA 81mg daily Proair 2 puffs [**Hospital1 **] Advair 500/50 1 puff [**Hospital1 **] Methenamine Hipp 1g [**Hospital1 **] Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Thioridazine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Outpatient Lab Work Please draw Na (Sodium) Friday [**8-20**] after discharge and send results to Dr. [**Last Name (STitle) 13613**],[**First Name3 (LF) **] J Address: [**Location (un) 82799**], [**Location (un) **],[**Numeric Identifier 82800**] Phone: [**Telephone/Fax (1) 77864**] Fax: [**Telephone/Fax (1) 77865**] 8. Methenamine Hippurate 1 gram Tablet Sig: One (1) Tablet PO twice a day. 9. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) Puff Inhalation twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Bilateral frontal and left temporal subarachnoid hemorrhages Bilateral intraventricular hemmorhage Small left epidural hematoma Hyponatremia Secondary diagnoses: Hypertension Anxiety Chronic obstructive pulmonary disease Chronic urinary tract infections Discharge Condition: Afebrile, vital signs stable and within normal limits, ambulating, tolerating oral PO, no changes in mental status, alert and oriented. Discharge Instructions: You were admitted after an unwitnessed fall in your bathroom the night of [**7-20**]. You apparently struck your head in this fall, causing some bleeding in your head. While you were at the hospital, your the level of sodium in your blood was also noted to be low. You were treated in the ICU. You were also seen by ENT for a wheeze when you get anxious. We took a CT scan of your neck, which did not show any obstructions. Changes to your medications: Dyazide (diuretic): discontinued Ciprofloxacin (antibiotic): Completed Methenamine (urinary tract infection prophylaxis): discontinued Thioridazine (antipsychotic): dose reduced to 2 pills (25 mg each) daily Hydrochlorothiazide: held at this time Metoprolol: increased to 25mg twice a day It is important that you continue to restrict your liquid intake. It is best to drink soups or juices instead of regular water until you see your primary care doctor. If you should feel dizziness, a sense of losing consciousness, chest pain, trouble breathing or any other medically concerning symptoms, please call your doctor or 911 or go to the emergency room. Followup Instructions: The following appointments have been scheduled for: Patient: [**Known lastname 1924**], [**Known firstname 2127**] [**Numeric Identifier 82801**] MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: PCP Date and time: [**2151-8-20**] 10:15am Location: [**Location (un) **], [**Location (un) 8242**] Phone number: [**Telephone/Fax (1) 77864**] Special instructions if applicable: Please arrive 10 minutes prior to appointment time. 1) You will need to obtain a sodium (Na) level at this visit. You will need to follow-up with your doctor about this sodium level. 2) You will need a CT scan in one year of your chest because there were findings of "pulmonary nodules" and the radiologist had recommended one year as a time frame to recheck a CT scan. Please let your doctor know. 3) You will need outpatient PFTs at some time after your visit with your primary care doctor. 4) He will need to check your BP at the time of your appointment. MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Specialty: Neurosurgery Date and time: [**2151-9-16**] 2:45pm Location: [**Hospital Unit Name 31391**] Phone number: [**Telephone/Fax (1) 3231**] Special instructions if applicable: You need to obtain a non-contrast head CT prior to seeing Dr. [**First Name (STitle) **]. An appointment has been made for you at 2:00pm on [**9-16**] (right before your appointment with Dr. [**First Name (STitle) **] at the radiology facility at [**Hospital1 82802**] ([**Hospital Ward Name 517**]) on the [**Location (un) 10043**]. Completed by:[**2151-8-26**]

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icd9cm

[ [ [] ] ]

[ "31.42" ]

icd9pcs

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Discharge summary

report+addendum

Admission Date: [**2142-5-11**] Discharge Date: [**2142-6-1**] Date of Birth: [**2095-6-24**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: Fulminant liver failure Major Surgical or Invasive Procedure: [**2142-5-15**] orthotopic liver transplant History of Present Illness: 46 y.o. W with hx of acute hepatitis in [**2134**], which was attributed at that time to ditropan vs unclear etiology, and multiple schlerosis, presents from an urgent care visit with her PCP where she presented with lower extremity edema, nausea, decreased PO intake for the past 2-3 days, and jaundice. . In [**2134**], patient had a complete work-up for hepatic failure including: hepatitis A, B, C serologies, leptospira, ceruloplasmin, copper, herpes type I and type II antibodies, HIV, ascites fluid for culture, blood cultures, and ophtho consult for Kayser-Fleischer rings, which were all negative. A CT of the liver as part of a liver transplant work-up showed a shrunken cirrhotic liver with regenerating nodules with hyperintense lesions susicious for hepatomas. There was evidence of ascites and portal hypertension as indicated by dilated portal vein and recanalization of the periumbilical vein. A transjugular liver biopsy showed (1) Confluent a bridging necrosis, submassive necrosis with collapse in bile ductular proliferation. (2) Lobular chronic inflammation with necrosis and hepatocellular cholelithiasis. (3) No fatty changes or viral cytopathic changes seen. (4) Focal increase in stainable iron seen. (5) Trichrome reticulin in ursine stains performed. The patient was put on the liver transplant list and followed by hepatology, but her hepatic failure slowly resolved over the course of about four months. . The patient says she has been in her usual state of health. She is on disability for her MS but otherwise has no other significant medical problems. She estimates drinking less than 1 alcoholic beverage per month, and denies any changes in her routine. No recent changes in medications, travel, sick contacts except for her six-year-old son who has a cough. . In the ED, Hepatology and Transplant Surgery were both consulted. A RUQ US was performed which showed possible cirrhosis, no ascites, and a CTA was ordered and is still pending. Head CT was negative. Hepatitis serologies and many other labs as detailed below in the A & P were sent. Serum tox screen was negative. Patient was admitted to MICU for close monitoring. Of note, when patient was admitted to the unit she was discovered to have an old tampon in place which had been there for at least several days. Past Medical History: 1. Multiple sclerosis diagnosed in [**2133**]. The patient complains of numbness and weakness in bilateral lower extremities. 2. Episode of fulminant liver failure in [**2134**] with negative work-up as above. 3. Status post C-section. Social History: Tobacco - quit [**9-/2136**] EtOH less than 1 glass of wine per month Drugs: remote hx of marijuana use No IVDU Married, has two children ages 7 and 9. On disability. Family History: No contact with father since young age. Mother died at 62, exact cause unknown. Physical Exam: VS: T: P: 120 BP: 134/75 RR: 18 O2 sat: 98% GEN: NAD, jaundiced HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, + icterus, OP clear, MM dry, neck supple, no carotid bruits CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: firm, NT, ND, + BS, EXT: warm, dry, +2 distal pulses BL, + 3 pitting edema in feet to ankles BL NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. + mild asterixis PSYCH: appropriate affect Brief Hospital Course: She was admitted to the MICU with acute liver failure and moderate encephalopathy with MELD score of 32 on admission. Patient now with but laboratories stable. Unclear etiology. Patient recently given solumedrol, which has been shown in case reports to be associated with acute liver failure. CTA showed cirrhosis, patent vasculature. Lactulose was given for encephalopathy and w/u for liver failure was done. She was intubated for respiratory failure from fluid overload and from inability to manage secretions from encephalopathy. On [**2142-5-15**] a liver donor was available and she underwent piggyback liver transplant. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Induction immunosuppression was given (solumedrol and cellcept). Per operative note, The GDA was taken. The common hepatic artery was dissected down to an appropriate spot where it could be clamped. A graybulldog was placed on the artery. The donor artery was cut to the appropriate length using a branch patch from the GDA and a running 6-0 Prolene anastomosis was accomplished. Please see operative report for further details. She tolerated the surgery without complications and was transferred immediately afterward to the SICU intubated. On POD 3 she was febrile to 101.5 and Pan-cultured. Her NGT was removed on POD 3 and she was extubated. She tolerated the extubation well, and was placed on cool Neb's only. On POD 5 and Insulin drip was started for Blood Sugars of 390. She was also started on clears and advanced to a regular diet. She was transferred to the floor and her foley was removed on POD 6 and neurology was consulted regarding management of her MS while she was in house. She was A+Ox2 and had persistent RUE weakness. Her mental status improved and she was A+Ox 3 on discharge. She continues to have RUE weakness, but she states this is her baseline during a "[**Last Name (NamePattern1) **]". Neurology recommended an MRI head +/- spine with contrast (which was done on [**5-27**]), Continue with PT/OT, and to continue steroids the immunosuppression should help her new MS [**Last Name (Titles) **]. Her husband to brought in the OSH MRI for comparison to the MRI on [**5-27**] and the MS lesions were stable. She will follow up with her Neurologist Dr [**Last Name (STitle) 32186**] in [**Location (un) **], MA. On POD 8 her Lasix was stopped. Another post-operative issue was hoarseness. She was evaluated by speech and swallow and aspiration was ruled out. After a video swallow she was placed on a diet of thin liquids and regular solids, and Tube Feeds were started to ensure adequate nutrition. She was encouraged to take in PO's. ENT was also consulted to assess [**Location (un) **] cords. She was scheduled for a video Stroboscopy on [**5-29**] which demonstrated Right [**Month/Year (2) **] [**Month/Year (2) **] paralysis. She will follow up with Dr [**First Name (STitle) **] as an outpatients regarding treatment of her [**First Name (STitle) **] cords. On POD 11 her JP drain was removed. Physical Therapy continued to work with her and she was placed in Rehab facility per physical therapy recommensations. She is being discharged afebrile, vital signs stable, tolerating her tube feeds, A+Ox3 and at her baseline physical ability. She will follow up with Dr [**Last Name (STitle) 816**], Dr [**First Name (STitle) **] from ENT, and her neurologist Dr [**Last Name (STitle) 32186**]. Medications on Admission: Baclofen Promethazine Naproxen Copaxone Tizanadine Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Cirrhosis etiology unknown MS [**First Name (Titles) **] [**Last Name (Titles) **] paralysis Discharge Condition: good Discharge Instructions: please call the Transplant Office [**Telephone/Fax (1) 673**] if you have fever, chills, nausea, vomiting, inability to take any of your medications, increased abdominal pain, incision redness/bleeding/drainage, jaundice or dark urine Labs every Monday and Thursday with results fax'd to [**Telephone/Fax (1) 697**] Name: [**Known lastname **],[**Known firstname 5592**] Unit No: [**Numeric Identifier 5593**] Admission Date: [**2142-5-11**] Discharge Date: [**2142-6-1**] Date of Birth: [**2095-6-24**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2648**] Addendum: prograf adjusted to 3.5mg [**Hospital1 **] starting pm [**5-22**] for trough level 6.4 Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**] Completed by:[**2142-6-1**]

[ "574.00", "571.49", "518.81", "514", "789.59", "241.0", "427.89", "E932.0", "571.5", "276.3", "287.5", "478.31", "276.0", "572.2", "570", "574.10", "V15.82", "251.8", "345.90", "286.9", "340", "285.9" ]

icd9cm

[ [ [] ] ]

[ "00.93", "96.6", "51.22", "54.91", "38.93", "96.72", "50.59", "96.04" ]

icd9pcs

[ [ [] ] ]

8537, 8774

3830, 7373

337, 383

7691, 7698

3178, 3259

7575, 7670

7399, 7452

7722, 8514

3274, 3807

274, 299

411, 2718

2740, 2977

2993, 3162

6,833

199,652

30543

Discharge summary

report

Admission Date: [**2179-5-25**] Discharge Date: [**2179-6-30**] Date of Birth: [**2127-7-26**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 695**] Chief Complaint: foul JP drainage Major Surgical or Invasive Procedure: [**2179-5-28**]: Right thoracotomy, total pulmonary decortication, diaphragmatic defect repair, pleural flap buttress, intercostal muscle flap buttress and flexible bronchoscopy. [**2179-6-28**]: PICC line insertion History of Present Illness: Ms. [**Known lastname **] is a 51 year old female diagnosed with multifocal hepatocellular carcinoma by wedge biopsy in [**2179-2-26**]. She underwent right portal vein embolization on [**2179-3-30**], followed by right hepatic trisegmentectomy, lysis of adhesions, appendectomy, and repair of cecal enterotomy on [**2179-5-7**]. It was complicated by bile leak. On [**2179-5-12**], she underwent ERCP with stent placement for stenosis of the proximal left intrahepatic duct. She presented to clinic on [**5-25**] with foul drainage from [**First Name9 (NamePattern2) 5283**] [**Doctor Last Name 406**] drain. CT chest/abd demonstrated a complicated hydropneumothorax with layering debris and moderate exudate adjacent to a 2.5 cm rent in the right hemidiaphram with collapse of the right middle lobe and pleuritis. She was admitted directly to the SICU. Past Medical History: cervical ca in [**2151**] s/p partial vaginal hysterectomy, ovaries still in place osteopenia benign breast tumor s/p resection Hypothyroidism Depression multifocal hepatocellular carcinoma s/p liver resection & appendectomy, s/p right portal vein embolization Social History: Married. Has high school education. Works as housecleaner. She has three adult children. Family History: Maternal grandfather died of stomach CA [**Name (NI) 6961**] alive with HTN Pertinent Results: ADMISSION LABS --> [**2179-5-25**] 07:18PM BLOOD WBC-66.0*# RBC-3.74* Hgb-11.0* Hct-31.8* MCV-85 MCH-29.3 MCHC-34.5 RDW-17.8* Plt Ct-387 [**2179-5-25**] 07:18PM BLOOD PT-15.9* PTT-32.0 INR(PT)-1.4* [**2179-5-25**] 07:18PM BLOOD Glucose-58* UreaN-20 Creat-0.6 Na-115* K-4.4 Cl-78* HCO3-21* AnGap-20 [**2179-5-25**] 07:18PM BLOOD ALT-26 AST-39 AlkPhos-198* TotBili-1.6* [**2179-5-25**] 07:18PM BLOOD Albumin-2.2* Calcium-7.8* Phos-4.4 Mg-2.0 Iron-15* [**2179-5-25**] 07:18PM BLOOD calTIBC-176* Ferritn-576* TRF-135* [**2179-5-26**] 12:44PM BLOOD Osmolal-250* [**2179-5-25**] 07:18PM BLOOD TSH-10* . [**5-25**] CT Abd/Pelvis: IMPRESSION: 1. Complicated hydropneumothorax with layering debris and moderate exudate adjacent to a 2.5- cm rent in the right hemidiaphragm. Collapse of the right middle lobe. Underlying pleural enhancement indicates component of pleuritis. Slight left sided mediastinal shift. 2. Two hepatic drains visualized surrounding right lobectomy site. These exit in the right lower quadrant. Air and fluid seen in the right lobectomy bed without definable collection. 3. Biliary drain in the right lobectomy bed, terminating adjacent to the right hemidiaphragm, not within the liver. The inferior course of the drain terminates within the duodenum at the ampulla. This may be within the course of the transected right hepatic ductal system, correlate with operative placement. 4. Three enhancing lesions within the remaining liver, subcentimeter in size, compatible with metastatic lesions. . [**5-26**] ERCP: FINDINGS: Six images were provided by Dr. [**Last Name (STitle) **]. These demonstrate a plastic biliary stent which per report was removed. No contrast-enhanced images are provided. Multiple drains are noted to project over the right upper quadrant. For further details, please consult the ERCP report in CareWeb. . [**5-26**] CXR: FINDINGS: Compared with [**2179-5-7**], there are now two chest tubes present at the right base. There is a medium-sized pneumothorax, mostly located at the right subpulmonic level, with a small component at the right apex. No obvious pleural fluid is seen. A new (presumed drainage) catheter is seen overlying the right upper quadrant. . [**5-29**] Gastrogaf Study: IMPRESSION: 1. The JP tube located at the hepatic resection bed is draining the right pleural cavity. The contrast injected through this drainage catheter is being suctioned by the chest tube. 2. Gastrografin enema was performed up to the level of the mid transverse colon. No fistula or leakage was identified in the opacified bowel loops. The cecum and ileocecal valve were not visualized, an underlying abnormality at the level of the cecum and right colon cannot be excluded. . [**5-29**] CXR: Small right pneumothorax is unchanged. The right pleural drains still in place. Congestion in the right lung is improving. Left lung is clear. Heart size is normal. Mediastinum midline. ET tube, nasogastric tube, and right subclavian line are in standard placements respectively. . [**5-30**] CXR: Single portable radiograph of the chest again demonstrates three right-sided chest tubes. There is a small apical right-sided pneumothorax, unchanged. Trachea is midline. There is a small right-sided pleural effusion. No left-sided pleural effusion. Left lung is clear. Cardiomediastinal contour is normal. Right subclavian central venous catheter is unchanged. . [**5-31**] CXR: Small right apical pneumothorax and tiny right pleural effusion unchanged over 48 hours, two right basal and two right upper chest tubes in place. Congestion in the right lower lung persists. Left lung clear. Heart size normal. Mediastinum midline. . [**6-2**] CXR: IMPRESSION: No short interval change with persistent small right PTX. . [**6-3**] ERCP: The scout images show two surgical tubes in the right upper quadrant. Cannulation and opacification of the biliary tree is noted. There is extravasation of the contrast noted at the upper end of the common hepatic duct. No opacification of the intrahepatic ducts was seen. . [**6-4**] CT Abd/Pelvis: IMPRESSIONS: 1. Minimal residual right pneumothorax and small amount of residual pleural fluid/pleural reaction. 2. No drainable fluid collection. 3. Anasarca. . Brief Hospital Course: This patient was admitted on [**5-25**] after she was seen at the clinic with foul-smelling [**Doctor Last Name 406**] drainage. She was immediately admitted to the SICU. On CXR, she was found to have a large PTX on the right and a large fluid collection with a white count of 66,000. She was started on abx (vanco, meropenem, fluc) and was also noted to have a sodium of 115. The patient was noted to be lethargic but arousable. She was given albumin for rehydration. Thoracic surgery was consulted for her lung issues. Chest tubes were then inserted. Daily chest xrays were performed (see above for reports). A CT was also obtained which showed a "large right PTX causing RUL/RML collapse, and compression of RLL. Fluid level in right pleural space communicates w/ peritoneum via defect in R hemidphragm, which is transited by surgical drain. Feculent material within fluid, consistent with empyema. No shift of MS structures". . On [**5-26**], an ERCP was done which showed: "Plastic stent was found in the major papilla. Evidence of a previous sphincterotomy. Stent was found in the bile duct. The plastic stent was removed". A JP study was done on [**5-28**] which showed communication with the chest; a gastrografin enemawas then obtained which showed transit to the mid transverse colon and with no leak. She was started on meropenem and vancomycin for VRE in her pleural fluid on [**5-26**]. ID recommended changing Fluc to Caspo for growth of [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] in her cultures on [**6-1**]. . On [**5-28**], she was also taken to the OR for a Right empyema and diaphragmatic injury with thoracic surgery; the procedure performed was Right thoracotomy, total pulmonary decortication, diaphragmatic defect repair, pleural flap buttress, intercostal muscle flap buttress and flexible bronchoscopy. . On [**5-31**], the patient's chest tube (posterior apical) was noted to have bilious drainage, confirmed by sending the fluid for a TBili. Methadone was started for pain control on [**5-31**]. She was started on TPN on [**6-1**] and was encouraged to increase her PO intake. She was hence scheduled for an ERCP on [**6-3**], which confirmed a biliary leak likely due to stent migration. GI was unable to put another stent in place. . On [**6-4**], she had a CT chest/abdomen performed which showed improvement of her fluid collections and no new focal collections amenable to drainage. She had a PTC on [**6-7**]; on the same day, her chest tubes were placed to water seal per the thoracics service. One chest tube was later d/c'd by thoracics. She also had an unsuccessful PTC on [**6-7**]. She received lasix daily, with a goal of 1 litre negative per 24 hours. Per family report, she began experiencing a low mood and was seen by psychiatry, who reccomended an increase in dosage of her Celexa. Repeat chest and abdominal films on [**6-9**] showed progression of contrast to her distal colon and sigmoid and no new cardipulmonary processes. TPN continued and its volume was decreased to half on [**6-10**]. She went for a repeat ERCP on [**6-11**], during which they were unable to place a stent. On [**6-13**], her apical CT was removed by thoracics and she spiked a temp to 101.2 later in the evening. Cultures were sent, and a CT was done the following day which showed an undrained fluid collection. Her JP drain was manipulated beside, with drainge of approx 100cc and she taken back to radiology for drainage of another 60cc. She remained afebrile overnight. On [**6-16**], she went for a repeat CT-guided drainage which showed adequate drainage of this collection. . Pt's chest tube was noted to have decreased drainage on [**6-18**]; hence, a CXR was done which showed a small amount of fluid within the right lateral basal pleural space, unchanged from prior films. She remained stable with improved nutritional intake. TPN was d/c'd as Kcals were ~1500-1700. The CT drained ~10cc per day. The Thoracic team converted this to an empyema tube on [**6-21**]. She tolerated this without problems. They recommended continuing antibiotics to finish a 6 week course. The plan was to back out the tube q week per Dr. [**Last Name (STitle) **]. This was done again on [**6-24**]. ID recommended using Ertapenem instead of meropenum, voriconazole instead of caspo and discontinuation of daptomycin. Linezolid was recommended if an oral [**Doctor Last Name 360**] for VRE was needed. Meropenem was switched to Ertapenem, capsofungin was switched to voriconazole, and dapto was stopped on [**6-23**]. She had a Tmax of 100.2 on [**6-24**], 102.3 on [**6-25**], and 100.7 on [**6-26**]. On [**6-25**], WBC increased to 15 and LFTs began to rise (AST went from 38 to 139, ALT from 57 to 142, and alk phos from 343 to 587). On [**6-25**], a torso CT demonstrated decreased subhepatic fluid collection with appropriate position of pigtail drain and nearly resolved right medial pneumothorax and foci of loculated air along prior chest tube tract. Stool was sent for C.diff, which was negative. Her PICC line was d/c'd and sent for culture, which was also negative. A urine culture grew only yeast. Blood cultures were still pending on discharge. On [**6-25**], meropenem and daptomycin were restarted; ertapenem was stopped. Voriconazole was continued until [**2179-6-28**], when it was stopped due to concerns about its effects on liver function; her LFTs were still elevated at that time. Following the switch, they began to decrease (AST 88, ALT 124, alk phos 348). Daptomycin was d/c'd on [**6-29**]. She continued meropenem until discharge, and was instructed to start ertapenem at home. At the time of discharge, her WBC was 9.4 and she was afebrile. Medications on Admission: Levoxyl 75', Celexa 10', Wellbutrin 300', Calcium, Magnesium Discharge Medications: 1. Ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous once a day. Disp:*30 units* Refills:*1* 2. PICC line care Please provide PICC line care per agency protocol -Heparin syringes (100 units/ml): # 30, refills 2 -PICC line dressings # 15 refills 2 -Normal Saline syringes # 30 refills 2 3. Outpatient Lab Work Weekly Labs: CBC, Chem 7, Liver Function tests Please fax results to : [**Telephone/Fax (1) 1419**] ([**Hospital **] clinic) AND [**Telephone/Fax (1) 697**] (DR[**Doctor Last Name 1369**] office, attn [**Doctor First Name **]) 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*5 Tablet(s)* Refills:*1* 10. Methadone 5 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day): for pain. Disp:*60 Tablet(s)* Refills:*0* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 12. Caspofungin 50 mg Recon Soln Sig: One (1) Intravenous once a day. Disp:*30 units* Refills:*2* 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Right empyema and diaphragmatic injury. Discharge Condition: Fair Discharge Instructions: Please call Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, shortness of breath, increased leg swelling, increasing abdominal pain, increased drainage via drain or chest (empyema) tube. Picc line care (VNA to assist) Empty drain when half full. Record outputs. Bring record of outputs to next appointment with Dr. [**Last Name (STitle) **]. Dry gauze secured with elastic at end of chest (empyema) tube once a day and as needed. Record number of dressings required. No showering as long as you have the chest tube. Followup Instructions: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2179-7-7**] 10:00 [**Hospital **] Medical building [**Hospital Unit Name **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2179-7-7**] 3:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2179-6-30**]

[ "997.4", "510.9", "276.1", "998.2", "998.11", "V10.07", "511.8", "V10.41" ]

icd9cm

[ [ [] ] ]

[ "99.15", "97.55", "38.93", "83.82", "51.10", "34.04", "34.84", "34.51", "34.93" ]

icd9pcs

[ [ [] ] ]

13560, 13643

6142, 11876

287, 505

13727, 13734

1898, 6119

14343, 14837

1802, 1879

11987, 13537

13664, 13706

11902, 11964

13758, 14320

231, 249

533, 1395

1417, 1679

1695, 1786

10,030

124,443

47918

Discharge summary

report

Admission Date: [**2137-8-21**] Discharge Date: [**2137-8-24**] Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 77-year-old man with a history of coronary artery bypass graft times two, aortic valve replacement, paroxysmal atrial fibrillation, and recurrent ventricular tachycardia, who was transferred to the [**Hospital6 256**] for an electrophysiology study and a possible ablation of ventricular tachycardia from an outside hospital after recurrent episodes of ventricular tachycardia setting off his ICD four times in the past three days. The patient has a history of paroxysmal atrial fibrillation since the [**2105**] and has had episodes of ventricular tachycardia for the past few years. He was recently admitted to [**Hospital6 256**] in [**Month (only) 205**] with fatigue and bradycardia with a heart rate in the 40s and [**1-31**] AV block. During that admission, he went into monomorphic ventricular tachycardia treated with intravenous lidocaine. He then went back into ventricular tachycardia and had a five second pause and a dual chamber ICD pacemaker was placed. At that time, he was able to end his episodes of ventricular tachycardia with overdrug pacing. He was sent home on sotalol and mexiletine. At a clinic visit two weeks later, his ICD was interrogated and he was found to have had multiple episodes of ventricular tachycardia. He was sent to the Electrophysiology Laboratory for ventricular tachycardia ablation. They found two foci and ablated one. The second one was not ablated because it was to close to his replacement valve. The ablation procedure was [**2137-8-14**]. After discharge, he was fine until Saturday when he felt his heart beating rapidly and he felt lightheaded. He presented to the [**Location (un) 13011**] Emergency Department but was sent home because there were no beds. He felt his ICD shock him twice on [**Last Name (LF) 766**], [**8-19**], and twice again yesterday [**8-20**]. He presented to [**Hospital **] Hospital at 5 p.m. [**8-20**] with a rapid heart rate and chest tightness and was found to be in ventricular tachycardia. His ventricular tachycardia was occasionally able to be stopped by overdrug pacing, but was not consistently stopped. He was started on a lidocaine drip and transferred to [**Hospital6 256**] for further electrophysiological evaluation. On admission, he denied chest pain, chest tightness, palpitations, shortness of breath, lightheadedness, headache, fever, chills, nausea and vomiting. He also denied hematemesis, hematochezia but says he has dark stools because he takes iron at home. He denied urinary difficulties, indigestion, weight loss. Has a history of claudication in his legs but denies rest pain. He also denies orthopnea. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Former smoker. 4. Paroxysmal atrial fibrillation. 5. Recurrent ventricular tachycardia. 6. Congestive heart failure. 7. Coronary artery bypass graft [**2131**]. 8. Coronary artery bypass graft and aortic valve replacement in [**2125**]. 9. Severe peripheral vascular disease. 10. Right renal percutaneous transluminal coronary angioplasty eight months ago. 11. He has a dual chamber ICD. 12. Right carotic endarterectomy in [**2127**]. 13. Abdominal aortic aneurysm repair in [**2126**]. 14. Left below the knee amputation in [**2131**]. 15. Chronic renal insufficiency with a baseline creatinine between 1.6 and 2.3. 16. Anemia. 17. Cataracts. MEDICATIONS ON ADMISSION: Sotalol 160 b.i.d., diltiazem 180 q.d., Mexiletine 150 b.i.d., Coumadin 3 mg q.h.s., Zocor 40 mg q.d., Imdur 90 mg q.d., niferex 150 mg b.i.d., Vasotec 5 mg b.i.d., aspirin 81 mg q.d., Lovenox 80 mg b.i.d. and amiodarone 400 mg q.d. ALLERGIES: Morphine causes mental status change, Procan causes ventricular tachycardia and shellfish. SOCIAL HISTORY: Mr. [**Known lastname **] is retired. He is married. He lives in [**State 108**]. He worked for the Fire Department. He quit smoking tobacco 30 years ago. He also quit using alcohol years ago. He is visiting his son in [**Name (NI) 13011**], [**State 350**]. FAMILY HISTORY: His brother died of an myocardial infarction at age 55. PHYSICAL EXAM ON ADMISSION: Pulse 68. Respiratory rate 17. Afebrile. Blood pressure 106/40. 02 saturation 97% on two liters. Generally, he was awake and alert, [**Location (un) 1131**] the newspaper. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light. Extraocular movements full. Oropharynx clear. Moist mucous membranes. Neck: He has a scar on the right neck from CEA, no jugular venous distention, supple. Lungs were clear to auscultation bilaterally. Heart was regular rate and rhythm, S1, S2 with a loud mechanical valve murmur. Abdomen was soft, nontender, nondistended, positive bowel sounds. Extremities: He had a left below the knee amputation well-healed. Right lower extremity warm, 2+ distal pulses, no edema. LABORATORIES ON ADMISSION: White blood cell count 4.9, hematocrit 25.4, platelets 166,000. Sodium 133, potassium 4.1, chloride 99, bicarbonate 21, BUN 22, creatinine 1.5, glucose 92, magnesium 1.9, LDH 251, CK 33, PT 22.7, INR 3.5, PTT 150. Other laboratory studies during the course of admission including iron studies with TIBC of 304, ferritin 121, reticulocyte count of 4, haptoglobin of less than 20. Electrocardiogram on admission showed atrial sensing, ventricular pacing at 70 beats per minute. ASSESSMENT AND PLAN: The patient is a 77-year-old with a history of coronary artery bypass graft times two, AVR, atrial fibrillation and recurrent ventricular tachycardia status post ICD pacer placement admitted now after a recent ventricular tachycardia ablation last week for further electrophysiology evaluation. 1. Cardiovascular: Rhythm. Patient has recurrent ventricular tachycardia. We discontinued lidocaine and started mexiletine at 130 mg t.i.d. Electrophysiology evaluated his ICD and changed various settings which will hopefully make the patient less likely to be shocked and hopefully will be able to terminate his episodes of recurrent ventricular tachycardia without being defibrillated. Throughout admission, the patient had intermittent episodes of ventricular tachycardia which were terminated without being defibrillated. The patient was started on mexiletine 150 mg t.i.d. His amiodarone was continued at 400 mg q.d. and it was decided that recurrent ventricular tachycardia ablation would be not undertaken at this time. 2. Pump: The patient had an echocardiogram during the course of admission which showed the left atrium mildly dilated, left atrium also elongated, the right atrium moderately dilated. There was moderate symmetric left ventricular function. The left ventricular cavity is mildly dilated, overall left ventricular systolic function is severely depression. Resting regional wall motion abnormalities include akinesis of the inferior septum and inferior walls at the base and mid ventricular levels. Lateral wall and apex demonstrated moderate hypokinesis. There is mild global right ventricular free wall hypokinesis. A bibasilar aortic valve prosthesis is present. Trace aortic regurgitation is seen. Moderate to severe 3+ mitral regurgitation. The patient was continued on enalapril and Lopressor for his cardiomyopathy. 3. Valve disease: The patient is status post aortic valve replacement. His Coumadin was held during his admission for possible electrophysiology study. He was started on a heparin drip. The patient was then restarted on his Coumadin at 3 mg q.p.m. with an INR goal of 2.5 to 3.5 and discharged on Lovenox. His PT and INR will be checked as an outpatient two days after discharge. 4. Coronary artery disease: The patient has a history of coronary artery bypass graft times two. He is on Zocor and aspirin. He is also on Imdur for angina. None of these medications were changed. 5. Pulmonary: The patient was saturating well on two liters of nasal cannula, then saturating well on room air. The patient has no home 02. Because the patient was started on amiodarone some time in the last month without any prior pulmonary function tests, the patient was sent for pulmonary function tests during this admission. 6. Renal: The patient is status post a right renal percutaneous transluminal coronary angioplasty. His baseline creatinine is 1.6 to 2.3. Creatinine remained stable around 1.5 throughout the hospital course. 7. Gastrointestinal: The patient had no issues. He was started on Zantac. 8. Infectious Disease: The patient remained afebrile throughout his hospital course with a stable white count. 9. Hematology: The patient has a history of chronic anemia. He is on iron at home. His anemia is most likely due to iron deficiency, possibly some slight hemolysis due his aortic valve replacement, as well as possibly renal disease. 10. Fluid, electrolytes and nutrition: The patient remained euvolemic. His electrolytes were followed and repleted as needed. Patient ate well during the hospital course. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home. DISCHARGE MEDICATIONS 1. Zocor 40 mg q.d. 2. Imdur 90 mg q.d. 3. Enalapril 5 mg b.i.d. 4. Aspirin 81 mg q.d. 5. Amiodarone 400 mg q.d. 6. Lopressor 75 mg b.i.d. 7. Mexiletine 150 mg t.i.d. 8. Coumadin 3 mg q.h.s. 9. Lovenox 80 mg subcutaneous b.i.d. [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**] Dictated By:[**Last Name (NamePattern1) 1203**] MEDQUIST36 D: [**2137-8-29**] 14:49 T: [**2137-8-29**] 14:49 JOB#: [**Job Number **]

[ "V45.81", "272.0", "427.31", "401.9", "366.9", "285.9", "427.1", "414.01", "V43.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9140, 9689

4166, 4237

3528, 3866

111, 2779

5015, 9118

2801, 3501

3883, 4149

17,997

182,756

1196

Discharge summary

report

Admission Date: [**2124-7-8**] Discharge Date: [**2124-7-13**] Date of Birth: [**2080-11-28**] Sex: F Service: [**Doctor Last Name 1181**] DISCHARGE MEDICATIONS: NPH insulin 17 units q.a.m., 6 uinits q.p.m. and a Humalog sliding scale. Humalog sliding scale was adjusted as determined also by the patient's husband [**Name (NI) **]. Also she was being given Epoetin alpha 4000 units subQ q Monday and Thursday, sodium bicarbonate 1200 mg po b.i.d., Amlodipine Besilate 10 mg po q day, calcium carbonate 1000 mg po t.i.d., Furosemide 80 mg po b.i.d., Phos-Lo 667 mg two tabs po t.i.d. before meals, Calcitrel .5 micrograms po q day, Labetalol 400 mg po b.i.d., aspirin 81 mg po q day. FOLLOW UP: The patient is going to be following up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1313**] on Monday [**7-17**]. CODE STATUS: She is full code. HISTORY OF PRESENT ILLNESS: The patient is a 43 year-old woman with type 1 diabetes, chronic renal insufficiency awaiting a renal transplant who had a recent Emergency Department visit for hypoglycemia and was found unresponsive at home. She was last seen around 3:00 p.m. by her husband and she was found by her friend at 8:30 p.m. EMS found that her finger stick glucose was 46. She was given Glucagon IM without improvement in her mental status. She was then given 1 amp of D50 with subsequent glucose in the 90s in the Emergency Department. She was intubated for airway protection. CT of the head was negative for acute process and by the time she was taken into the Intensive Care Unit she had mild return of function on the ventilator, mentally and her hemodynamics were stable. PAST MEDICAL HISTORY: Type 1 diabetes since the age of 7. She has had significant neuropathy with blindness, renal disease and neuropathy. She has chronic renal insufficiency approaching end stage renal disease with a creatinine of 5.5 to 6.0 and she has coronary artery disease status post a catheterization in [**2124-6-7**], which showed a right dominant system with an left anterior descending coronary artery of a proximal left anterior descending coronary artery obstruction, 40% mid left anterior descending coronary artery, 60% diagonal, 80% stenosis. Left circumflex showed mid 40% stenosis, right coronary artery proximal 40%, distal 30% stenosis and the right posterior descending coronary artery was 30%. She also has severe hypertension a history of transient ischemic attack. ALLERGIES: Penicillin, cefazolin cause rash. MEDICATIONS FROM HOME: Labetalol 400 mg po b.i.d., Lasix 20 mg po b.i.d., Calcitrel .5 micrograms q day, Enalapril 40 mg po b.i.d., Valsartan 80 mg po q day, fludrocortisone .05 mg q.o.d. and Procrit 3000 units subQ q Mondays and Thursday. MEDICATIONS ON TRANSFER FROM THE MICU TO THE INTERNAL MEDICINE TEAM ON THE FLOOR: Famotidine 10 mg po q day, aspirin 81 mg po q day, Procrit [**2122**] units subQ q Mondays and Thursdays, Labetalol 400 mg po b.i.d., Lasix 40 mg po b.i.d., Flagyl 500 mg intravenous q 8 hours and Calcitrel .5 micrograms po q day. MICU COURSE: The patient was followed by the Renal and Endocrine Services. Her mental status improved and she was extubated 24 hours after admission. Her temperature spiked to 101.2 and the patient was given empiric treatment with Flagyl and Vancomycin and she was eventually given Levofloxacin. The cultures remained negative. Chest x-ray showed that she had decreased congestive heart failure, hazy opacity in the mid and lower zones and there was a possibility of being an infiltrate. One complication in her MICU stay was that she did not seem to get her NPH dose in the morning of [**7-10**] and the patient went into diabetic ketoacidosis. She was then put on an insulin drip and her pH and mental status improved and during that time her renal function declined in terms of her BUN and creatinine levels going up and the patient suffered a myocardial infarction by enzymes. She was evaluated by echocardiography after the detection of the increase in enzymes and echocardiogram showed a large left atrium, right atrium was elongated and there was mild symmetric left ventricular hypertrophy. The left ventricular cavity size was normal and the overall left ventricular function was found to be greater then 55%. The RV chamber size and free wall motion were normal and the valve movements structurally normal with good leaflet and no aortic regurgitation. Mitral valves were structurally normal with trivial mitral regurgitation. Mild pulmonary artery systolic hypertension. There was a small pericardial effusion. In spite of the fact that the patient had myocardial infarction by virtue of her enzymes, her heart did not demonstrate any acute changes of function. The rest of her course on the floor was characterized as follows by systems: 1. Cardiovascular: Her serial enzymes were followed and they declined during her stay monotonically and at discharge her CK was found to be 248 down from 250 and the MB index was 4.8. Her troponin was down to eventually 1.1 from the 4s. She was maintained with the following cardiac medications, aspirin 81 mg, Labetalol 400 mg po b.i.d., and she was also started on Amlodipine 10 mg to control her hypertension. She remained in the 130 to 170 range. The Valsartan and Enalapril were held, because of her decline in renal function. She was never given any Fludrocortisone. 2. Endocrine: The patient was eventually brought up to NPH doses of 17 q.a.m. and 6 units q.p.m. with a Humalog sliding scale. Her finger sticks actually remained quite high in the range of 338, 411, 314 and 312 by the day of admission, however, it was believed to be due to the fact that the patient was not exercising sufficiently and the goal was to actually err on the side of hyperglycemia versus hypoglycemia since that was the cause of her two recent admissions. The patient and her husband [**Name (NI) **] were very involved in determining when and how the sliding scale would be implanted with appropriate medical monitoring as well. 3. Renal: The patient's creatinine increased steadily during her stay such that by the time she was discharged her serum creatinine went from 5.5 on admission to 6.8 on discharge and her BUN rose to 98 whereas on admission it was considerably less in the lower 80s. The patient started developing acidosis likely due to her decline renal function so that she was started on sodium bicarbonate at first 650 mg po b.i.d. and then eventually 1300 mg po b.i.d. and since her phosphate began to increase to 6.1 she was started on Phos-Lo 667 mg two tabs po t.i.d. for eating and that helped bring her phosphate down to 5.4 by the day of discharge. 4. Hematology/oncology: The patient was transfused 2 units total to get her hematocrit above 30 and toward 33, because she had suffered a myocardial event and her epo levels were increased from 3000 to 4000 units twice a week on Mondays and Thursdays. Prior to her transfusion she was given Furosemide 40 mg intravenous and in general her Furosemide dose was increased to 80 mg po t.i.d. DISPOSITION: She remained full code. She was discharged to home in improved condition. She will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1313**] on Monday [**7-17**] for further management and assessment and coordination of her renal transplant, which is currently tentatively scheduled for [**2124-7-27**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7576**] Dictated By:[**Last Name (NamePattern1) 3033**] MEDQUIST36 D: [**2124-7-13**] 13:56 T: [**2124-7-14**] 11:56 JOB#: [**Job Number 7577**]

[ "583.81", "401.9", "357.2", "410.91", "250.61", "250.21", "585", "250.81", "250.41" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

180, 705

717, 892

921, 1685

1708, 7726

17,894

186,841

11606

Discharge summary

report

Admission Date: [**2169-4-27**] Discharge Date: [**2169-5-26**] Date of Birth: [**2105-6-2**] Sex: M Service: TSURG Allergies: Morphine Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: difficulty breathing Major Surgical or Invasive Procedure: tracheobronchoplasty PICC line placement History of Present Illness: This patient is a 40 pack-year smoker with prior exposure to asbestos. He has had recurrent aspiration pneumonia since having a radical prostatectomy in [**2160**]. He was diagnosed with GERD, Barrett's esophagus, and tracheobronchomalacia in 12/[**2165**]. He had a right main bronchus stent placed in [**2167-5-2**], which was complicated by a stent infection likely starting in 12/[**2167**]. He has been treated with levofloxacin and Zosyn for ten days and ultimately had the stent removed in [**2169-3-2**]. Mr. [**Known lastname 36852**] was discharged on [**2169-4-8**] with 3 weeks of coverage with bactrim DS, nystatin, Advair, inhalers, and prednisone 50 mg po qd. He developed RLE swelling and was admitted to [**Hospital **] Medical Center with DVT. He began coumadin and switched to enoxaparin on discharge. He has been complaining of SOB since his last admission with fever of 103 for three days. He has been on home oxygen since his discharge from [**Hospital **] Medical Center. Past Medical History: [**First Name9 (NamePattern2) 36853**] [**Doctor Last Name 6530**] syndrome tracheobronchomalacia s/p b/l stent placments and removals COPD GERD/Barrett's esophagus prostate ca s/p radical prostatectomy DVT HTN s/p back surgery [**2160**] Social History: asbestos exposure for four years in the Navy formerly a 40 pack-year smoker (quit in [**2160**]) Family History: father with COPD died at 73 from CVA identical twin- former smoker without medical issues sister with asthma, recurrent bronchitis on inhalers Physical Exam: T: 97.6 HR: 86 BP: 134/91 RR: 20 Oxygen: 94-98% on 3L NAD, SOB with long sentences, abdominal breathing HEENT: normocephalic, nontraumatic, PERRLA, EOMI, trachea midline, no JVD Pulmonary: bilateral wheezes and rhonchi diffusely, decreased breath sounds on right lower field with dullness to percussion cardiac: RR with S1S2 abdominal: large abdomen due to abdominal breathing, non-tender extremeties: RLE pitting edema above the knee neuro: A + O x 3 Pertinent Results: [**2169-4-27**] 05:18PM GLUCOSE-135* UREA N-19 CREAT-0.9 SODIUM-135 POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15 [**2169-4-27**] 05:18PM CALCIUM-9.5 PHOSPHATE-4.0 MAGNESIUM-2.0 [**2169-4-27**] 05:18PM WBC-9.1 RBC-4.43* HGB-12.5* HCT-37.5* MCV-85 MCH-28.3 MCHC-33.4 RDW-16.5* [**2169-4-27**] 05:18PM PLT COUNT-362# [**2169-4-27**] 05:18PM PT-12.4 PTT-30.9 INR(PT)-1.0 Brief Hospital Course: Mr. [**Known lastname 36852**] [**Last Name (Titles) 1834**] a broncoscopy on [**2169-4-28**] which confirmed his need for tracheobronchoplasty, which he [**Date Range 1834**] on [**2169-5-2**]. Broncoscopy also revealed significant mucopurulent secretions, for which the ID service was consulted. ID treated his infection with levofloxacin, Zosyn. On [**2169-5-16**] he was put on meropenem for extended spectrum klebsiella, which he was to stay on for four weeks. He required a PICC line for the administration of this antibiotic. He has continued to improve in terms of his breathing and comfort level and has remained afebrile throughout his stay. Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). Disp:*450 ML(s)* Refills:*2* 3. Fluticasone-Salmeterol 500-50 mcg/DOSE Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Disk with Device(s)* Refills:*2* 4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO QD (once a day). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 5. Meropenem 1000 mg IV Q8H 6. Sodium Chloride 0.9 % Parenteral Solution Sig: One (1) 3.5 ML Intravenous every eight (8) hours as needed. Disp:*50 3.5 ML(s)* Refills:*0* 7. Heparin Flush (Porcine) in NS 100 unit/mL Kit Sig: One (1) 100 units/mL, 3 mL/flush Intravenous every eight (8) hours. Disp:*50 * Refills:*0* 8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: take one 5 mg tablet for five days followed by one 2.5 mg tablet for five days, then discontinue medication. Disp:*5 Tablet(s)* Refills:*0* 10. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: take one 5 mg tablet for five days followed by one 2.5 mg tablet for five days, then discontinue medication. Disp:*5 Tablet(s)* Refills:*0* 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-2**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 * Refills:*0* 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q4H (every 4 hours). Disp:*6 ML(s)* Refills:*2* 16. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 17. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for prn constipation. ML(s) 18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 19. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO QD (once a day). 20. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: 63yo male with [**First Name9 (NamePattern2) 36854**] [**Doctor Last Name 6530**] syndrome leading to severe tracheobronchomalacia. chronic obstructive pulmonary disease, infected stent, hypertension, gastroesophageal reflux disease/Barrett's esophagus, prostate cancer (s/p radical prostatectomy '[**60**]), left lower extremety deep vein thrombosis (s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter placement '[**60**]) Discharge Condition: good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. No heavy lifting or exertion for at least 6 weeks. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. Take complete course of antibiotics. You may resume your regular diet as tolerated. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 952**] ([**Telephone/Fax (1) 170**], and Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 29075**] for appointments in 3 months. Also, please don't hesitate to call Dr. [**Last Name (STitle) 952**] if you feel your condition is worsening.

[ "482.0", "117.3", "530.81", "560.1", "519.1", "V10.46", "494.0", "427.1" ]

icd9cm

[ [ [] ] ]

[ "96.05", "38.93", "33.24", "33.48", "33.23" ]

icd9pcs

[ [ [] ] ]

6070, 6131

2803, 3461

294, 337

6623, 6629

2395, 2780

7163, 7457

1763, 1907

3484, 6047

6152, 6602

6653, 7140

1922, 2376

234, 256

365, 1371

1393, 1633

1649, 1747

8,934

181,309

29937

Discharge summary

report

Admission Date: [**2108-12-21**] Discharge Date: [**2108-12-30**] Date of Birth: [**2032-12-13**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 9240**] Chief Complaint: Rising Cr, SOB Major Surgical or Invasive Procedure: none History of Present Illness: (hx per notes as pt lethargic, on morphine gtt) 76yo female who was initially transfered from [**Hospital1 1474**] with invasive SCC of vulva to the Gynecology service here. She was admitted to [**Hospital1 1474**] on [**12-10**]. There she was diagnosed with the invasive SCC and a potential & vesicovulvar fistula by dye test (but not on cysto). She was treated for a pseudomonas UTI s/p Zosyn, and was then found to have VRE growing from the vulva ulcer/fistula? and was started on Linezolid. On [**12-11**] she underwent a CT abdomen with iv contrast to evaluate for metastases, which was concerning for possible liver metastases, but could not be confirmed on US and repeat CT without contrast here. After the CT her creatinine started to rise from BL 1.7 and was 3.3 at the time of transfer on [**12-21**]. It continued to rise here and is currently at 4.8. Despite the worsening renal failure the pt was initially continued on Atenolol and Glyburide. Renal was consulted and both medications were discontinued on the [**12-22**] in the evening. The pt started to be hypoglycemic overnight, worsening in am and intermittently had BG in the 20-40 despite 3x amp of D50. Her mental status worsened as well and she was only oriented to self but not to place or time. She was then transferred to the [**Hospital Unit Name 153**] on a D20 gtt. . While in the [**Hospital Unit Name 153**], she was essentially anuric. She was evaluated by Urology for ? of renal failure [**1-25**] obstruction, who recommended a Mag3 scan. Plan earlier today was to place Quinton catheter and began HD. However, after discussions between her family and the ICU team, it was decided to make her CMO, and so she was transferred to the floor on [**12-24**]. Past Medical History: A-fib s/p pacemaker [**2104**] HTN CRF (baseline Cr 1.5) CHF (?EF50%) - unclear etiology [**Name (NI) 19917**] disease in R shoulder Anemia of chronic disease h/o recent C. diff, completed course of Vanco po Diverticular disease DM Social History: per daughter at baseline AAOx3, ambulates around the house, lives with family (daughter and grandchildren), ETOH? unclear amount Family History: NC Physical Exam: T: 97.2 BP: 96/60 HR: 76 R: 16 94%2L Gen: elderly female, lying in bed, opens eyes to voice, follows commands, unintelligible answers to questions HEENT: NC, AT, anicteric sclera, mm dry CV: RRR, distant heart sounds, nl S1 S2, no m/r/g audible Lungs: decreased breath sounds at bases anteriorly Abd: soft, NT, ND, + BS Ext: 2+ DP pulses, anasarca Skin: edematous, diffuse echhymosis Pertinent Results: [**2108-12-21**] 10:12PM URINE HOURS-RANDOM UREA N-121 CREAT-118 SODIUM-42 [**2108-12-21**] 10:12PM URINE OSMOLAL-308 [**2108-12-21**] 10:12PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020 [**2108-12-21**] 10:12PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2108-12-21**] 10:12PM URINE RBC-[**2-25**]* WBC-21-50* BACTERIA-MOD YEAST-MOD EPI-[**2-25**] [**2108-12-21**] 09:30PM GLUCOSE-77 UREA N-33* CREAT-3.8* SODIUM-141 POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-16* ANION GAP-17 [**2108-12-21**] 09:30PM estGFR-Using this [**2108-12-21**] 09:30PM ALT(SGPT)-10 AST(SGOT)-17 LD(LDH)-107 ALK PHOS-121* TOT BILI-0.3 [**2108-12-21**] 09:30PM ALBUMIN-2.6* CALCIUM-8.8 PHOSPHATE-5.9* MAGNESIUM-2.0 [**2108-12-21**] 09:30PM WBC-8.9 RBC-3.57* HGB-10.9* HCT-34.1* MCV-96 MCH-30.5 MCHC-31.9 RDW-18.6* [**2108-12-21**] 09:30PM NEUTS-73.5* LYMPHS-19.5 MONOS-5.1 EOS-1.6 BASOS-0.3 [**2108-12-21**] 09:30PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ [**2108-12-21**] 09:30PM PLT COUNT-181 [**2108-12-21**] 09:30PM PT-17.3* PTT-38.8* INR(PT)-1.6* . CXR [**12-21**]: Retrocardiac collapse/consolidation. Cardiomegaly without evidence of failure. . CT Chest/Abd/Pelvis [**12-22**]: Extremely limited study given the lack of intravenous contrast. 1. Patholgically enlarged left inguinal lymph nodes are concerning for nodal metastases. These lesions would be amenable to ultrasound guided biopsy. 2. Bilateral pleural effusions, cardiomegaly, and anasarca consistent with patient's known CHF. 3. Large anterior abdominal wall hernia containing a normal appearing loop of transverse colon. 4. Nodular appearance of the right adrenal gland. Further evaluation with MRI or dedicated CT could be performed as clinically indicated. 5. Atrophic kidneys consistent with patient's known renal failure. . CXR [**12-23**]: Worsening CHF. . Brief Hospital Course: 1. ARF: Started to develop rising Cr after CT with contrast at [**Hospital1 1474**], was 3.3 on [**12-21**] on transfer to the gyn service here up from 1.3. Rapidly developed anuria and was transferred from the gynecology service to the [**Hospital Unit Name 153**]. Initially urology was consulted for concern of obstructive uropathy playing a role, they were recommending a renal scan. However after discussion with the family in the ICU the decision was made not to persue dialysis or other invasive treatment and make the patient comfort measures only. In the [**Hospital Unit Name 153**] here medications were simplified to ativan, morphine, and antiemetics. Palliative Care was consulted and she was transferred to the floor. On the floor she began to deteriorate more rapidly she was started on sublingual morphine. We met with the family and Palliative Care and discussed the goal of inpatient hospice care. The patient died on [**2108-12-30**] at 3:45am. The family was notified. The PCP's coverage was notified as well. 2. hypoglycemia: She developed hypoglycemia in the setting of being on glyburide with rapidly declining renal function. She was initially treated with a D20 gtt in the [**Hospital Unit Name 153**]. This improved after holding her glyburide however and this was discontinued. 3. SCC of vulva: Extensive disease, with evidence of a vessiovulvar fistula. Had been growing VRE from this tract at [**Hospital1 1474**] and was on linezolid there. Wound care was consulted however after making the patient comfort measures, it was felt that aggressive wound care would be too painful and not benefit the patient. 4. CHF: Developed increasing CHF as her renal function declined. Her dyspnea was controlled with sublingual morphine in standing and prn doses. Medications on Admission: tylenol prn morphine prn ativan prn Discharge Medications: died on [**2108-12-30**] at 3:45 am Discharge Disposition: Expired Discharge Diagnosis: died [**2108-12-30**] Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6798, 6807

4867, 6652

299, 305

6872, 6882

2921, 4844

6939, 6950

2497, 2501

6738, 6775

6828, 6851

6678, 6715

6906, 6916

2516, 2902

245, 261

333, 2079

2101, 2335

2351, 2481

17,949

197,056

3707

Discharge summary

report

Admission Date: [**2184-9-15**] Discharge Date: [**2184-9-22**] Date of Birth: [**2120-9-24**] Sex: M Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9554**] Chief Complaint: Severe acute back pain Major Surgical or Invasive Procedure: None History of Present Illness: 63 year old African American man w/h/o HTN, DM2, CRI, BPH who presented on [**9-15**] with 10/10 sharp mid-upper-back pain that began while he was sitting. No CP, SOB, F/C. No trauma/strain. CTA in ED revealed "large intramural aortic hematoma beginning at the arch & extending to celiac trunk." ECG w/o evidence of ischemia. Pt's VS controlled w/esmolol & nipride & pain improved with morphine. CT surgery initially recommended medical management and pt admitted to CCU for closer monitoring. Past Medical History: 1. HTN on mult meds; 2. DM2 on orals; 3. CRI (baseline creat 1.8-2); 4. BPH Social History: retired; [**Company 16714**] @ airport 6 children; 30 grandchildren; 4 great grandchildren no etoh, drug use, tobacco use Family History: non-contributory Physical Exam: From Emergency Departmetn VITALS: T "afebrile" BP 178/93 P 62 98%RA RR 20 Gen AOx3 HEENT mmm CV holosystolic murmur on left side of sternum, no radiation Lungs decreased breath sounds bilaterally Abd soft, +BS Ext +edema Pertinent Results: Chemistries [**2184-9-14**] 11:35PM GLUCOSE-146* UREA N-24* CREAT-2.4* SODIUM-141 POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-33* ANION GAP-12 [**2184-9-15**] 03:30AM GLUCOSE-170* UREA N-24* CREAT-2.2* SODIUM-140 POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12 [**2184-9-15**] 09:14AM POTASSIUM-3.5 [**2184-9-15**] 03:34PM POTASSIUM-3.3 CBC [**2184-9-14**] 11:35PM WBC-8.2 RBC-4.03* HGB-12.3* HCT-36.5* MCV-91 MCH-30.4 MCHC-33.6 RDW-14.0 [**2184-9-14**] 11:35PM NEUTS-50.6 LYMPHS-43.9* MONOS-4.1 EOS-0.8 BASOS-0.6 [**2184-9-14**] 11:35PM PLT COUNT-189 Coags [**2184-9-14**] 11:35PM PT-13.6 PTT-25.4 INR(PT)-1.2 Hemolysis labs negative Cardiac Enzymes [**2184-9-14**] 11:35PM CK(CPK)-238* [**2184-9-14**] 11:35PM CK-MB-2 [**2184-9-14**] 11:36PM cTropnT-<0.01 [**2184-9-15**] 03:30AM CK(CPK)-199* [**2184-9-15**] 03:30AM CK-MB-2 cTropnT-<0.01 Diabetes Control [**2184-9-15**] 11:35AM %HbA1c-7.3* CTA ([**9-14**]) IMPRESSION: 1. Extensive aortic mural hematoma extending to the celiac trunk from the common origin of the right brachiocephalic and left common carotid arteries. As there is no ulceration or identifiable flap, intramral hematoma is likely due to a vasa vazoral bleed. 2. Left hydronephrosis with cortical atrophy, likely chronicity. Clinical correlation is suggested. 3. Right lower lobe lung nodule. Followup is suggested in three months. CTA Repeated on [**9-20**]: IMPRESSION: 1) Decrease in thickness of para-aortic hematoma. Entire hematoma not visualized, and there is a questionable intimal flap, raising suspicion for aortic dissection, but evaluation is limited due to bolus timing. Further evaluation with MRA is recommended. 2) Nonspecific area of ground-glass opacity in the right upper lobe, not present on prior study, and could be due to early infection or inflammation. 3) Small bilateral pleural effusions, increased in size, with bibasilar atelectasis. MRA ([**2184-9-21**]): IMPRESSION: Peri-aortic hematoma involving the descending aorta without evidence of an intimal flap. EKG ([**9-14**]) Sinus bradycardia with PVCs Left axis deviation Left atrial abnormality Nonspecific ST-T abnormalities Since previous tracing of [**2183-2-6**], no significant change Repeated on [**9-16**] (sinus rhythm), [**9-17**], [**9-18**], [**9-21**] with no significant changes ECHO ([**9-15**]) Conclusions: The left atrium is moderately dilated. The right atrium is markedly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The ascending aorta is moderately dilated but is not well visualized (cannot adequately assess for aortic dissection). The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal.with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. An aortic dissection/intramural hematoma cannot be excluded on images of the aortic arch. ECHO Repeated ([**9-17**]) to evaluate aortic valve Conclusions: 1. The left ventricular cavity is mildly dilated. LV systolic function appears depressed. 2. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 3. The mitral valve leaflets are mildly thickened. CXR ([**9-16**]) IMPRESSION: No interval change from previous exam. No evidence of pneumonia. CXR ([**9-22**]): r/o PNA Brief Hospital Course: 1) Intramural aortic hematoma: The patient presented with a classic story: a history of hypertension and a sudden onset of sharp back pain. A CTA revealed an intramural aortic hematoma. An ECHO done on [**10-24**] had shown a moderately dilated aortic root. A TTE done on [**9-17**] did not show evidence of AI. A repeat ECHO could not r/o a dissection but again showed stable aortic root dilation and unchanged aortic valve. The patient was seen by CT surgery who felt that medical management would be most appropriate so he was admitted to the CCU for intensive treatment. His BP & HR were initially controlled on IV medications with a goal of HR<65, MAP<80. He was subsequently transitioned to oral meds upon transfer to floor on HD 4 ([**9-18**]). He did well with good control of his blood pressure, and a repeat CTA was performed on [**9-20**] c/w resolving aortic hematoma, but ?flap in descending aorta near left pulmonary artery. An MRA was therefore done the following day which showed no evidence of a flap, and revealed a resolving hematoma. CT surgery recommended a repeat CTA in 6 months which can be followed up by his primary physician. [**Name10 (NameIs) **] has an appointment for both the CTA ([**2184-3-20**]) as well as the follow up with his primary physician ([**2185-4-6**]). * 2) HTN: The patient was initially placed on IV meds and then transitioned to oral meds (transitioned [**Date range (1) 16715**]). He was discharged with Labatolol 800tid, terazosin 5hs, nifedipine cr 90qd, lisinopril 10qd (creatinine was 2.5 when ACEI added back on [**9-18**]). He was on HCTZ @ home, but this was held and he was switched to Lasix 40qd (started [**9-19**]). His blood pressure was well controlled during hospitalization. He was discharged on labetolol, nifedipine, lisinopril, terazosin, and lasix. He will be seen in [**Hospital 191**] clinic on Friday [**9-24**] for f/u on his blood pressure and his low grade fevers, cultures. * 3) Renal: The patient's creatinine was elevated above baseline to as high as 2.5 during his hospitalization (baseline creat 1.8-2.2). He was pretreated with gentle hydration and given mucomyst before his CTA and he tolerated it well without a significant bump in his creatinine. Pt also c/o dysuria but had a negative U/A and UCx. He was empirically started on levo on [**9-18**] but this was stopped on [**9-20**] given negative BCx and urine Cx, he was given 3 days of pyridine for his urinary sx. * 4) Fever: Pt spiked fever on [**9-17**]; pt pan cultured and started on levo for possible UTI (dc'd [**9-20**] as above). Bld cx ngtd, Urine Cx neg. CXR negative for PNA. He was given Levofloxacin empirically, but this was discontinued on [**9-20**]. On [**9-21**] the patient began to have low grade temperatures which resolved before discharge. Blood cultures and urine cultures were resent, and were pending on discharge. A chest xray was done to r/o PNA on [**9-22**]. * 5) DM2: Initially his avandia was held in case of surgery, and he was covered with a HISS. The avandia was added back on [**9-22**]. The patient's glucose was well controlled while admitted. * 6) Sleep Apnea: The patient was diagnosed with sleep apnea while admitted. Started on bipap but did not use the machine at night [**2-23**] discomfort. He was set up for an outpt sleep study - the sleep center will contact him to arrange a time - phone [**Telephone/Fax (1) 16716**]. * 7) Pulmonary Nodule: Pulmonary nodule seen on CT scan, he should follow up in three months to see if nodule changing. His primary care physician has been alerted of this. * 8) BPH: Pt has BPH, started pt on terazosin in house. Has c/o delayed initiation and weak stream. A PSA was sent and returned at 42. Urology was consulted and said this issue could be followed up on an outpatient basis. The patient sees Dr. [**Last Name (STitle) 986**] as his urologist and Dr. [**Last Name (STitle) 986**] was contact[**Name (NI) **] regarding this possible prostate cancer. The patient will follow up with Dr. [**Last Name (STitle) 986**] as an outpatient. His primary care physician is aware of this issue. * 9) Opacity in RUL seen on CT ([**9-20**]): This was interpreted to be early infection vs. inflammation. The patient maintained good sats without pulm sx while hospitalized. A chest xray was done on [**9-22**] to assess for pneumonia. * 10) FEN: Maintained on a cardiac diet. The patient's electrolytes were repleted as needed. Received Mucomyst and bicarb prior to CTA. Medications on Admission: atenolol 100mg qd HCTZ 25mg qd ASA 325 qd Avandia 2 [**Hospital1 **] Hytrin 5mg qhs KCL 20 meq [**Hospital1 **] Moexipril 15 qd Niacin 500 TID nifedipine 90 qd Discharge Medications: 1. Labetalol HCl 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*2* 2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QD (once a day). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 5. Rosiglitazone Maleate 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1) Aortic hematoma 2) Hypertension 3) Chronic Renal Insufficiency, baseline Cr 1.8-2.2 4) BPH, with PSA 42 5) Obstructive Sleep Apnea Discharge Condition: Stable, blood pressure well controlled, afebrile, tolerating an oral diet. Discharge Instructions: Please take all your newly prescribed medications. Also continue your Avandia and your potassium. Return to the emergency department or call your primary physician if you notice continued fevers, chills, chest pain, back pain, nausea, vomiting, or any other symptoms concerning to you. Followup Instructions: Please follow up on Friday to make sure your blood pressure is well controlled and you are not having fevers any longer: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 16717**], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2184-9-24**] 3:30 The sleep center will call you to arrange a time for a sleep study to better evaluate your obstructive sleep apnea. Please call [**Telephone/Fax (1) 250**] in late [**Month (only) 404**] and make an appointment to get your "renal function tests drawn" in early [**Month (only) 956**] (before your CTA appointment). Please get a repeat "CTA to assess aortic hematoma." Your appointment is on Mon [**2185-3-21**] at 10:30am arrival for 11:30am CT, [**Hospital Ward Name 23**] [**Location (un) **], nothing to eat or drink 3 hours before. If you need to reschedule the appointment the number is [**Telephone/Fax (1) 16718**]. Please follow up with your primary physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**4-6**] at 2pm, [**Hospital Ward Name 23**] [**Location (un) **], North Suite. [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]

[ "593.9", "518.89", "401.9", "788.1", "780.57", "600.90", "441.03", "478.29", "250.00" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

10535, 10541

5069, 9583

358, 365

10719, 10795

1420, 5046

11131, 12394

1142, 1160

9794, 10512

10562, 10698

9609, 9771

10819, 11108

1175, 1401

296, 320

393, 888

910, 987

1003, 1126

62,913

150,253

54788

Discharge summary

report

Admission Date: [**2111-7-13**] Discharge Date: [**2111-7-15**] Date of Birth: [**2080-10-12**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2751**] Chief Complaint: Rash and subjective throat swelling Major Surgical or Invasive Procedure: None History of Present Illness: 30-year-old female history of anxiety and depression that presented to [**Hospital3 417**] Medical Center on [**2111-7-11**] with a pruritic rash. On Friday, she noticed a left hip lesion that looked like a "mosquito bite" and presented to the ED. She was seen in the ED and given benadryl, steroids, and "allergic cocktails" and was discharged. She returned the same day because the rash was more pruritic and spread to her hands, face, neck, and torso. She also had a sensation of mild throat swelling. She was given epinephrine and treated for suspected angioedema. She denies any recent new medications, insect, tick bites. Only positive ROS was possible viral illness in her family over the past week with everyone else recovering without any sequelae. For instance, both her husband and her had sore throat and flu-like symptoms. Her only significant cosmetic exposure was [**Location (un) **] lip cleaner. She was also working on her house, which is new construction. She denies any prior dermatological history except Pruritic Urticarial Papules and Plaques of Pregnancy. The patient was admitted to the floor where she had increased respiratory distress requiring some epinephrine and was subsequently transferred to the ICU. She did initially complain of some facial edema as well as swollen lips and ears. On exam, she was found to have a pruritic rash with circumferential lesions, which were non-blanching, largest of which was 7 cm x 4 cm on the left lateral back with no desquamation noted. She was started on dexamethasone on [**2111-7-11**] and was weaned off this the day prior to transfer to prednisone 45 mg PO qD; however, she felt increasing throat swelling as well as increasing swelling of her left parotid area, which resolved with administration of IV steroids. Given the rash seemed to be getting worse and lack of response with PO steroids, a decision was to transfer her to [**Hospital1 18**] for possible skin biopsy and further evaluation by dermatology. She also noted a rash in gluteal crease. For her throat swelling, she had her first episode on Saturday afternoon with a total of [**2-26**] episodes in the setting of "being nervous." She had associated swelling of the ears and neck and difficulty breathing with trouble swallowing as well that is transient. There is suspicion that the diagnosis is erythema multiforme minor with no mucosal involvement likely secondary to viral ilness. She denies eye soreness/involvement, vaginal soreness, or other manifestations. Testing to date is summarized in the laboratory section. Past Medical History: - Anxiety - Depression - History of gestational diabetes - ? Pre-diabetes based on Alc 6.4 - History of "chronic GI pathology" such as diarrhea and H. pylori with ulcer in [**2109**] s/p treatment - History of Pruritic Urticarial Papules and Plaques of Pregnancy - History of varicella Social History: - Tobacco: None - Alcohol: None - Illicits: None She is married and lives with her husband and she has one toddler (daughter). She feels safe at home. Family History: Her father had DM, CVA, heart disease. Physical Exam: Admission exam: General Appearance: No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), III/VI heart murmur best heard at LUSB, no radiation to axilla or carotids Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ), no stridor Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Warm, Rash: reported skin rash has resolved for most part, rash in gluteal cleft, facial flushing, ? urticarial lesions dynamic Neurologic: Attentive, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Discharge exam - unchanged from above, except as below: General: NAD, comfortable HEENT: mild facial flushing Lungs: CTAB, no stridor Skin: mild blanching erythema of the upper trunk, no other rashes notable Pertinent Results: Admission labs: [**2111-7-14**] 12:43AM BLOOD WBC-14.7* RBC-4.60 Hgb-12.8* Hct-37.6* MCV-82 MCH-27.9 MCHC-34.1 RDW-13.5 Plt Ct-214 [**2111-7-14**] 12:43AM BLOOD Neuts-87.7* Lymphs-9.3* Monos-2.7 Eos-0.1 Baso-0.2 [**2111-7-14**] 12:43AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.2 [**2111-7-14**] 12:43AM BLOOD HCG-<5 [**2111-7-14**] 03:32AM BLOOD [**Doctor First Name **]-NEGATIVE [**2111-7-14**] 12:43AM BLOOD CRP-4.4 [**2111-7-15**] 10:50AM BLOOD HIV Ab-NEGATIVE [**2111-7-15**] 06:45AM BLOOD HCV Ab-NEGATIVE Discharge labs: [**2111-7-15**] 06:45AM BLOOD WBC-13.2* RBC-4.56 Hgb-12.8 Hct-37.3 MCV-82 MCH-28.0 MCHC-34.3 RDW-13.2 Plt Ct-198 [**2111-7-15**] 06:45AM BLOOD Glucose-99 UreaN-18 Creat-0.6 Na-137 K-3.8 Cl-100 HCO3-29 AnGap-12 [**2111-7-15**] 06:45AM BLOOD Calcium-8.7 Phos-2.3* Mg-2.2 Micro: Lyme serology - neg HSV1 serology - pos HSV2 serology - neg GAS throat swab - neg Imaging: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild mitral regurgitation with normal valve morphology. No right sided valvular pathology or pathologic flow identified. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Brief Hospital Course: 30F with depression/anxiety who presented with episodic intensely pruritic erythematous rash associated with facial swelling and subjective dyspnea. # Erythematous, pruritic rash with facial flushing. Patient had initially noticed a "mosquito bite" on the left hip on [**2111-7-10**] which progressed to a pruritic rash involving the hands, face, neck and torso. Due to subjective sensation of mild throat swelling and respiratory distress, she was treated for angioedema and admitted to ICU at [**Hospital3 417**]. She was noted to have a pruritic, non-blanching rash on the L lateral back/thigh without desquamation and was started on steroids. Because the rash worsened and did not respond to steroids, patient was transferred to [**Hospital1 18**] MICU directly for further care. Her rash was initially thought to be consistent with erythema multiforme minor secondary to a preceding viral illness. Patient was never intubated and never demonstrated any signs of airway compromise. After one day in the MICU, patient was called out to the floor. The Allergy and Dermatology teams were consulted for further evaluation. Initially on exam at OSH, patient had mild facial flushing and scattered, erythematous, ringed macular rash on the bilateral antecubital fossa (confirmed with photos from OSH). Subsequently, she developed a confluent erythematous rash involving the bilateral upper arms, upper chest, upper back associated with significant facial flushing. By the time dermatology evaluated the patient, there was minimal erythema of the face and no rash on her trunks or extremities. Currently, the differential diagnosis for her rash is broad including uncomplicated hypersensitivity reaction, deep gyrate erthema from recent URI, or carcinoid syndome (although this is less likely). Erythema muliforme minor thought to be unlikely given transient nature of the rash. No biopsy was performed as the rash had resolved by transfer. A 24 hour urine collection was sent to assess for 5-HIAA to evaluate for carcinoid syndrome, which is pending at the time of discharge. Futhermore, patient had initially complained of joint swelling and morning stiffness in her hands at admission but on subsequent exam did not demonstrate swelling, erythema of the hands. [**Doctor First Name **] was negative, CRP/ERS normal and no significant swellingo n exam. Patient's symptoms were managed with oral steroids, fexofenadine, famotidine, and prn Benadryl per Allergy team recommendations. Patient's anxiety symptoms were managed with prn Ativan. By the time of discharge, patient demonstrated only mild flushing of the face but no peripheral or truncal rash. Labs at discharge notable for HIV Ab negative, ESR 5, CRP 4.4. She will taper her PO prednisone over the next 16 days with a course of 30mg [**Hospital1 **] for four days, 20mg [**Hospital1 **] for four days, 10mg [**Hospital1 **] for four days, and 10mg daily for four days. She will follow up in the outpatient setting with Allergy to evaluate further need of famotidine and fexofenadine in 1 week time. She will be seen by her PCP [**Last Name (NamePattern4) **] [**2111-7-22**]. # Imapired glucose intolerance. Patient A1c was 6.4 at OSH and has a history of gestational diabetes. She currently has impaired glucose intolerance due to steroid administration. She was maintained on a HISS while inpatient. # Leukocytosis. Patient was noted to have a leukocytosis on admission at OSH with trend (21.9 --> 19.2 --> 16.4 --> 14) and also at [**Hospital1 18**] (14.7 ->13.2). This was most likely due to the steroids which she received prior to transfer. No CBC is available prior to her initial steroids at the OSH ED. She had no signs/symptoms suggestive of active infection. # Chronic issues: All other chronic medical issues (insomnia, depression/anxiety) were managed with home medications as prescribed. # Code status: She was FULL CODE throughout the hospital course. # Transitional Issues - Follow-up on Mycoplasma, hepatitis serology, 5-HIAA urine, Lyme, tryptase - Patient to taper PO prednisone over sixteen days. - WIll follow-up with PCP and allergy after discharge Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Sertraline 100 mg PO DAILY 2. traZODONE 75 mg PO HS:PRN insomnia 3. Naproxen Dose is Unknown PO Q8H:PRN pain Discharge Medications: 1. Sertraline 100 mg PO DAILY 2. traZODONE 75 mg PO HS:PRN insomnia 3. Acetaminophen 650 mg PO Q4H:PRN Pain 4. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth Twice daily Disp #*60 Tablet Refills:*0 5. Fexofenadine 180 mg PO BID RX *fexofenadine 180 mg 1 tablet(s) by mouth Twice daily Disp #*60 Tablet Refills:*0 6. PredniSONE 30 mg PO BID Please take 3 tabs twice daily ([**Date range (1) 111982**]). Please take 2 tabs twice daily ([**Date range (1) 111983**]), Please take 1 tab twice daily ([**Date range (1) 111984**]). Please take 1 tab daily ([**Date range (1) 111985**]). RX *prednisone 10 mg Taper tablet(s) by mouth Twice daily Disp #*52 Tablet Refills:*0 7. Epinephrine 1:1000 0.3 mg IM ONCE difficulty breathing Duration: 1 Doses RX *epinephrine [EpiPen] 0.3 mg/0.3 mL (1:1,000) Inject into lateral thigh Once Disp #*1 Each Refills:*0 8. Naproxen 500 mg PO Q8H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Rash and urticaria Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], You were transferred from [**Hospital3 417**] Hospital on [**2111-7-13**] due to an itchy, red warm rash that started suddenly on [**2111-7-10**]. Becauase your rash had worsened and there was no reponse to steroids, you were transferred to [**Hospital1 18**] for further care. You initially stayed in the intensive care unit because of concern that your airway was compromised due to your symptoms of shortness of breath and throat swelling. You were then transferred to the medicine floor, where you were treated with steroids, anti-histamines. The Allergy and Dermatology teams were consulted in regards to your rash and facial flushing. We have given you the phone number for the allergy clinic. If your symptoms return, please make an appointment with them. Followup Instructions: Name: [**Last Name (un) **],ASNAT E. Location: [**Hospital **] MEDICAL GROUP Address: [**Street Address(2) 9646**], [**Hospital1 **],[**Numeric Identifier 9647**] Phone: [**Telephone/Fax (1) 3183**] Appointment: Wednesday [**2111-7-22**] 11:00am If you continue to have hives please call the department of Allergy and book a follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9313**]. The office number is [**Telephone/Fax (1) 9316**]. Any questions or concerns please either call the office or you PCP.

[ "300.00", "782.1", "708.0", "311", "790.29", "780.52", "782.62" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11842, 11848

6497, 10245

341, 348

11930, 11930

4585, 4585

12902, 13452

3438, 3478

10915, 11819

11869, 11869

10674, 10892

12081, 12879

5104, 6474

3493, 4566

266, 303

376, 2945

4601, 5088

11888, 11909

11945, 12057

10261, 10648

2967, 3254

3270, 3422

4,570

125,107

1628

Discharge summary

report

Admission Date: [**2189-7-26**] Discharge Date: [**2189-7-31**] Service: Medicine CHIEF COMPLAINT: Status post fall and syncope. HISTORY OF PRESENT ILLNESS: This is a 77-year-old male with a history of coronary artery disease status post coronary artery bypass grafting with a history of atrial flutter status post ablation on Coumadin, status post CEA, who was admitted to the MICU for management of a subarachnoid hemorrhage. The patient was in his usual state of health until 8:30 AM on the morning of admission when he fell while doing his usual morning exercises on his deck. He struck the occiput of his head and lost consciousness. He did not know why he fell. He denies chest pain, shortness of breath, nausea, vomiting, lightheadedness, dizziness, vertigo. The patient denies tripping or falling, no loss of balance. He was found by his son and brought to [**Name (NI) **] Hospital. At [**Location (un) **] he had a head CT that showed a small subarachnoid hemorrhage of his interhemispheric falx which was thought to be post-traumatic. He then had an MRI/MRA of his head which showed interhemispheric subarachnoid hemorrhage with no aneurysm. He was noted to have an INR of 2.3 on Coumadin. He was transferred to [**Hospital6 256**] for a neurosurgical evaluation. At [**Hospital6 256**] in the Emergency Room he was comfortable except for posterior headache. Neurosurgery was consulted and it was felt that the patient's subarachnoid hemorrhage was secondary to trauma and no the reason for his fall. It was recommended that he be admitted to the MICU for monitoring. Vitamin K 10 mg subcutaneous was given in the Emergency Room x1. PAST MEDICAL HISTORY: 1. Left carotid endarterectomy in [**2176**], asymptomatic. In 02/99 a carotid ultrasound showed right internal carotid artery 40-59% stenosis and left internal carotid artery patent. 2. Coronary artery disease status post coronary artery bypass grafting in [**2176**] with negative stress thallium one year ago. 3. History of atrial fibrillation, atrial flutter, status post radiofrequency ablation in [**2189-6-9**]. Holter monitor showed sinus rhythm with VPBs on [**2189-6-11**]. 4. Hyperlipidemia. 5. Gout. 6. Congestive heart failure. 7. Arthritis. 8. Status post cataract surgery. 9. Status post cyst removal on his thigh in [**2185**]. 10. Hyperhomocysteinemia. 11. Hypertension. 12. Lumbar disc herniations. MEDICATIONS ON ADMISSION: 1. Ismo 20 mg p.o. b.i.d. 2. Zestril 30 mg p.o. q. day. 3. Ziac 25\6.25 mg p.o. q. day. 4. Aspirin. 5. Allopurinol 300 mg p.o. q.p.m. 6. Colchicine 0.6 mg p.o. q.p.m. 7. Baycol 0.4 mg p.o. q.p.m. 8. Coumadin q.h.s. 9. Vitamin C, vitamin E. 10. Zocor. 11. Glucosamine chondroitin. SOCIAL HISTORY: No tobacco, no alcohol use. He is retired from the Army and lives with his wife. FAMILY HISTORY: Two brothers with coronary artery disease. No sudden cardiac death. PHYSICAL EXAMINATION: VITAL SIGNS: On admission temperature was 98.8, heart rate irregular at 79 beats per minute. Blood pressure 192/65, O2 saturation 96% on room air. GENERAL: No acute distress. HEENT: Mucous membranes moist. Tongue midline. Pupils reactive. Extraocular movements intact. NECK: Supple, no lymphadenopathy. Bilateral carotid bruits were noted right greater than left. CARDIOVASCULAR: Irregularly irregular. Normal S1, S2, with a II/VI systolic murmur at the left upper sternal border radiating to the carotids into the apex. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended, positive bowel sounds. EXTREMITIES: Warm, no edema. NEUROLOGIC: Alert and appropriate. Mental status: Alert and oriented x3 with fluent speech. Cranial nerves two through 12 intact. Motor - normal tone. Strength - [**6-13**] bilateral upper and lower extremities throughout. Sensation intact to light touch and pinprick. Reflexes 1+ symmetrical; no pronator drift. LABORATORY DATA: On admission the white count was 4.1, hematocrit 39.7, platelet count 119, INR 2.3, sodium 139, potassium 4.3, chloride 100, bicarbonate 29, BUN 19, creatinine 1.2, glucose 115, calcium 9.1. EKG: Atrial flutter at 69 beats per minute with variable block. PVCs showed no acute ST-T wave changes. HOSPITAL COURSE: The patient was admitted initially to the MICU where he was monitored overnight and was stable. He was called out to the [**Hospital1 **] the following day. 1. CARDIOVASCULAR: The patient remained on telemetry overnight and was first noted to have sinus pauses of greater than three seconds at a time and sinus bradycardia. The patient was ruled out for an acute myocardial infarction by cardiac enzymes and was evaluated by the EP service for question of sinus bradycardia and pauses causing syncope. An EP study was performed on [**2189-7-28**] and the patient was noted to have inducible ventricular tachycardia and was scheduled for an ICD the following morning. On [**2189-7-29**] the patient had an ICD with pacer capabilities placed without complications. Afterward the patient was noted to have a run of ventricular tachycardia of 27 beats which was asymptomatic. He had no further episodes of pauses or bradycardia once his beta blocker was discontinued. The patient was loaded on amiodarone and will be discharged on amiodarone. He will follow up with the EP service after discharge. The patient also underwent a repeat echocardiogram to rule out valvular abnormalities as the cause for his syncope. His echocardiogram showed left ventricular ejection fraction of 40%, mild AF, moderate AR, moderate to severe pulmonary hypertension, moderate mitral regurgitation, moderate tricuspid regurgitation, and some focal wall motion abnormalities. The patient also underwent repeat carotid ultrasound which showed right side with 40-59% stenosis which was unchanged from his prior study, and less than 40% stenosis. Hypertension - the patient had elevated blood pressures during his hospitalization. He was started on hydralazine 20 mg p.o. q.i.d., hydrochlorothiazide 25 mg p.o. q. day, and continued on his lisinopril at 40 mg p.o. q. day. Blood pressure was better controlled at that point. He will have his blood pressure checked as an outpatient. A home visiting nurse will help teach the patient how to check his blood pressure at home. 2. NEUROLOGIC: The patient was taken off Coumadin and reversed with vitamin K. He had no further episodes of bleeding and was felt stable by neurosurgery. The plan was to keep his INR less than 3 for at least seven days and then have his Coumadin restarted. This will be restarted as an outpatient. His neurologic examination remained completely normal. DISPOSITION: The patient was discharged home in stable condition. Physical Therapy will evaluate him for home safety prior to discharge. FOLLOW UP: He will follow up in [**Hospital **] clinic on [**2189-8-6**] at 2:30 PM and he will also have pulmonary function tests performed on [**8-6**] at 1:30 PM for baseline for amiodarone. The patient will also have a Holter monitor placed for evaluation after discharge to be followed up by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], his primary cardiologist. DISCHARGE MEDICATIONS: 1. Lisinopril 40 mg p.o. q. day. 2. Ismo 20 mg p.o. b.i.d. 3. Allopurinol 300 mg p.o. q. day. 4. Hydrochlorothiazide 25 mg p.o. q. day. 5. Potassium chloride 10 mEq p.o. q. day. 6. Baycol 0.4 mg p.o. q.p.m. 7. Amiodarone 200 mg p.o. b.i.d. 8. Colchicine 0.6 mg p.o. q. day. 9. Hydralazine 20 mg p.o. q.i.d. prn. for systolic blood pressure greater than 160. 10. The patient will not be taking aspirin, Coumadin, or Ziac until further instructed. DISCHARGE DIAGNOSES: 1. Syncope secondary to cardiac arrhythmia. Patient with inducible ventricular tachycardia and history of atrial fibrillation/atrial flutter status post radiofrequency ablation with ICD placement/pacer placement on [**2189-7-29**]. 2. Subarachnoid hemorrhage secondary to trauma. 3. Coronary artery disease status post coronary artery bypass grafting in [**2176**]. 4. Bilateral carotid stenoses. 5. Hyperlipidemia. 6. Gout. 7. Congestive heart failure. 8. Arthritis. 9. Status post cataract surgery. 10. Hyperhomocysteinemia. 11. Hypertension. 12. Lumbar disc herniations. 13. Status post cyst removal from his thigh in the past. [**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**] Dictated By:[**Last Name (NamePattern1) 9422**] MEDQUIST36 D: [**2189-7-31**] 14:41 T: [**2189-8-2**] 09:45 JOB#: [**Job Number 9423**]

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icd9cm

[ [ [] ] ]

[ "37.27", "37.26", "37.94" ]

icd9pcs

[ [ [] ] ]

2858, 2927

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110, 141

170, 1670

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2758, 2841

22,606

128,120

18690

Discharge summary

report

Admission Date: [**2104-8-22**] Discharge Date: [**2104-8-31**] Service: NEUROMEDIC CHIEF COMPLAINT: Weakness and confusion. HISTORY OF PRESENT ILLNESS: This is an 81 year old woman with no significant past medical history except for epistaxis who was admitted on [**2104-8-22**], after having been outdoors raking leaves and had the abrupt onset of "loss of feeling" in her arms. She had crawled on the floor and called her family member who called EMS to the house. She was brought to an outside hospital where she was disoriented and confused according to the EMT report and progressively more awake on the way to that outside hospital. She had apparently complained of a headache prior to this the night prior with some weakness in the legs although this story is not entirely clear at this point. She was awake when she arrived to the outside hospital but was still disoriented. She was noted to have a right sided hemiplegia with the head turned to the left as well as an aphasia. She was stuporous upon examination by the neurosurgery consultant. CT of the head there showed a large left frontoparietal bleed with mass effect. She was given Decadron and Ativan and intubated. She was also loaded with one gram of Dilantin intravenously. She was hyperventilated but no Mannitol was given there and she was subsequently transferred to the [**Hospital1 190**] for further care. After being admitted to the [**Hospital1 69**] NSICU, her examination was unchanged throughout from the outside hospital examination. She was seen by the neurosurgery consult team who felt that a ventricular drain was not warranted and unlikely to be beneficial even though there was evidence of small interventricular bleeding and some falcine herniation seen on the repeat head CT here. She was kept in the Neurosurgical Intensive Care Unit, hyperventilated and on Mannitol, and eventually was extubated three days later. She was admitted to the neurology floor after she had been extubated. PAST MEDICAL HISTORY: Epistaxis that resolved after a procedure done at [**State 51252**]. OUTPATIENT MEDICATIONS: 1. Aspirin. 2. Tylenol as needed for pain. MEDICATIONS ON TRANSFER (INPATIENT): 1. Vancomycin one gram intravenously q24hours. 2. Hydralazine 10 mg intravenously q6hours. 3. Acetaminophen 650 mg PR q4-6hours p.r.n. fever. 4. Famotidine 20 mg intravenously q12hours. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives alone, very independent woman according to family, doing all her activities of daily living. No tobacco or alcohol. FAMILY HISTORY: No history of stroke or bleeding. PHYSICAL EXAMINATION: Temperature is 98.3, axillary blood pressure 194/80, heart rate 94, oxygen saturation 95% in room air. In general, she is an elderly woman lying in bed with her head turned to the left. Head, eyes, ears, nose and throat examination - There is no scleral icterus. The lungs revealed coarse breath sounds at the bases bilaterally. Cardiovascular is regular rate and rhythm without murmurs, rubs or gallops. The abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities show marked edema in the right arm and leg. On neurologic examination, mental status - The patient is alert, eyes open, does not close eyes to command or stick out tongue to command. She is aphasic. Her pupils are small approximately 2.0 millimeters and minimally reactive. She does not track eye movements. Her VOR is intact. Corneals are present. The eyes are deviated to the left and she does not blink to threat approaching the right. On motor examination, her left leg withdraws with hip flexion and painful stimulus. There is a flicker of toes on the right foot to stimulus. There is normal tone on the left side, however, there is increased tone on the right upper extremity and right lower extremity. Sensory - She grimaces to pain on the left side and less so on the right side. LABORATORY DATA ON TRANSFER: White blood cell count was 11.2, hematocrit 34.3, MCV 89, platelet count 188,000. Partial thromboplastin time 21.3, INR 1.1. Chem7 is unremarkable. Her glucose is 109, blood urea nitrogen 19, creatinine 0.4, sodium 143, potassium 3.0, chloride 111, bicarbonate 23, albumin 3.1. Her microbiology studies included urine culture which was positive for Streptococcus povus. Sputum culture is positive for Oxacillin sensitive Staphylococcus aureus that is coagulase positive. There are two out of four blood cultures from [**2104-8-24**], from the same set growing coagulase negative Staphylococcus with subsequent surveillance cultures that are negative. HOSPITAL COURSE: 1. Right hemiparesis with aphasia - The patient's examination is consistent with the left frontoparietal as well as temporal lobe impairment likely due to the edema from the hemorrhage. She is spontaneously breathing and has a right sided hemiparesis and aphasia and does not appear to follow commands. Because she is unable to intake nutrition reliably on her own, a percutaneous endoscopic gastrostomy tube was placed and this will be used for tube feeding for nutrition. 2. Staphylococcus pneumonia - This is likely ventilator associated but is pansensitive. She was treated with Vancomycin for three days initially but after sensitivities came back, she was switched to Levofloxacin for which this was sensitive and she will be continued on this for a total course of antibiotics for fourteen days. The blood cultures were felt to be a contaminant since surveillance cultures were negative and the patient continued to be afebrile on the antibiotics. DISCHARGE STATUS: The patient was discharged to rehabilitation. CONDITION ON DISCHARGE: Good. MEDICATIONS ON DISCHARGE: 1. Tylenol 650 mg PR q4-6hours p.r.n. fever. 2. Levofloxacin 500 mg nasogastric once daily for seven days. 3. Captopril 37.5 mg nasogastric twice a day. 4. Pantoprazole 40 mg nasogastric once daily. 5. Lansoprazole 30 mg nasogastric once daily. 6. Tube feeds are Promote with fiber full strength with starting rate of 20ml/hour to advance to a goal rate of 60ml/hour by 20ml every six hours. Flush with 200ml of water twice a day and hold feedings for residual of 150ml. FOLLOW-UP PLANS: The patient is to follow-up with her primary care physician as needed. At this time, the patient's code status is DNR/DNI. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**] Dictated By:[**Name8 (MD) 4064**] MEDQUIST36 D: [**2104-8-31**] 08:10 T: [**2104-8-31**] 11:22 JOB#: [**Job Number 51253**]

[ "482.41", "431", "599.0", "348.5", "784.3", "342.90", "348.4", "790.7" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.6", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

2604, 2639

5742, 6221

4655, 5684

2121, 2434

2662, 4638

6239, 6614

114, 139

168, 2004

2027, 2097

2451, 2587

5709, 5716

29,553

131,258

12248

Discharge summary

report

Admission Date: [**2197-5-12**] Discharge Date: [**2197-5-15**] Date of Birth: [**2145-6-8**] Sex: M Service: MEDICINE Allergies: Lipitor / Gammagard Liquid Attending:[**First Name3 (LF) 896**] Chief Complaint: eye and head pain Major Surgical or Invasive Procedure: None this hospitalization History of Present Illness: This is a 51 year-old Male with PMH significant for coronary artery disease (s/p 2-vessel CABG - LIMA-LAD, SVG-D1), type 1 diabetes mellitus, chronic kidney disease (s/p living-unrelated kidney [**First Name3 (LF) **] in [**3-/2194**] on chronic immunesuppression with some rejection issues) who presented with right eye pain and right-sided headache. . Patient states that he has been having loss of vision over the last month, believes to be a complication from "eye occlusion" which he had a couple weeks ago. He's had pain since that retinal artery occlusion episode but states his pain had acutely worsened the day of admission, and his vision had worsened. His headache was right-sided, especially retro-orbital. . In the ED, initial VS 97.6 70 197/111 18 100% RA. On exam patient had notable right-sided proptosis and a midline fixed pupil. Intra-occular pressures were found to be elevated in the right eye and urgent Ophthalmology consultation was obtained. Ophtho found pressures to be greater than 60 (normal < 20) and he was started on strict Q1 hour eye drop regimen (Brimonidine, Dorazolamide, Latanoprost, Prednisolone and Erythromycin) which required MICU admission for nursing care. He was also dosed Mannitol 100 mg IV x 1 in the ED and his creatinine was closely trended (currently 4.3); later he received Acetazolamide 250 mg IV (4-doses). A head CT was obtained given his headache complaints and was reassuring, but was notable for bilateral proptosis of unknown etiology. He also received Labetalol 10 mg IV for elevated [**Year (4 digits) **] presusre and Morphine IV for pain control. His eye drop regimen was adjusted to twice daily dosing following stabilization, per Ophthalmology and his [**Year (4 digits) **] pressure improved. He was transitioned to PO Oxycodone for pain control. Intra-ocular pressure 23 in the AM. . Patient also has a corneal abrasion on the right-eye and was evaluated by Ophthalmology and they recommended Erythromycin gtt. . On arrival to the floor, appears stable and right-sided headache and eye pain improved. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: 1. Coronary artery disease (s/p 2-vessel CABG, LIMA-LAD, SVG-D1, [**2192**]) 2. End-stage renal disease (secondary to diabetic nephropathy; with liver-unrelated donor [**Year (4 digits) **] in [**2194-3-25**] with some element of rejection on chronic immunesuppression) 3. Diabetes mellitus, type 1 4. Known cholelithiasis 5. History of acute diverticulitis 6. s/p arthroscopic knee surgery 7. s/p left vitrectomy and right vitrectomy Social History: He used to work as a medical assistant at [**Last Name (un) **], but quit in order to avoid infectious exposures, and now works in real estate. He lives with his partner who is HIV+. He practices safe sex and is HIV- as of [**5-26**], smokes tobacco (40-50 pack years), drinks EtOH socially, and denies IVDU. He works as a motivational speaker. Family History: His mother has diabetes, as does maternal aunt and uncle. There is also history of gastric cancer in his father's side. Physical Exam: ADMISSION EXAM: . General: Alert, oriented, squeezing R eye closed currently, appears comfortable HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Sternotomy scar, RRR, normal S1 + S2, 2/6 SEM at RUSB Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred . DISCHARGE EXAM: . VITALS: 98.3 98.3 127-130/75-77 66 18 94% RA I/Os: 80 / - | BRP GENERAL: Appears in no acute distress. Alert and interactive. HEENT: Normocephalic, atraumatic. EOMI. Nares clear. Mucous membranes moist. EYES: right afferent pupillary reflex minimal with midline fixed pupil at 2-3 mm and no irritation or injection. Mild right-eye ptosis. Bilateral mild proptosis. NECK: supple without lymphadenopathy. JVD not elevated. CVS: Regular rate and rhythm, II/VI systolic ejection murmur at RUSB, no rubs or gallops. S1 and S2 normal. RESP: Clear to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. Stable inspiratory effort. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses NEURO: CN II-XII intact throughout. Alert and oriented x 3. Strength 5/5 bilaterally, sensation grossly intact. Gait deferred. Pertinent Results: ADMISSION LABS: . [**2197-5-12**] 11:35AM [**Month/Day/Year 3143**] WBC-4.9 RBC-4.15* Hgb-11.9* Hct-37.3* MCV-90 MCH-28.8 MCHC-32.0 RDW-14.1 Plt Ct-186 [**2197-5-12**] 11:35AM [**Month/Day/Year 3143**] Neuts-76.7* Lymphs-12.3* Monos-3.8 Eos-6.2* Baso-1.0 [**2197-5-12**] 11:35AM [**Month/Day/Year 3143**] Glucose-138* UreaN-28* Creat-4.3* Na-141 K-4.8 Cl-106 HCO3-21* AnGap-19 [**2197-5-13**] 05:00AM [**Month/Day/Year 3143**] Glucose-108* UreaN-27* Creat-4.3* Na-133 K-5.3* Cl-100 HCO3-19* AnGap-19 [**2197-5-13**] 05:00AM [**Month/Day/Year 3143**] Calcium-9.1 Phos-4.9* Mg-2.0 . DISCHARGE & PERTINENT LABS: . [**2197-5-15**] 05:19AM [**Month/Day/Year 3143**] WBC-5.7 RBC-3.44* Hgb-10.2* Hct-32.3* MCV-94 MCH-29.5 MCHC-31.4 RDW-14.3 Plt Ct-158 [**2197-5-15**] 05:19AM [**Month/Day/Year 3143**] Plt Ct-158 [**2197-5-15**] 05:19AM [**Month/Day/Year 3143**] Glucose-196* UreaN-51* Creat-5.1* Na-136 K-5.4* Cl-109* HCO3-17* AnGap-15 [**2197-5-15**] 05:19AM [**Month/Day/Year 3143**] Calcium-8.8 Phos-4.7* Mg-2.0 [**2197-5-15**] 05:19AM [**Month/Day/Year 3143**] Osmolal-311* . MICROBIOLOGY DATA: None . IMAGING: [**2197-5-12**] CT HEAD W/O CONTRAST - No evidence of acute intracranial process. Unchanged bilateral proptosis without an identifiable cause. Brief Hospital Course: IMPRESSION: 51M with a PMH significant for coronary artery disease (s/p 2-vessel CABG - LIMA-LAD, SVG-D1), type 1 diabetes mellitus, chronic kidney disease (s/p living-unrelated kidney [**Month/Day/Year **] in [**3-/2194**] on chronic immunesuppression with some rejection issues) who presented with right eye pain and right-sided headache found to have neovascular glaucoma (NVG) with dangerously high intra-ocular pressures, responsive to pressure-lowering eye drops complicated by acute on chronic renal insufficiency. # ACUTE NEOVASCULAR GLAUCOMA OF THE RIGHT EYE - Presented with right-sided headache and right-sided eye pain with evidence of increased intra-ocular pressures > 60 mmHg. Ophthalmology was urgently consulted and confirmed acute neovascular glaucoma. Had adequate response to Q1 hour pressure-lowering drops. Visual acuity appeared stable, but impaired. The patient also have some evidence of bilateral proptosis that is of unclear etiology and was noted on CT head imaging. In discussion with Ophthalmology, the patient's diabetic nephropathy resulted in central retinal vein occlusion that then progressed to over-active VEGF response resulting in vascular proliferation that caused acute neovascular glaucoma (secondary angle closure or pulling). Of note, he was receiving anti-VEGF injections (Avastin) as an outpatient at [**Hospital **] clinic to prevent this complication. With admission to MICU and Q1-hour pressure-lowering eye drops, as well as systemic osmotic diuretics (mannitol and acetazolamide), the patient improved. He will see Ophthalomology as an oupatient, but will continue on a strict pressure-lowering eye drop regimen: Brimonidine Tartrate 0.15% Ophth. 1 drop to right eye Q8H, Dorzolamide 2%/Timolol 0.5% Ophth. 1 drop to right eye [**Hospital1 **], Latanoprost 0.005% Ophth. Soln. 1 drop to right eye QHS and Prednisolone acetate 1% Ophth. Susp. 1 drop to right eye QID. His intra-ocular pressure was stable at 22-23 mmHg on [**2197-5-14**]. The patient will need outpatient Ophthalmology follow-up Wednesday, [**2197-5-17**]. # ACUTE ON CHRONIC KIDNEY DISEASE, PRIOR RENAL TRANSPLANTATION - End-stage renal disease (secondary to diabetic nephropathy; with liver-unrelated donor [**Month/Day/Year **] in [**2194-3-25**] with some element of rejection on chronic immunesuppression). Had cellular-humoral rejection in [**11/2195**] and currently in stage IV-V chronic kidney disease. No evidence of volume overload on exam. PTH 612 in 3/[**2196**]. On chronic immunesuppression at baseline. Elevation in creatinine on admission to 4.3-4.8 (baseline in the mid 3.0 range) in the setting of decreased PO intake and osmotic diuretic administration. [**Year (4 digits) 1326**] Nephrology was consulted and noted this acute renal injury was likely attributed to his recent Mannitol and osmotic diuretic needs and that this would improve. We continued to monitor his Tacrolimus levels and adjusted his dosing accordingly; we also continued Prednisone and Mycophenolate dosing for immunesuppression. We continued Bactrim and Valganciclovir prophylaxis. We did hold his home diuretic given his worsening renal function. # HYPERTENSION - Admitted with evidence of hypertension, 197/111. Known chronic kidney disease. Hypertension responded to IV Labetalol dosing. Outpatient regimen includes CCB and beta-blocker with Lasix. We continued beta-blocker dosing and CCB dosing this admission. # CORONARY ARTERY DISEASE - Coronary artery disease (s/p 2-vessel CABG, LIMA-LAD, SVG-D1, [**2192**]). No active chest pain or trouble breathing. EKG reassuring on admission. We continued his home Aspirin 81 mg PO daily and Metoprolol succinate 150 mg PO daily. The patient has a known statin allergy and is not on this medication. # DIABETES MELLITUS, TYPE 1 (INSULIN-DEPENDENT) - [**Year (4 digits) **] sugars in the 200-215 mg/dL range while in the MICU. HbA1c in [**2-/2197**] was 8.0%. We continued his home dosing of Lantus 24 units SC daily and an insulin sliding scale while he was hospitalized. TRANSITION OF CARE ISSUES: 1. Outpatient follow-up with Ophthalmology scheduled for Wednesday, [**2197-5-7**]. Will continue 4-drug pressure lowering eye drops for now. 2. Will need outpatient [**Last Name (un) **] Diabetes follow-up and monitoring for adequate glucose control. 3. Will need [**Last Name (un) 1326**] Nephrology follow-up given recent creatinine elevation. Medications on Admission: - tacrolimus 1 mg [**Hospital1 **] - mycophenolate mofetil 1000mg [**Hospital1 **] - prednisone 20 mg daily - sulfamethoxazole-trimethoprim 400-80 mg Tablet daily - valganciclovir 450 mg Tablet Q48hrs - sodium bicarbonate 650 mg Tablet TID - metoprolol succinate 150mg daily - amlodipine 10 mg daily - furosemide 20 mg daily - insulin glargine Twenty Four (24) units Subcutaneous Qhs - insulin lispro ISS Discharge Medications: 1. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) drop Ophthalmic [**Hospital1 **] (2 times a day) for 5 days: started [**2197-5-13**], ending [**2197-5-17**]. Disp:*10 drop* Refills:*0* 2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). Disp:*1 bottle* Refills:*1* 3. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). Disp:*1 bottle* Refills:*1* 4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*1* 5. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*1 bottle* Refills:*1* 6. tacrolimus 1 mg Capsule Sig: 1.5 Capsules PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 7. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 11. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO three times a day. 12. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). 13. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. insulin glargine 100 unit/mL Solution Sig: Twenty Four (24) units Subcutaneous at bedtime. 15. insulin lispro 100 unit/mL Solution Sig: per sliding scale units Subcutaneous per sliding scale. 16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 17. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Acute neovascular glaucoma 2. Acute on chronic renal insufficiency . Secondary Diagnoses: 1. Diabetes mellitus, type 1 2. End-stage renal disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Patient Discharge Instructions: . You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of your right-sided eye pain and headache and were found to have neovascular glaucoma, in discussion with Ophthalmology. You responded to ophthalamic pressure-lowering drops and you will need close follow-up. Your creatinine was noted to be elevated as well, in the setting of recent diuretics for your eye symptoms, and this improved with hydration. The kidney specialists were following your kidney issues. . 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 wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If 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 [**Hospital1 **] or dark/black material when you vomit, or have a bowel movement. * You experience burning when you urinate, have [**Hospital1 **] in your urine, or experience an unusual discharge. * You have pain that 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 other concerning symptoms. . CHANGES IN YOUR MEDICATION RECONCILIATION: . * Upon admission, we ADDED: START: Brimonidine Tartrate 0.15% Ophth. 1 drop to right eye every 8-hours START: Dorzolamide 2%/Timolol 0.5% Ophth. 1 drop to right eye twice daily START: Latanoprost 0.005% Ophth. Soln. 1 drop to right eye at nighttime START: Prednisolone acetate 1% Ophth. Susp. 1 drop to right eye four times daily START: Erythromycin 0.5% Ophth Oint 0.5 in both eyes twice daily for 5-days (started [**2197-5-13**], ending [**2197-5-17**]) INCREASE: Tacrolimus to 1.5 mg [**Hospital1 **]. Please discuss further dose adjustments with your [**Hospital1 **] doctors when [**Name5 (PTitle) **] have your next appointment. . * The following medications were DISCONTINUED on admission and you should NOT resume: DISCONTINUE: Furosemide (Lasix) . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: Please schedule a follow up appointment with Dr. [**First Name (STitle) 805**]. You already have an appointment with Dr. [**Last Name (STitle) **] scheduled (see below), but it is CRUCIAL that you call Dr.[**Name (NI) 27688**] office at [**Telephone/Fax (1) 38268**] TOMORROW, to schedule an appointment by Friday [**5-19**], at the latest. Scheduled appointments: Department: [**Hospital3 249**] When: MONDAY [**2197-6-5**] at 10:10 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital Ward Name **] CENTER When: MONDAY [**2197-6-26**] at 4:00 PM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "V42.0", "276.7", "250.41", "584.9", "403.90", "365.22", "V45.81", "584.5", "V58.67", "276.2", "305.1", "365.70" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12873, 12879

6279, 10689

303, 331

13091, 13091

5003, 5003

15666, 16683

3298, 3420

11145, 12850

12900, 12991

10715, 11122

13274, 15643

3435, 4006

13012, 13070

4022, 4984

246, 265

359, 2427

5019, 5596

13106, 13218

5612, 6256

2449, 2918

2934, 3282

79,511

109,613

37499

Discharge summary

report

Admission Date: [**2176-11-21**] Discharge Date: [**2176-11-25**] Date of Birth: [**2101-5-5**] Sex: F Service: MEDICINE Allergies: Cephalosporins / Penicillins Attending:[**First Name3 (LF) 2485**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 80848**] is a 75yo woman with h/o dementia and CHF who comes in from her nursing home after being found hypoxic. Per her nursing home, she was short of breath all day with O2 sats of 86% on RA. She also complained of generalized weakness, decreased po intake, and increased confusion per reports. Also had tachypnea. She initially presented to the [**Hospital 1562**] Hospital ED with VS BP 83/45, HR 97, RR 16, T 97.4, O2 Sat 91% on 2L. Her Hct was low at 25 and she received 1 units of packed RBCs. She was guaiac negative. CXR was felt to show LLL PNA as well as some heart failure. Peripheral dopamine was started for a systolic blood pressure in the 80s. She also received hydrocortisone 100mg IV as well as levofloxacin, vancomycin, and imipenem for coverage of health-care associated pneumonia in an ICU-level patient. She also had hyperglycemia to the 400's and has no past h/o diabetes. Upon arrival at [**Hospital1 18**] ED, her initial VS were: 97.6 66/53 87 86% on ?L. She remained talkative and pleasant. CXR demonstrated possible b/l consolidations. She was given 1500cc of IV fluids and continued on a dopamine gtt. Her guardian was [**Name (NI) 653**], and it was agreed that placement of a central line would be consistent with her care. Therefore, a right IJ catheter was placed and her pressors were transitioned to levophed. Her code status was confirmed with her guardian as DNR/DNI. Upon arrival to the ICU, she wasn't sure, but she thought she was short of breath. She denied headaches, chest pain, or abdominal pain. Past Medical History: Dementia, alert and oriented x 1 at baseline CHF, unknown EF SIADH Hypertension COPD Anemia RBBB on ECG h/o Right hip fracture Social History: Lives in nursing home. Prior heavy smoker. Family History: NC Physical Exam: VS: 97.1 121/90 111 25 85% on 15L face mask, but mask not on GENERAL: Pleasant, somewhat confused but interactive elderly woman. HEENT: No conjunctival pallor. No scleral icterus. PERRL/EOMI. Mucous membranes dry. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular tachycardia. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: Crackles b/l up to about half way up the lung fields. +Bronchial breath sounds at left base. ABDOMEN: BS present. Obese but soft. There is a firm, nontender subcutaneous nodule in the LUQ and what feels like gas-filled bowel loops in the RUQ. No tenderness to palpation, no distention. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis on left and 1+ on right. SKIN: No rashes/lesions, ecchymoses. NEURO: Alert, oriented to self only. Answers questions about where she grew up appropriately. CN 2-12 intact. Preserved sensation throughout. Strength is [**4-23**] in LUE and LLE. In RUE, distal strength appears intact but she has 4+/5 proximal strength. In RLE, she has difficulty raising her leg from the bed or bending her knee from the bed but can bend her knee with gravity. 2+ reflexes in UE that are equal BL, difficult to elicit knee or ankle jerk b/l. Gait assessment deferred Pertinent Results: Admission Labs: [**2176-11-21**] 01:00AM WBC-13.4* RBC-3.46* HGB-8.5* HCT-26.8* MCV-77* MCH-24.6* MCHC-31.8 RDW-19.4* [**2176-11-21**] 01:00AM PLT COUNT-374 [**2176-11-21**] 01:00AM NEUTS-92.8* LYMPHS-4.5* MONOS-1.7* EOS-0.8 BASOS-0.2 [**2176-11-21**] 01:00AM ALT(SGPT)-54* AST(SGOT)-147* LD(LDH)-596* CK(CPK)-169* ALK PHOS-287* AMYLASE-15 TOT BILI-0.4 [**2176-11-21**] 01:00AM GLUCOSE-157* UREA N-45* CREAT-0.8 SODIUM-137 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13 [**2176-11-21**] 01:00AM LIPASE-25 [**2176-11-21**] 01:00AM cTropnT-<0.01 [**2176-11-21**] 01:00AM CK-MB-3 [**2176-11-21**] 01:00AM ALBUMIN-2.8* [**2176-11-21**] 01:08AM LACTATE-1.5 Studies: ECG [**2176-11-21**] Sinus rhythm with first degree atrio-ventricular conduction delay. Right bundle-branch block. Diffuse non-diagnostic repolarization abnormalities. No previous tracing available for comparison. Echo [**2176-11-21**] The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60-70%). There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: dilated, hypocontractile right ventricle without evidence of major pulmonary hypertension (although pulmonary artery pressure may have been underestimated), tricuspid regurgitation, or pulmonic valve dysfunction Chest Xray [**2176-11-21**] Extensive left lung changes including interstial opacity, effusion and hilar enlargement as well as right pulmonary edema. Ongoing followup to resolution is recommended to exclude left lung malignancy. CTA Head/Neck [**2176-11-21**] 1. 7-mm aneurysm of the right M2 segment of the MCA. 3-mm aneurysm of the 2 segment of the left MCA. No hemorrhage or areas of significant vascular stenosis or occlusion. 2. Left pleural effusion and soft tissue density along the left pulmonary artery, incompletely assessed. CT Chest Abd Pelvis [**2176-11-21**] 1. Left hilar mass with upper lobe lymphangitic spread concerning for a primary lung malignancy. 2. Left greater than right pleural effusions. 3. Numerous diffuse metastases within the liver and right adrenal gland. 4. Left anterior abdominal wall subcutaneous metastasis Abdominal ultrasound [**2176-11-21**]: 1. Diffusely infiltrated liver with innumerable nodules, concerning for diffuse metastatic disease. A CT is recommended for further evaluation 2. Small perihepatic ascites, and as well as right pleural effusion. Brief Hospital Course: 75 year old woman with history of dementia and CHF who presented with hypoxia, dyspnea, and septic shock and found to have metastatic cancer. She expired on [**2176-11-25**] at 1:40pm. # Hypoxic Respiratory Failure. She originally presented with hypoxia and dyspnea, likely related to an underlying lung malignancy. Her respiratory status continued to decline despite high flow oxygen mask use and she ultimately went into hypoxic respiratory arrest causing her death. She was DNR/DNI during this stay. # Septic Shock: She presented with hypotension requiring pressors. She met SIRS criteria with leukocytosis > 12K, RR>20 and it was felt most likely to be a pulmonary source of infection. She was started on Vancomycin and Meropenem, as well as Levaquin for healthcare-associated pneumonia. She was later found to have a left hilar lung mass that may have been contributing to a post-obstructive pneumonia. She was given IV fluids for resuscitation and maintained on Levophed for pressure support. # Metastatic Cancer: She was diagnosed with metastatic cancer during this admission of unknown primary. She had subcutaneous nodule on her abdomen and elevated liver enzymes and was found to have a left hilar lung mass suspicious for a lung cancer primary on CT scan. She was also found to have multiple metastases to her liver. # Congestive Heart Failure: She had some evidence of volume overload on exam and chest xray but was not diuresed due to likely septic shock. She had a TTE on admission that showed a preserved EF but hypocontractile right ventricle with severe pulmonary hypertension. # Weakness on neurologic exam: She had right lower extremity weakness that was felt to be due to her prior hip fracture. # Anemia: On admission she had a hematocrit of 25 and was given 2 units PRBCs. Her hematocrit subsequently remained stable. # Elevated INR: She had an INRo on admission that was felt to be both nutritional and due to her substantial liver disease due to metastases. # Contacts: [**Name2 (NI) **] legal guardian until death was [**Name (NI) **] [**Name (NI) 84227**] [**Telephone/Fax (1) 84228**] cell, [**Telephone/Fax (1) 84229**]. He was appointed by the court since patient has mentally-ill daughter. [**Name (NI) **] daughter also visited Ms. [**Known lastname 80848**] in the hospital and was present at the time of her death. Medications on Admission: HCTZ 25mg po daily Albuterol Sulfate 2.5 mg q2h prn Vit D 1000 units po daily Tums 500: 2 tabs po BID Dulcolax 200mg po BID MVI 1 tab po daily Milk of Mag prn Tylenol 650mg prn Bisacodyl 10mg PR prn Guaifenesin 10mg po q4h prn Mag Ox 400mg po daily Folic acid 1mg po daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: Metastatic Cancer Hypoxemic Respiratory Arrest Secondary Diagnosis: Chronic diastolic heart failure Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "790.92", "995.92", "785.52", "162.2", "496", "518.81", "285.9", "428.0", "485", "197.7", "038.9", "401.9", "790.29", "294.8", "416.8", "428.33", "511.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9183, 9192

6460, 8085

298, 304

9355, 9364

3439, 3439

9420, 9430

2146, 2150

9154, 9160

9213, 9213

8857, 9131

9388, 9397

2165, 3420

251, 260

332, 1919

9301, 9334

3455, 6437

9232, 9280

8102, 8831

1941, 2069

2085, 2130

28,374

178,302

51810

Discharge summary

report

Admission Date: [**2122-10-23**] Discharge Date: [**2122-10-26**] Date of Birth: [**2066-8-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: asymtomatic Major Surgical or Invasive Procedure: MVRepair(#34 Annuloplasty ring/resection)Left side maze w/ligation of Left atrial appendage. [**10-23**] History of Present Illness: 56 yo M with known severe MR [**First Name (Titles) **] [**Last Name (Titles) **]. Past Medical History: MVR/MVP, [**Last Name (Titles) **], Asthma Social History: lives with wife no tobacco [**1-13**] etoh per week Family History: NC Physical Exam: WDWN M in NAD, Actinic keratosis on forehead Lungs CTAB Heart RRR 3/6 late systolic murmur Abdomen soft, NT, ND Extrem wrm, no edema No varitcosities 2+ pp no carotid bruits Pertinent Results: [**2122-10-26**] 06:50AM BLOOD WBC-5.6 RBC-2.98* Hgb-9.6* Hct-27.7* MCV-93 MCH-32.1* MCHC-34.5 RDW-13.3 Plt Ct-122* [**2122-10-25**] 12:51AM BLOOD WBC-7.6 RBC-2.96* Hgb-9.8* Hct-27.9* MCV-94 MCH-33.0* MCHC-35.0 RDW-13.2 Plt Ct-104* [**2122-10-26**] 06:50AM BLOOD Plt Ct-122* [**2122-10-26**] 06:50AM BLOOD PT-12.8 PTT-26.7 INR(PT)-1.1 [**2122-10-26**] 06:50AM BLOOD Glucose-102 UreaN-12 Creat-0.9 Na-139 K-4.4 Cl-106 HCO3-26 AnGap-11 CHEST (PORTABLE AP) [**2122-10-25**] 10:33 AM Single portable radiograph of the chest demonstrates interval removal of the support lines seen on [**2122-10-23**]. No pneumothorax. Patient is again noted to be status post prosthetic cardiac valve placement and median sternotomy. Blunting of the left costophrenic angle persists as does bibasilar atelectasis. Trachea is midline. IMPRESSION: Persistent bibasilar atelectasis and left-sided pleural effusion. No pneumothorax. Brief Hospital Course: On [**10-23**] he was taken to the operating room where he underwent a MVRepair, and full left sided maze with ligation of the left atrial appendage. He was transferred to the ICU in critical but stable condition.He was extubated later that day. He was transferred to the floor on POD #1. He was restarted on coumadin. He did well post operatively and was ready for discharge on POD #3. Medications on Admission: bisoprolol 2.5', coumadin 7.5' Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Bisoprolol Fumarate 5 mg Tablet Sig: 0.5 Tablet PO once a day. Disp:*15 Tablet(s)* Refills:*0* 7. Coumadin 5 mg Tablet Sig: 1.5 Tablets PO once a day. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of [**Hospital3 **] Discharge Diagnosis: MVR/MVP [**Hospital3 **] Asthma Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] (PCP) 2 weeks Dr. [**Last Name (STitle) 914**] (Cardiac Surgeon) 4 weeks Dr. [**Last Name (STitle) **] (Cardiologist) 2 weeks Completed by:[**2122-10-26**]

[ "493.90", "518.0", "427.31", "424.0", "458.29", "511.9" ]

icd9cm

[ [ [] ] ]

[ "88.72", "37.33", "39.61", "37.99", "35.33" ]

icd9pcs

[ [ [] ] ]

3154, 3208

1854, 2242

334, 441

3284, 3292

917, 1831

3591, 3779

704, 708

2323, 3131

3229, 3263

2268, 2300

3316, 3568

723, 898

283, 296

469, 553

575, 619

635, 688

5,139

165,318

14381

Discharge summary

report

Admission Date: [**2199-8-23**] Discharge Date: [**2199-9-24**] Date of Birth: [**2144-12-19**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 42629**] is a 50-year-old gentleman with end stage renal disease status post myocardial infarction in [**2187**]. During a work up for a kidney transplant, was shown to have coronary artery disease and underwent off pump coronary artery bypass grafting x3 in [**2199-5-18**]. Postoperative course was complicated by a prolonged ICU stay with pressor dependence. The patient was discharged home on [**6-24**]. At home, the patient had been recovering slowly until one week prior to admission at which time he began experiencing loss of appetite, lethargy and general malaise. No fevers or chills at this time. His sternal incision began to drain clear fluid initially and then purulent fluid. His saw his primary care provider who started him on ciprofloxacin and referred him to a local surgeon who subsequently referred him back to [**Hospital6 1760**] and Dr. [**Last Name (STitle) 1537**]. PAST MEDICAL HISTORY: 1. Coronary artery bypass graft x3 off pump [**2199-5-31**] 2. Status post myocardial infarction in [**2187**] 3. History of upper gastrointestinal bleed 4. Status post cauterization 5. Status post stenting of urethral stricture 6. End stage renal disease, currently on peritoneal dialysis 7. Status post left arm fistula placement which is now non functional 8. Insulin dependent diabetes mellitus 9. Peripheral neuropathy 10. Hypertension 11. Gastroesophageal reflux disease 12. Restless leg syndrome ADMISSION MEDICATIONS: 1. Aspirin 325 qd 2. Endocet 5/325 prn 3. Epogen 7500 q Wednesday and Sunday 4. Folate 1 mg tid 5. NPH 15 in the morning and 15 in the p.m. 6. Humalog sliding scale 7. Niferex 150 [**Hospital1 **] 8. Nephrocaps 1 [**Hospital1 **] 9. Neurontin 100 prn 10. Paxil 10 qd 11. Plavix 75 qd 12. Pravachol 40 qd 13. Protonix 40 qd 14. Renagel 800 tid 15. Colace 100 [**Hospital1 **] 16. Valium 5 prn 17. Vitamin E 400 qd 18. Cipro 500 [**Hospital1 **] ADMISSION PHYSICAL EXAM: VITAL SIGNS: Temperature 99.3??????, heart rate 87, blood pressure 117/44, respiratory rate 20, O2 saturation 97% on room air. GENERAL: Chronically ill appearing man in no acute distress. NEUROLOGIC: Nonfocal. CARDIOVASCULAR: Regular rate and rhythm. EXTREMITIES: Warm and well perfused. RESPIRATORY: Bilateral wheezes. No crackles or rhonchi. GASTROINTESTINAL: Abdomen is distended, hypoactive bowel sounds, nontender. PD catheter in the right lower abdomen. Site clean and dry. Sternal incision. Mid distal incision widely open. Dressing with yellow drainage and a foul odor, 1 to 2 cm opening surrounding erythema with yellow eschar. Wound bed yellow, fatty tissue. STERNUM: Click along the entire sternum. EXTREMITIES: Right lower extremity vein harvest site dry with no erythema. Right great toe is dark and necrotic. LAB DATA: Sodium 132, potassium 4.8, BUN 53, creatinine 10.9, phos 7.9, calcium 8.3, hemoglobin A1C 5.3. White blood cell count 10.4, hematocrit 28.4. HOSPITAL COURSE: The patient was admitted to the cardiothoracic service. His wound was superficially debrided. He was begun on intravenous antibiotics in preparation for a sternal debridement in the Operating Room. On [**8-27**], the patient was brought to the operating room at which time he underwent sharp debridement of his chest wound and a sternectomy. At that time, he was evaluated by plastics. A vacuum assisted closure device was implanted and the patient was returned to the CSRU following his surgery which the patient tolerated well. Please see the OR report for full details. The patient also had a double lumen PICC line placed at that time. For a week postoperatively, the patient remained in the Cardiothoracic Intensive Care Unit. During that time, he remained chemically paralyzed and sedated. On full ventilation, he remained hemodynamically stable and his VAC remained in place, changed periodically by the plastic surgery service whose initial intent was to do a right rectus and pec closure within one week of the initial sternal debridement. Following one week of VAC treatment, plastic surgery team felt that the wound still was not ready for flap closure and a decision was made to delay closure for a period between two and six weeks during which time the patient wound receive additional nutritional support and antibiotic treatment. Wound to be reassessed by the plastics team periodically during that time in anticipation of rectus and pec flap closure. The patient was begun on both hyperalimentation and tube feedings following his initial sternectomy. Following one week of chemical paralysis, given that the plastic surgery service wanted to delay flap closure, it was decided to discontinue chemical paralysis. Following discontinuation of chemical paralysis, the patient was weaned from the ventilator and successfully intubated on postoperative day 8. He remained in the cardiothoracic Intensive Care Unit for several additional days to monitor his respiratory status, as well as initiate tube feedings through a Dobbhoff tube which was placed at that time. Additionally, the patient was continued on hyperalimentation while the tube feeds were being advanced to aggressive goal rate. The patient was also allowed to take oral nutrition at that time. Postoperative day 10, the patient was deemed to be stable and ready for transfer to the floor for continuing postoperative care and nutritional support. For the next two weeks, the patient remained stable hemodynamically. From an infectious disease standpoint, he also remained stable on Levaquin and vancomycin. He advanced his oral intake to the point where his hyperalimentation and tube feedings were both discontinued and he was maintained strictly on oral diet. His VAC dressing continued to be changed every third day by the plastic surgery service and on the week of [**9-26**], work was begun to prepare the patient for transfer back to [**Location (un) 1514**], [**Hospital 3844**] hospital for continuing wound and nutritional support while awaiting flap closure of his sternal wound. The anticipated date of transfer would be sometime following the week of [**9-23**]. At that time, the patient's condition is stable. PHYSICAL EXAM ON [**9-24**]: VITAL SIGNS: Temperature 97.2??????, heart rate 90 sinus rhythm, blood pressure 116/52, respiratory rate 20, O2 saturation 96% on room air. NEUROLOGIC: Alert and oriented x3, moves all extremities, follows commands, nonfocal exam. RESPIRATORY: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm, S1, S2 with no murmur. Sternal wound with VAC dressing in place. No erythema at the margins. ABDOMEN: Soft, nontender, nondistended, Tenckhoff catheter site clean and dry with no erythema. EXTREMITIES: Warm and well perfuse with no edema. DISCHARGE MEDICATIONS: 1. Epogen [**Numeric Identifier 961**] units subcutaneous 3x per week 2. Vitamin C 500 mg q od 3. Nicotine patch 14 cm topically 4. Lansoprazole 30 mg qd 5. Heparin 5000 units [**Hospital1 **] 6. Combivent 2 to 4 puffs q6h 7. Zinc 200 mg qd 8. Thiamine 100 mg qd 9. Folic acid 1 mg qd 10. Nephrocaps 1 qd 11. Tocopherol 400 international units qd 12. Pravastatin 40 mg qd 13. Paroxetine 10 mg qd 14. Colace 100 mg [**Hospital1 **] 15. Aspirin 325 mg qd 16. Insulin NPH 7 units q a.m. and q p.m. 17. Insulin regular sliding scale 18. Percocet 5/325 1 to 2 tablets q4h prn 19. Milk of Magnesia 30 cc q hs prn 20. Bisacodyl 10 mg pr qd prn 21. Ambien 5 mg hs prn ANTIBIOTICS: 1. Vancomycin 1 gm intravenous whenever his level drops below 15 2. Levaquin 250 mg q od DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass grafting x3 complicated by sternal drainage requiring sternal debridement and VAC placement 2. Insulin dependent diabetes mellitus 3. End stage renal disease requiring peritoneal dialysis 4. Gastroesophageal reflux disease 5. Hypertension 6. Hypercholesterolemia 7. Upper gastrointestinal bleed 8. Urethral stenting 9. Status post left arm fistula that is now non functioning 10. Status post PICC line placement 11. Restless leg syndrome The patient is to be discharged to [**Hospital 1514**] Hospital and the Plastic Surgery Clinic in two weeks. That is a [**Hospital 2974**] clinic and the phone number to make an appointment is ([**Telephone/Fax (1) 18746**]. He is also to have follow up with Dr. [**Last Name (STitle) 1537**] at the time of being seen by the plastic surgery service. An addendum to this dictation will follow on the day of discharge. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2199-9-24**] 11:27 T: [**2199-9-24**] 12:46 JOB#: [**Job Number 42630**]

[ "707.0", "403.91", "357.2", "412", "V45.81", "250.61", "998.59", "276.1" ]

icd9cm

[ [ [] ] ]

[ "99.15", "38.93", "54.98", "77.61" ]

icd9pcs

[ [ [] ] ]

7771, 8970

6975, 7750

3131, 6952

1641, 2105

2120, 3113

160, 1083

1105, 1618

24,835

123,529

44427

Discharge summary

report

Admission Date: [**2131-1-19**] Discharge Date: [**2131-2-16**] Date of Birth: [**2056-6-25**] Sex: M Service: [**Doctor Last Name **] Firm CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old man with history of non small cell lung cancer stage 3A, status post neoadjuvant therapy with chemotherapy and x-ray therapy who presents for left pneumonectomy. The patient underwent left pneumonectomy on [**2131-1-19**]. PAST MEDICAL HISTORY: Lung cancer, spinal stenosis, AAA, nephrolithiasis, bladder cancer. MEDICATIONS: Albuterol, Atrovent, Serevent, Theophylline, Celexa, Proscar. ALLERGIES: Aspirin. PHYSICAL EXAMINATION: The patient had a temperature of 97.8, pulse 75, blood pressure 115/64, respiratory rate 20 and 100% oxygen saturation. Generally the patient was ill appearing, elderly man in no apparent distress. Cardiac exam revealed regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. Abdominal exam revealed the belly was soft, nontender, non distended with normal bowel sounds. Lung examination revealed lungs that were clear to auscultation bilaterally. HOSPITAL COURSE: The patient underwent left pneumonectomy for stage 3A non small cell lung cancer on [**2131-1-19**]. His course was complicated by postoperative atrial fibrillation, Serratia bacteremia and bronchopleural fistula requiring a chest tube placement as well as COPD exacerbation requiring steroids. The patient was scheduled to undergo bronchoscopy for evaluation and possible drainage of infected material thought to be seated from his Serratia bacteremia. At the time of bronchoscopy the patient's respiratory status decompensated and a bronchoscopy was not performed. At that point the patient elected to be DNR/DNI with possibility of cardioversion for rapid atrial fibrillation. The patient progressed in his respiratory decompensation and the patient eventually expired on [**2131-2-16**] at 1:15 a.m. His wife was notified of the patient's expiration and the attending was also notified. CONDITION ON DISCHARGE: Deceased. DISCHARGE DIAGNOSIS: 1. Non small cell lung cancer. 2. Chronic obstructive pulmonary disease. 3. Abdominal aortic aneurysm. 4. Hypertension. 5. Atrial fibrillation. 6. Serratia pneumonia with bacteremia. 7. Bronchopleural fistula. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**] Dictated By:[**Last Name (NamePattern1) 5246**] MEDQUIST36 D: [**2131-2-16**] 01:48 T: [**2131-2-20**] 19:13 JOB#: [**Job Number 95239**]

[ "162.5", "997.3", "510.0", "038.49", "427.31", "997.1", "441.4", "482.83", "491.21" ]

icd9cm

[ [ [] ] ]

[ "33.23", "32.5", "96.6", "34.04" ]

icd9pcs

[ [ [] ] ]

2136, 2626

1181, 2079

694, 1163

175, 197

226, 480

503, 671

2104, 2115

8,608

163,636

15700

Discharge summary

report

Admission Date: [**2134-10-8**] Discharge Date: [**2134-10-9**] Date of Birth: [**2090-1-22**] Sex: M Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Right carotid artery stenosis Major Surgical or Invasive Procedure: Right Carotid stent History of Present Illness: 44yo man with hisotry of CAD s/p CABG in [**10-2**] and carotid stenosis s/p right CEA [**1-2**] admitted for right carotid stent after routine follow-up ultrasound showed restenosis of 70-90%. Past Medical History: 1. CAD s/p CABG with LIMA-LAD, SVG-OM1, OM2, radial to RCA -complicated by wire protrusion and revision 2. s/p Right CEA 3. Type 2 DM Social History: Single, works at [**Company 3004**] doing heavy lifting daily, single, non-smoker Family History: No early CAD Brother died at 10yo of congenital [**Last Name **] problem Physical Exam: VS: 99.0 124/70 HR: 80 RR: 16 97% RA Gen: pleaseant, NAD HEENT: moist oral mucosa Neck: no JVD, no bruit CV: S1S2 regular without murmur Resp: CTA b/l Abd: +BS, soft, NT/ND Groin: no hematoma, no bruit, soft, NT Ext: no C/C/E Neuro: CN II-XII intact, 5/5 strength throughout, no sensory deficits, speech normal, memory intact, good concentration Pertinent Results: [**2134-10-8**] 04:31PM GLUCOSE-99 UREA N-10 CREAT-0.7 SODIUM-137 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-22 ANION GAP-16 [**2134-10-8**] 04:31PM CALCIUM-8.7 PHOSPHATE-3.3 MAGNESIUM-1.7 CHOLEST-126 [**2134-10-8**] 04:31PM TRIGLYCER-96 HDL CHOL-46 CHOL/HDL-2.7 LDL(CALC)-61 [**2134-10-8**] 04:31PM WBC-6.5 RBC-4.65 HGB-13.8* HCT-38.2* MCV-82 MCH-29.6 MCHC-36.1* RDW-12.4 [**2134-10-8**] 04:31PM PLT COUNT-231 Brief Hospital Course: 1. S/p Carotid stent: pt admitted to CCU for monitoring following PCI. Upon arrival, pt had no complaints. While getting blood drawn, had vagal episode with bradycardia, hypotension, diaphoresis and dizziness. Resolved with IVF bolus, Neosynephrine. ECG unchanged. Remained on low-dose Neo overnight to maintain SBP >120. By the morning, his Neo was weaned off and BP improved with activity. Lopressor was held pending follow-up with Dr. [**First Name (STitle) **]. 2. CAD: was continued on ASA, Plavix and Statin 3. DM: oral meds continued Medications on Admission: ASA 81 QD Plavix 75 QD Lipitor 10 QD Glyburide 2.5 QD Metformin 850 [**Hospital1 **] Lopressor 25 [**Hospital1 **] Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (once a day). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Metformin HCl 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Right carotid stenosis Coronary Artery Disease Discharge Condition: Right carotid widely patent s/p intervention Discharge Instructions: Call Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 7236**] or come to the ER if experiencing any headache, dizziness, lightheadedness, numbness or weakness in any part of your body. DO not take your blood pressure medication (Lopressor)until following up with Dr. [**First Name (STitle) **] on Monday. Followup Instructions: See Dr. [**First Name (STitle) **] on Monday in his office for blood pressure check at which time he will likely restart your blood pressure medication.

[ "414.01", "V45.81", "427.89", "250.00", "458.29", "433.10" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

2903, 2909

1784, 2332

365, 387

3000, 3046

1345, 1761

3404, 3560

886, 960

2497, 2880

2930, 2979

2358, 2474

3070, 3381

975, 1326

296, 327

415, 610

632, 771

787, 870

28,936

107,797

43427

Discharge summary

report

Admission Date: [**2168-5-30**] Discharge Date: [**2168-7-16**] Date of Birth: [**2098-3-24**] Sex: M Service: MEDICINE Allergies: Levaquin Attending:[**First Name3 (LF) 3913**] Chief Complaint: fever Major Surgical or Invasive Procedure: bone marrow biopsy removal of Hickman PICC placement Lumbar puncture History of Present Illness: 70 year old male with history of diffuse large B cell lymphoma, s/p 4 cycles of R-CHOP, 4 cycles of ESHAP and one cycle of [**Hospital1 **] and Zevalin, discharged recently (2 days PTA) after elective admission for mini-MUDS. He is now day 27 status post a nonablative allogeneic transplant with Campath conditioning. His recent admission was c/b febrile neutropenia (no source identified, treated empirically with vanc, cefepime, flagyl and caspo, then subsequently weaned off of these agents), anorexia requiring TPN, diarrhea (c. diff negative x6) and transiently elevated LFTs of unknown etiology (negative ultrasounds). By the time of discharge he was tolerating po's well, had been afebrile for >1week, was constipated and was ambulating. Today he presented to clinic and was noted to have shaking chills and temp to 100.6. He says yesteday he had loose stools (had been given stool softeners on day of admission due to constipation) and his wife feels his line "looks worse". Peripheral and line cultures were drawn in clinic. He was given 1 gram of Vancomycin IV and 2grams of Cefipime and a liter of normal saline with 2 grams of Magnesium Sulfate while in clinic. He was admitted for evaluation of low grade fever. . The patient reports that his overall energy level and endurance has been improving. Denies any drenching nightsweats. He denies any fevers. He is without any pain. He denies any new or worsening lymphadenopathy. Notes that he feels as though his left submandibular node as well as left inguinal node has gotten smaller. Also feels as though his splenomegaly may have improved somewhat. He denies any cough, shortness of breath, chest pain, palpitations, or any other cardiac or respiratory difficulties. Denies any pain anywhere, denies any shortness of breath upon exertion. Denies any vomiting, diarrhea, or constipation. Does continue with a little bit of nausea. He says that he has had intermittent R and L LQ abdominal pain with bloating that is relieved with BMs. He is starting to feel some now and would like a stool softener. Denies any numbness or tingling in the fingers or toes. Past Medical History: 1. Diffuse large cell lymphoma - Initially presented with splenomegaly [**7-2**], found to have bulky disease above and below diaphram - S/p 4 cycles of R-CHOP and then switched to ESHAP due to disease progression. Had persistent pelvic nodes and new inguinal node after second cycle of ESHAP. Autologous transplant planned so underwent stem cell mobilization but had poor cell collection. Restaging PET scans revealed progressive disease both above and below diaphram. He was therefore treated with gemzar/navelbine/prednisone with only partial response. - S/P 3rd cycle of ESHAP [**1-12**] discharged [**1-17**]. - S/P 4th Cycle of ESHAP ([**2168-2-3**]) - S/P [**Hospital1 **] + Zevalin ([**2168-3-22**]) - s/p CAMPATH and mini-MUDS ([**2168-5-3**]) 2. s/p cataract surgery 3. left inguinal hernia 4. Right UPJ Stone Social History: He is married, Russian (from [**Location (un) 3156**]), was a music composer and played the saxophone, no tobacco (quit 40 years ago), no alcohol, no drugs. Also practices yoga on a regular basis. Was a professional soccer player in the past. Family History: Two siblings are healthy. No history of malignancy. Physical Exam: Temp: 98.7 BP: 144/82 HR: 92 RR: 20 O2 SAT: 98%RA 144.2lbs GEN: No acute distress, alert, oriented, thin elderly man HEENT: Extraocular movements intact, pupils equal at ~2mm, reactive to light. pharynx is non injected. Neck: supple, palpable L submandibular node, small left-sided inguinal node palpable CV: Regular rate, no murmurs, rubs or gallops. S1, S2 auscultated LUNGS: Clear to auscultation bilaterally, no rales, rhonchi or wheezes. ABD: Soft, non tender, non distended, with palpable spleen at the left inferior costal margin, palpable hepatic edge. No rebound tenderness. Extr: mild puffiness in feet, no pitting edema, 2+DPs Neuro: Cranial nerves II-XII grossly intact. [**5-30**] strenght at biceps, triceps, quadriceps and ankle extensors. R port c/d/i mild erythema at entry but no pus/drainage Pertinent Results: MICROBIOLOGY [**2168-5-30**] 9:15 am Immunology (CMV) **FINAL REPORT [**2168-5-31**]** CMV Viral Load (Final [**2168-5-31**]): CMV DNA not detected. Performed by PCR. Detection Range: 600 - 100,000 copies/ml. [**2168-5-30**] 12:20 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2168-5-31**]** URINE CULTURE (Final [**2168-5-31**]): NO GROWTH. [**2168-5-31**] ASPERGILLUS GALACTOMANNAN ANTIGEN 0.082 (NEG) < 0.5 Index [**2168-5-31**] B-GLUCAN <31 pg/ml Negative Less than 60 pg/ml IMAGING: [**2168-5-30**] PORTABLE CXR- In comparison with the study of [**5-18**], there is no interval change. Minimal streak of atelectasis at the left base above the slightly elevated left hemidiaphragm. No evidence of acute pneumonia or vascular congestion. Central catheter remains in place. . CT TORSO W/O CONTRAST [**2168-5-31**] 2:27 PM CT CHEST WITHOUT INTRAVENOUS CONTRAST: Multiple mediastinal lymph nodes have slightly increased in size and number. Bilateral axillary lymph nodes have also increased in size. Largest left axillary lymph node measures 12 mm, compared to 8 mm in short axis diameter previously. Central airways are patent to the segmental levels bilaterally. Lung windows continue to demonstrate biapical scarring. Numerous pulmonary nodules are again noted. Right upper lobe pulmonary nodule, series 2, image 18, has slightly increased in size. Left upper lobe pulmonary nodule, series 2, image 21, remains stable in size. Peripheral right upper lobe pulmonary nodule, series 2, image 24, has slightly increased in size, measuring 3 mm compared to 1.5 mm previously. Left upper lobe pulmonary nodule, series 2, image 33, measures 5 mm, compared to 3 mm previously. Multiple other nodules are stable in size. CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Numerous hypodense splenic lesions have increased in size and number. Multiple hypodense lesions in the hepatic parenchyma also appear more prominent on today's study. Right adrenal nodule is stable. Extensive mesenteric and retroperitoneal lymphadenopathy has significantly increased in extent when compared to the prior study. There is no free air and no free fluid in the abdomen. The pancreas, abdominal loops of large and small bowel are unremarkable. CT PELVIS WITHOUT CONTRAST: The 7-mm calculus at the right ureterovesical junction is unchanged in size and appearance. Marked lymphadenopathy is present in the pelvis along the internal and external iliac chains. BONE WINDOWS: Demonstrate no definite evidence of suspicious lytic or sclerotic lesions. IMPRESSION: 1. Interval significant worsening of mediastinal, axillary, retroperitoneal and mesenteric lymphadenopathy, as well as slight increase in size of pulmonary nodules and splenic lesions, concerning for disease progression. 2. More prominent appearance of the hepatic lesions. SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: Hypocellular bone marrow with erythroid and megakaryocytic dysplasia. See note. Histiocytes with ingested hematopoietic cells. See note. No diagnostic morphologic features of involvement by lymphoma seen. Note 1: The dyspoiesis may be related to recent chemotherapy. Note 2: Several histiocytes with ingested hematopoietic precursors were noted. Findings discussed with Dr. [**Last Name (STitle) **] and Dr [**Last Name (STitle) **]. Correlation with clinical findings as well as other laboratory findings is needed to exclude the possibility of an evolving hemophagocytic process. FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: Kappa, Lambda, and CD antigens: 2, 19, 45. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. CD45-bright mature lymphoid cells comprise 1% of total analyzed events. Of these, B cells are extremely scant in number precluding evaluation of clonality. INTERPRETATION Cell marker analysis demonstrates an extremely scant population of B-cells. Clonality could not be assessed in this case due to insufficient numbers of B cells. Correlation with clinical findings and morphology (see S08-[**Numeric Identifier 93446**]) is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. CT CAP: IMPRESSION: 1. Slight increase in mesenteric and pelvic lymphadenopathy as well as size of hepatic lesions. Stable appearance of axillary, retroperitoneal lymphadenopathy, pulmonary nodules and splenic lesions. 2. 5-mm calculus at the right ureterovesical junction. 3. Interval development of small ascites and worsening of the pericardial and small right pleural effusion. CT AP [**2168-7-7**]: IMPRESSION: 1. Disease progression with increase in size of several liver lesions, splenic lesions and retroperitoneal lymph nodes as described above. 2. Overall, more heterogeneous appearance of the liver raises concern for significant disease progression in the liver. Ultrasound examination is recommended to confirm the presence of multiple subcentimeter hypodense lesions as this is a new finding. [**2168-5-29**] 09:54AM PLT COUNT-28* [**2168-5-29**] 09:54AM NEUTS-69.8 LYMPHS-13.1* MONOS-8.5 EOS-8.0* BASOS-0.5 [**2168-5-29**] 09:54AM WBC-4.3 RBC-3.16* HGB-9.6* HCT-27.5* MCV-87 MCH-30.3 MCHC-34.8 RDW-19.9* [**2168-5-29**] 09:54AM CYCLSPRN-186 [**2168-5-29**] 09:54AM ALBUMIN-3.4 CALCIUM-9.4 PHOSPHATE-3.9 MAGNESIUM-1.7 [**2168-5-29**] 09:54AM ALT(SGPT)-17 AST(SGOT)-29 LD(LDH)-358* ALK PHOS-82 TOT BILI-1.2 [**2168-5-29**] 09:54AM GLUCOSE-117* UREA N-36* CREAT-1.4* SODIUM-141 POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14 [**2168-5-30**] 09:15AM GRAN CT-2820 [**2168-5-30**] 09:15AM PLT COUNT-25* [**2168-5-30**] 09:15AM NEUTS-69.4 LYMPHS-14.8* MONOS-7.9 EOS-7.3* BASOS-0.5 [**2168-5-30**] 09:15AM WBC-4.1 RBC-3.09* HGB-9.5* HCT-26.7* MCV-86 MCH-30.9 MCHC-35.7* RDW-20.1* [**2168-5-30**] 09:15AM CYCLSPRN-153 [**2168-5-30**] 09:15AM CALCIUM-9.3 PHOSPHATE-3.6 MAGNESIUM-1.6 URIC ACID-5.5 [**2168-5-30**] 09:15AM ALT(SGPT)-20 AST(SGOT)-27 LD(LDH)-363* ALK PHOS-79 TOT BILI-1.1 DIR BILI-0.5* INDIR BIL-0.6 [**2168-5-30**] 09:15AM UREA N-23* CREAT-1.2 SODIUM-139 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-25 ANION GAP-12 [**2168-5-30**] 12:20PM URINE MUCOUS-RARE [**2168-5-30**] 12:20PM URINE HYALINE-1* [**2168-5-30**] 12:20PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE EPI-0 [**2168-5-30**] 12:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2168-5-30**] 12:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007 Brief Hospital Course: #. Diffuse Large B-Cell Lymphoma: S/p Mini-MUDS w/ cells given on [**2168-5-3**]. WBC recovered well, but with persistent low platelets concerning for slow engraftment v. autoimmune phenomena posttransplant v. disease-related issues, or GVHD (though there were no other signs of GVHD to support this). Given CT findings of increased size and number of [**Doctor First Name **], increased LDH, and BM read, concern for recurrence of disease v. hemophagocytic syndrome. BM bx day 30 concerning for hemophagocytic cells and hemophagocytic syndrome. CT torso ([**6-7**]) to eval for further progression and for abdominal pain etiology noted unchanged to slightly larger LNs and liver lesions. MRI negative for leptomeningeal disease, LP results positive for HHV-6, otherwise, non-diagnostic study given paucity of cells. Started ETOPOSIDE/decadron/cyclosporin [**6-10**] as per HLH protocol to treat disease as well as hemophagocytic syndrome as patient developed mental status changes and high fevers. Patient had significant clinical response with recurrence of neutropenia after doses. Decadron and cyclosporin slowly weaned down. Started on on GCSF on [**6-28**] with subsequent increase in counts. Patient then began to develop increased back pain and mental status changes. CT of CAP showing progression in liver and splenic disease as well as increase in size of lymphanopathy. Patient also began to develop increasing liver function tests (voriconazole dc'd due to hepatotoxicity with no improvement). Plan was for BM biopsy but patient refused. Given increased mental status changes and fevers, concern for recurrence of HLH. Patient was given an additional dose of etoposide. Subsequently patient began refusing all treatment. After much discussion, patient and family were in agreement regarding discontinuation of care. Focus was changed to comfort care. Patient passed away on [**2168-7-16**] comfortably and with family at bedside. . #. Fever: The patient had been febrile when neutropenic during his last admission and had been treated with cefepime (d/c'd [**5-19**]), flagyl, caspo, and Vanco (DC'd [**5-20**]), all of which were weaned as he defervesced. Imaging, cultures and screens for c. diff were unrevealing and he had been transitioned to fluconazole, acyclovir and bactrim for prophylaxis. On admission he had no localizing symptoms, but did have a line which was a potential infectious source. He had one day of loose stools but this was in the context of taking stool softeners for constipation. Suspected line infection v. fungal pulmonary infection v. disease recurrence v. hemophagocytic syndrome. All infectious work up was negative including CMV, EBV, parvovirus, toxoplasma, measles, HHV-8, adenoviral PCR, salmonella stools studies and numerous blood and urine cultures. B-glucan/galactomannan negative. Patient did become positive for HHV-6 both in peripheral blood and CNS. In addition to broad spectrum antibiotics, patient was treated with Foscarnet and one dose of Cidofovir. Given decreased calcium, foscarnet was discontinued and patient was restarted on acyclovir for ppx as HHV-6 had cleared in the peripheral blood. Patient then began spiking fevers on his last week of admission despite broad spectrum antibiotic medications including antifungal therapy. This was thought to be due to progressive disease versus recurrence of hemophagocytosis. Patient was given additional dose of etoposide as above, then began to refuse further treatment. . #. Bradycardia, prolonged QTC: Patient did have episode of torsades, though due to cyclosporine and fluconazole, respectively. EP saw patient and felt no risk of torsades now that off fluconazole. Actually resolved with pulling back PICC line. Patient had no further episodes. . #. Nutrition: Patient unable to tolerate POs. Was on TPN for the majority of his admission. Nutrition followed on a daily basis. . Medications on Admission: 1. Cyclosporine Modified 25 mg Capsule Sig: Five (5) Capsule PO Q12H 2. Folic Acid 1 mg TabletPO DAILY 3. Hexavitamin 1 Cap PO DAILY 4. Fluconazole 200 mg TabletPO Q24H 5. Acyclovir 200 mg Capsule Two (2) Capsule PO Q8H 6. Metoprolol Tartrate 25 mg Tablet 0.5 Tablet PO BID 7. Oxycodone 5 mg Tablet 1-2 Tablets PO Q4H (every 4 hours) prn 8. Nifedipine 90 mg Tab,Sust Rel Osmotic Push 24hr PO DAILY 9. Senna 8.6 mg Tablet 1 Tablet PO BID 10. Docusate Sodium 100 mg Capsule PO BID 11. Saliva Substitution Combo No.2 Thirty (30)ML Mucous membrane QID 12. Bactrim 80-400 mg Tablet One Tablet PO once a day. Discharge Medications: NA - expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "427.89", "584.9", "427.1", "401.9", "275.42", "428.0", "780.6", "V42.81", "287.5", "288.4", "428.22", "789.59", "202.80", "288.00" ]

icd9cm

[ [ [] ] ]

[ "41.31", "99.15", "03.31", "99.25", "38.93" ]

icd9pcs

[ [ [] ] ]

15814, 15823

11198, 15119

275, 346

15874, 15883

4518, 11175

15939, 15949

3618, 3671

15777, 15791

15844, 15853

15145, 15754

15907, 15916

3686, 4499

230, 237

374, 2497

2519, 3341

3357, 3602

10,451

173,699

1872

Discharge summary

report

Admission Date: [**2195-4-12**] Discharge Date: [**2195-4-17**] Date of Birth: [**2129-11-25**] Sex: M Service: CARDIAC MEDICINE CHIEF COMPLAINT: ICD firing. HISTORY OF PRESENT ILLNESS: This is a 65-year-old gentleman, with a history of CD, status post a VT arrest, and PTCA of the LAD in [**2186**], who presents with ICD firing several times over last night. The patient had instances of the ICD firing about 2 weeks ago without any preceding symptoms. He was seen at [**Hospital3 68**] where he was observed for about four days and then released. He had been feeling well until the night before admission when, at about 2:00 am, he began to feel nauseous and then the ICD fired. He did not have preceding chest pain, shortness of breath, palpitations, lightheadedness, or diaphoresis. The ICD fired a second time, and he was seen again at [**Hospital3 68**]. He was observed overnight and then discharged. When the ICD fired again that next day, he called 911 and was brought to [**Hospital1 18**]. He was noted to be in recurrent V-tach and was shocked multiple times by the ICD. RECENT REVIEW OF SYSTEMS: Notable only for diarrhea for the last several days. PAST MEDICAL HISTORY: 1. CAD, status post anterior MI. 2. Prostate cancer, on chemotherapy, last dose 3 weeks ago. 3. Type 2 diabetes x 4 years with the complication of neuropathy. 4. ?History of atrial fibrillation. 5. Hypertension. 6. Hyperlipidemia. MEDICATIONS: 1. Hydralazine 25 mg. 2. Isosorbide 10 mg tid. 3. Metoprolol 50 [**Hospital1 **]. 4. Gemfibrozil 600 [**Hospital1 **]. 5. Warfarin alternating doses of 2 and 4 mg qd. 6. Furosemide. 7. Aspirin 325 qd 8. Glipizide 5 [**Hospital1 **]. 9. Potassium 20 qd. 10.Neurontin 100 tid. 11.Amiodarone 200 qd. ALLERGIES: NKDA. SOCIAL HISTORY: Has smoked about 1-1/2 packs a day for the past 60 years. Denies alcohol or IVDU. Lives with his wife. PHYSICAL EXAM: Vitals on arrival were temperature 98.7, blood pressure 100/60, heart rate 68, respiratory rate 18, 100% on 3 liters. This was an obese gentleman, sitting at 60%, in no apparent distress. He was alert and oriented x 3. He had dry mucous membranes. Pupils were equal and reactive with anicteric sclerae. Neck was supple. It was difficult to assess JVP secondary to habitus. He had very distant heart sounds, but usually regular rate with occasional premature beats. Lungs had decreased breath sounds in the right lower lobe and crackles noted in the left lower lobe. Abdomen was soft, nontender, nondistended, with positive bowel sounds. He had 1+ pitting edema bilaterally to the knees with stasis dermatitis noted. LABS AND STUDIES: EKG showed sinus with AV delay, questionable right bundle branch pattern with left anterior fascicular block. Left axis deviation. Inverted T waves were noted in AVL. Q waves in V1, V2, with poor R wave progression. On rhythm strips taken during events, he was noted to have a wide complex regular tachycardia at a rate of approximately 250, that after shock responded by changing into an irregular more narrow complex tachycardia (AF). Initial CBC showed a white count of 8.1, hematocrit 34.4, platelet count 180. He had a PT of 16.6, PTT 22, INR 1.8. Chem-7 showed a sodium of 140, potassium 3.8, chloride 104, CO2 24, BUN 15, creatinine 0.8, glucose 170. He had a calcium of 9.2, mag 2.0, phos 3.4. Initial set of enzymes showed a CK of 26, troponin-T less than 0.01. Previous cath performed in [**2186-4-12**] showed a 100% RCA lesion, LAD of 100% that was PTCA'd, EF 25%, with apical and anterolateral akinesis. HOSPITAL COURSE: The patient was admitted to cardiac medicine on telemetry. He was scheduled for an ICD pacer interrogation by EP. His enzymes were followed to rule out MI. On the evening of admission, [**4-12**], the patient experienced multiple runs of V-tach with the rate in the 200s. He was shocked by his ICD multiple times. His vital signs were initially stable, other than the rhythm of VT. He was given 150 mg IV amiodarone, 5 mg IV metoprolol x 2, 2 gm of magnesium, 40 mEq of KCL, and 0.5 mg of versed. After receiving these medications, the patient's blood pressure decreased to the 70s/40s. He was given a bolus of fluids, after which he increased to 90/60. The EKG showed no ischemic changes. However, he was transferred to the ICU for further monitoring and continuation of the amiodarone GTT. He had a femoral line placement at that time. He was monitored in the ICU until [**4-13**]. At this point, he was determined stable enough to return to the floor. He underwent a VT ablation procedure by electrophysiology on [**4-14**]. Overnight, on the [**4-15**], the patient developed intermittent AFIB with rates into the 120s-130s, and a blood pressure, systolic, in the 90s/70s. He received IV beta blocker and converted back into normal sinus rhythm with a rate in the 80s. He had no chest pain or shortness of breath during this episode. In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor. Given his recurrent episodes of AFIB with rapid ventricular response, he was taken to the EP Lab for a synchronous cardioversion on the morning of the 4. He received 1 shock of 200 joules and converted to normal sinus rhythm with a rate in the mid-80s. He was changed to an amiodarone rate of 400 [**Hospital1 **], his beta blocker was increased to tid dosing of 37.5 metoprolol, a low dose ACE inhibitor was added at 6.25 tid, and digoxin qd of 0.125 was added as well. The patient remained stable status post cardioversion, and by the [**4-17**], on hospital day #6, he was feeling well with stable heart rate and blood pressure. His INR was noted to be therapeutic between 2 and 3. The patient was evaluated by physical therapy and determined that he did not need home services. It was decided that he was prepared for discharge with a 4-week follow-up with Device Clinic and [**Doctor Last Name 1911**] in cardiology. DISCHARGE CONDITION: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Ventricular tachycardia. 3. Atrial fibrillation with rapid ventricular response. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg qd. 2. Gabapentin 100 mg q 8 h. 3. Gemfibrozil 600 mg [**Hospital1 **]. 4. Lasix 20 mg qd. 5. Glipizide 5 mg [**Hospital1 **]. 6. Metoprolol 37.5 mg tid. 7. Amiodarone 400 mg [**Hospital1 **] for the first 2 weeks post discharge, with instructions to the patient to decrease to 400 mg qd thereafter until seen in [**Hospital **] Clinic. 8. Digoxin 0.125 qd. 9. Captopril 6.25 tid. 10.Warfarin 2.5 qd. FOLLOW-UP: The patient is scheduled to be seen in Device Clinic and by Dr. [**Last Name (STitle) 1911**] on [**5-11**]. He was instructed to continue his Coumadin blood draws as he had been prior to his admission to the hospital. [**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**] Dictated By:[**Last Name (NamePattern1) 10454**] MEDQUIST36 D: [**2195-4-17**] 12:21 T: [**2195-4-17**] 12:25 JOB#: [**Job Number 10455**]

[ "V45.82", "272.4", "427.1", "357.2", "414.01", "412", "427.31", "250.60", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.61", "37.34" ]

icd9pcs

[ [ [] ] ]

6255, 6291

6312, 6425

6448, 7384

3611, 6233

1921, 3593

1144, 1198

168, 181

210, 1124

1220, 1782

1799, 1905

27,788

133,330

33953

Discharge summary

report

Admission Date: [**2151-8-2**] Discharge Date: [**2151-8-6**] Date of Birth: [**2090-8-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: arrythmia Major Surgical or Invasive Procedure: Mitral valve replacement #33 Mosaic porcine valve, MAZE with left atrial ligation on [**2151-8-2**] History of Present Illness: Mr. [**Known lastname **] is a 60 year old gentleman who was diagnosed with atrial fibrillation in [**4-20**]. Upon a recent hospitalization for palpitations, he was found to have mitral valve regurgitation also. Past Medical History: mitral valve regurgitation atrial fibrillation juvenile rheumatoid arthritis Social History: Mr. [**Known lastname **] works in real estate sales. He smoked for 20 years, but quit in [**2124**]. Family History: His brother was diagnosed with coronary artery disease and congestive heart failure at age 55. He lives with his wife in [**Name (NI) 3844**]. Physical Exam: At the time of discharge, Mr. [**Known lastname **] was awake, alert, and oriented. Upon auscultation of his lungs, be was found to have rales scattered throughout. His heart was of regular rate and rhythm. His abdomen was soft, non-tender, and non-distended. His sternum was clean, dry , and intact. His sternum was stable. Trace edema was noted. Pertinent Results: [**2151-8-5**] 07:15AM BLOOD WBC-16.9* RBC-3.27* Hgb-9.8* Hct-29.0* MCV-89 MCH-30.1 MCHC-33.9 RDW-14.3 Plt Ct-157 [**2151-8-5**] 07:15AM BLOOD PT-30.3* INR(PT)-3.1* [**2151-8-4**] 06:50AM BLOOD Glucose-134* UreaN-11 Creat-0.6 Na-133 K-4.6 Cl-99 HCO3-25 AnGap-14 [**2151-8-6**] 06:20AM BLOOD WBC-15.7* RBC-3.18* Hgb-9.6* Hct-27.4* MCV-86 MCH-30.1 MCHC-35.0 RDW-14.5 Plt Ct-237# [**2151-8-6**] 06:20AM BLOOD Glucose-118* UreaN-12 Creat-0.5 Na-135 K-3.9 Cl-100 HCO3-25 AnGap-14 [**2151-8-6**] 06:20AM BLOOD Plt Ct-237# Brief Hospital Course: On [**2151-8-2**] Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a mitral valve replacement with a #33 Mosaic porcine valve and a MAZE with left atrial appendage ligation. This procedure was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**]. He tolerated the procedure well and was able to be transferred in critical but stable condition to the surgical intensive care unit. He was extubated on the evening after surgery and was weaned from his pressors. His chest tubes were removed. Mr. [**Known lastname **] was transferred to the surgical step down floor. He was placed on coumadin for his atrial fibrillation, although he remained in sinus rhythm post-operatively. Keflex was started for slight sternal incision erythema. He was seen in consultation by the elctrophysiology service. The physical therapy service evaluated him and was gently diuresed. Beta-blockade was not started beyond what is offered by the sotalol secondary to a systolic blood pressure in the 110's. By post-operative day four he was ready for discharge to home. Medications on Admission: sotalol 120 mg [**Hospital1 **] Simvastatin 40 mg daily Discharge Medications: 1. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): for constipation while taking percocet. Disp:*60 Capsule(s)* Refills:*0* 6. Outpatient Lab Work INR drawn on [**2151-8-7**] with results sent to the office of Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 78431**]. INR goal of [**2-13**].5 for atrial fibrillation 7. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days. Disp:*20 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 5 days: for sternal incision erythema. Disp:*20 Capsule(s)* Refills:*0* 10. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day for 1 days: take 4 mg nightly unless otherwise directed by the office of Dr. [**Last Name (STitle) **]. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] care Discharge Diagnosis: mitral valve regurgitation atrial fibrillation juvenile rheumatoid arthritis Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please see Dr [**Last Name (STitle) **] in 2 weeks (PCP) ([**Telephone/Fax (1) 78431**] please call for appointment Please see Dr [**Last Name (STitle) 78250**] in 4 weeks (cardiologist in NH) ([**Telephone/Fax (1) 78432**] please call for appointment Please see Dr [**Last Name (STitle) 914**] in 2 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Patient will need INR for atrial fibrillation history drawn on Saturday [**2151-8-7**] with results sent to the office of Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 78431**] with a goal INR of [**2-13**].5. Plan confirmed with [**Doctor First Name **] from the office of Dr. [**Last Name (STitle) **]. Completed by:[**2151-8-6**]

[ "714.30", "424.0", "998.59", "E878.1", "427.31", "695.9" ]

icd9cm

[ [ [] ] ]

[ "88.72", "39.61", "37.26", "35.23", "37.33" ]

icd9pcs

[ [ [] ] ]

4687, 4739

1982, 3077

328, 430

4860, 4867

1442, 1959

5378, 6087

909, 1054

3183, 4664

4760, 4839

3103, 3160

4891, 5355

1069, 1423

279, 290

458, 673

695, 773

789, 893

14,271

188,934

13169

Discharge summary

report

Admission Date: [**2166-7-22**] Discharge Date: [**2166-7-26**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2078**] Chief Complaint: Transfer from outside hospital for cardiac catheterization s/p ST elevation MI Major Surgical or Invasive Procedure: Cardiac catheterization with cypher stent to right cornary artery History of Present Illness: 87 yo F transferred from [**Location (un) 620**] with STD antero-laterally for cath. On day of admission, she had pre-syncope at her [**Hospital 4382**] facility. EMT was called and found to be brady to 30's with BP 80/40. EKG showed junctional rhythm, rate of 40. She was given atropine and Ca gluconate, glucagon at [**Location (un) 620**] and started on dopamine gtt. Head CT neg for bleed at [**Location (un) 620**]. She was temporarily externally paced. She then went into SR, rate 80, STD anterolaterally. She was given ASA, plavix 600 mg, heparin gtt and integrillin and tranferred to [**Hospital1 18**] cath lab. CK 26, trop <0.02 at [**Location (un) 620**]. Cath showed LMCA with no angiographic apparent CAD, LAD with mid and distal long tubular 50% stenosis, LCX with no angiographic apparent stenosis, RCA with mid 95% long stenosis that was stented. She was more confused at [**Location (un) 620**] and there was concern for ischemic stroke and was sent to MRI/MRA to rule out stroke after cath. Per son, at baseline she is sharp, oriented. Past Medical History: Facial droop Hypercholesterolemia ?CAD Jaw cancer s/p resection and hip bone graft (leading to weakness in L hip) [**2156**] Social History: Lives in [**Hospital3 **] facility, 3 children. Husband deceased. Family History: Father with MI at young age. Physical Exam: 96.4, 200/85, 68, 18, 100% on 2L GENL: pleasant, NAD HEENT: dry MM CV: RRR, systolic murmur Lungs: CTA anteriorly ABD: soft, nt, nd, +bs Ext: 1+ DP, PT pulses Neuro: alert and oriented (date [**2166-7-20**]), slightly confused at cath MRI, better oriented with son in room in CCU. strength 4+/5 in L foot ext/flexorsy, [**4-3**] in R foot flexors/ext, [**4-3**] in finger extensors, flexors. FTN with slight dysmetria, Pupils 5-6mm and not reactive, EOMI, OP clear, L facial droop (chronic). Pertinent Results: EKG: 11:47 AM: junctional rhythm, rate 40, nl axis, narrow QRS. 1:15PM: ?afibrate 69, STD in I, II, V2-V6. 1:27PM: SR, rate 80, STD in I, II, V2-V6 Post cath: NSR, rate 70, nl axis, nl int, STD normalized. Head CT - no bleed from OSH Head MRI/MRA - chronic ischemic changes. no acute bleed. [**2166-7-22**] 06:20PM BLOOD WBC-10.5 RBC-3.16* Hgb-10.4* Hct-29.1* MCV-92 MCH-32.8* MCHC-35.5* RDW-13.2 Plt Ct-213 [**2166-7-23**] 05:15PM BLOOD Hct-26.4* [**2166-7-26**] 07:15AM BLOOD WBC-4.7 RBC-3.67* Hgb-11.7* Hct-33.8* MCV-92 MCH-31.8 MCHC-34.5 RDW-13.8 Plt Ct-209 [**2166-7-22**] 06:20PM BLOOD PT-13.1 PTT-21.8* INR(PT)-1.1 [**2166-7-23**] 01:50AM BLOOD Plt Ct-202 [**2166-7-23**] 03:38AM BLOOD PT-12.9 PTT-19.3* INR(PT)-1.1 [**2166-7-26**] 07:15AM BLOOD Plt Ct-209 [**2166-7-22**] 06:20PM BLOOD Ret Aut-2.1 [**2166-7-22**] 06:20PM BLOOD Glucose-137* UreaN-20 Creat-1.1 Na-137 K-4.2 Cl-104 HCO3-20* AnGap-17 [**2166-7-23**] 09:10AM BLOOD Glucose-166* UreaN-17 Creat-0.7 Na-133 K-3.7 Cl-100 HCO3-19* AnGap-18 [**2166-7-26**] 07:15AM BLOOD Glucose-132* UreaN-14 Creat-0.7 Na-141 K-3.9 Cl-107 HCO3-23 AnGap-15 [**2166-7-22**] 06:20PM BLOOD ALT-27 AST-43* LD(LDH)-186 CK(CPK)-59 AlkPhos-44 TotBili-0.3 [**2166-7-23**] 01:50AM BLOOD CK(CPK)-142* [**2166-7-23**] 09:10AM BLOOD CK(CPK)-163* [**2166-7-23**] 05:15PM BLOOD CK(CPK)-155* [**2166-7-22**] 06:20PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2166-7-23**] 01:50AM BLOOD CK-MB-7 cTropnT-0.08* [**2166-7-23**] 09:10AM BLOOD CK-MB-12* MB Indx-7.4* cTropnT-0.14* [**2166-7-23**] 05:15PM BLOOD CK-MB-11* MB Indx-7.1* cTropnT-0.15* [**2166-7-22**] 06:20PM BLOOD Albumin-4.1 Calcium-9.2 Phos-3.7 Mg-1.6 Iron-36 Cholest-175 [**2166-7-23**] 11:58PM BLOOD Mg-1.8 [**2166-7-26**] 07:15AM BLOOD Mg-1.7 [**2166-7-22**] 06:20PM BLOOD calTIBC-425 Ferritn-316* TRF-327 [**2166-7-23**] 09:10AM BLOOD VitB12-456 Folate-20.0 [**2166-7-22**] 06:20PM BLOOD Triglyc-386* HDL-44 CHOL/HD-4.0 LDLcalc-54 [**2166-7-22**] 04:50PM BLOOD Type-ART pO2-92 pCO2-37 pH-7.26* calHCO3-17* Base XS--9 Intubat-NOT INTUBA [**2166-7-22**] 04:50PM BLOOD Hgb-10.5* calcHCT-32 O2 Sat-96 [**2166-7-22**] 06:20PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . Blood and urine cultures negative . Cardiac catheterization: 1. Coronary angiography of this right dominant circulation demonstrated two vessel coronary artery disease. The LMCA had no angiographically apparent CAD. The LAD had mid and distal long tubular 50% stenosis. The LCX had no angiographically apparent CAD. The RCA had 95% long mid vessel stenosis. 2. Left ventriculography demonstrated normal wall motion with contrast calculated ejection fraction of 57%. There was 2+ mitral regurgitation. There was no gradient across the aortic valve. 3. Resting hemodynamics demonstrated elevated filling pressures with mRAP of 14 mmHg and mPCWP of 32 mmHg. There was moderate pulmonary hypertension with mPAP of 35 mmHg. The Fick calculated cardiac output and cardiac index were slightly reduced at 3.9 L/min and 2.2 L/min/m2, respectively. 4. Successful PCI of the anterior takeoff mid-RCA with a 3.0 x 28 mm Cypher DES, post-dilated with a 3.5 mm balloon. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Elevated filling pressures. 3. Normal left ventricular systolic function. 4. Moderate diastolic dysfunction. 5. Successful PCI of the mid-RCA. . PORTABLE AP CHEST AT 8:05: No prior studies are available for comparison. Heart size, mediastinal contours, and pulmonary vessels are normal. There is no pulmonary edema/CHF or pleural effusion. The lungs are clear. . Echo:The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is very mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal inferior wall. . The remaining left ventricular segments contract normally and overall systolic function is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Very mild regional left ventricular systolic dysfunction c/w CAD. Mild aortic regurgitation. Mild mitral regurgitation. Brief Hospital Course: 87 yo female admitted with presyncope found to be bradycardic, with ST depressions on EKG, s/p cath with stent to RCA. . 1. ST elevation MI: Patient was transferred from outside hospital for cardiac catheterization. A 95% RCA lesion was revealed and a cypher stent was placed without complications. She was stable for transfer to the floor by the second day of admission. Her anti-hypertensives were titrated to control her blood pressure. Her echo showed very mild regional left ventricular systolic dysfunction c/w CAD, mild aortic regurgitation and mild mitral regurgitation. Her EKG revealed NSR with a rate of 75 and non-specific T wave changes at discharge. She was discharged on lisinopril 40 mg po qd, metoprolol XL 50 mg po qd, Plavix, aspirin, Lipitor and gemfibrozil. She will follow up with her PCP to have her LFTs checked in 1 month as she is on a Statin and a fibrate, and next week to have her HCT and lytes checked. She will follow up with Dr. [**Last Name (STitle) **] for her cardiology care. . 2. Rhythm: On arrival to [**Location (un) 620**] patient was in junctional rhythm. The etiology of this was unclear but may have been from verapamil. She was bradycardic on transfer but was in NSR. Her atenolol and verapamil were discontinued. She was started on metoprolol as mentioned above and her heart rate was stable in NSR with rates in 60's-70's by discharge. . 3. Hypertension: Patient was hypertensive to 200's on arrival with unclear precipitant. CXR did not reveal any pulmonary edema. Her antihypertensives were titrated as mentioned above and her SBPs in the 130's by discharge. . 4. Conjunctivitis: Patient had some conjuntival injection and eye discharge and was given Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID with near resolution by discharge. 5. Hypercholesterolemia: Triglycerides were elevated, therefore gemfibrozil was continued and atorvastatin was added. She will follow up with her PCP to have her LFTs checked in 1 month. . 6. Change in mental status: Neurology consult was obtained and recommended MRI which was negative for bleed. Blood cultures, urine cultures and CXR were negative. It was believed that this was medication related given the amount of atropine she was given at OSH. Her mental status cleared by the second hospital day and she had no neurological deficits. 7. Anemia: Unclear etiology. Iron studies and coags were unremarkable. She was transfused 1 unit pRBCs. Her HCT bumped appropriately and remained stable. She follow up as an outpatient for a colonoscopy. Medications on Admission: Verapamil SA 180 mg QD Gemfibrozil 600 mg QD Lopid 600 mg [**Hospital1 **] Premarin 0.625 mg QD Atenolol 25 mg QD Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). Disp:*1 * Refills:*2* 6. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). Disp:*1 * Refills:*2* 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1411**] VNA/[**Company 1519**] Phone Discharge Diagnosis: 1. NSTEMI 2. Bradycardia 3. Hypertension 4. Conjunctivitis Discharge Condition: hemodynamically stable, asymptomatic Discharge Instructions: If you have any chest pain, shortness of breath, dizziness, or nausea call you doctor or go to the emergency room. Your new medications include: 1. Lisinopril 40 mg once daily 2. Metoprolol XL 50 mg once daily 3. Plavix 75 mg once daily 4. Aspirin 325 mg once daily 5. Lipitor 20 mg once daily 6. You can continue your gemfibrozil 600 mg twice daily but should have your liver function tests checked by your primary doctor in [**3-5**] weeks as lipitor was added to you regimen and can cause an increase in liver enzymes in combination with gemfibrozil. DO NOT TAKE YOUR ATENOLOL OR VERAPAMIL. Followup Instructions: You should follow-up with your primary care doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] [**Telephone/Fax (1) 8506**] on [**Last Name (LF) 766**], [**7-28**] at 11:15 am to check your blood pressure and to check your blood electrolytes and hematocrit. You should also have him follow your blood glucose levels as they were mildly elevated during your admission. It is also recommmended that you have an outpatient colonscopy as you were anemic during your admission. You have a follow up appointment with a cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5543**] [**Telephone/Fax (1) 4105**] and the [**Hospital1 **] in [**Location (un) 620**] on Thursday, [**8-7**] at 10:15 am. You should go to the registration desk with your insurance information first and they will direct you to Dr.[**Name (NI) 40168**] office.

[ "424.0", "414.01", "410.71", "272.0", "372.30", "401.9" ]

icd9cm

[ [ [] ] ]

[ "36.01", "37.23", "36.07", "00.17", "88.53", "88.56" ]

icd9pcs

[ [ [] ] ]

10474, 10558

6763, 8760

298, 366

10661, 10700

2256, 5443

11345, 12236

1698, 1729

9472, 10451

10579, 10640

9333, 9449

5460, 6740

10724, 11322

1744, 2237

180, 260

394, 1450

8775, 9307

1472, 1598

1614, 1682

19,689

180,660

506

Discharge summary

report

Admission Date: [**2196-6-26**] Discharge Date: [**2196-7-4**] Date of Birth: [**2137-10-7**] Sex: F Service: [**Doctor Last Name 1181**] HISTORY OF PRESENT ILLNESS: This is a 59-year-old woman with multiple medical problems, including coronary artery disease status post coronary artery bypass graft, chronic obstructive pulmonary disease on home oxygen, insulin-dependent diabetes mellitus, peripheral vascular disease status post above the knee amputation, bilateral carotid endarterectomies, femoral-popliteal bypass, who presented on [**6-26**] with shortness of breath after being found by her daughter obtunded and cyanotic, with the oxygen nasal cannula removed. The patient presented to the Emergency Room on [**6-26**] with shortness of breath, progressive over the course of the preceding days. Her daughter reported finding the patient cyanotic and obtunded, lying in bed with her oxygen nasal cannula removed from her face. The patient also reported progressively increasing swelling of her extremities in the days preceding admission. On arrival to the Emergency Department, the patient was 98% on 3 liters nasal cannula. She denied any chest pain, cough, fever or chills. According to the patient, she had been admitted to [**Hospital 4199**] Hospital several times between [**Month (only) 958**] and [**2196-4-22**] for volume overload and chronic obstructive pulmonary disease exacerbations. Per patient, she was admitted in [**Month (only) 958**] for three months, and required three visits to the Medical Intensive Care Unit, with multiple intubations. She was discharged from [**Last Name (un) 4199**] in [**Month (only) **], and she had just completed her steroid taper that was initiated with these flares. She was then readmitted to [**Last Name (un) 4199**] on [**2196-6-10**] with nausea, vomiting, and lethargy, and was found on admission to be febrile, with a potassium of 6.8, a blood sugar of 460, and elevated transaminases. At this time, the hyperkalemia was thought secondary to Zestril, which was discontinued. She was treated with insulin and Kayexalate and discharged to home on [**2196-6-22**]. PAST MEDICAL HISTORY: 1. Insulin-dependent diabetes mellitus 2. Chronic obstructive pulmonary disease (dependent on home oxygen, uses steroids during flares, history of multiple intubations) 3. Coronary artery disease status post coronary artery bypass graft in [**2189**] 4. Peripheral vascular disease status post femoral-popliteal bypass, right above the knee amputation, bilateral carotid endarterectomies 5. Status post abdominal aortic aneurysm repair 6. Bipolar disorder ALLERGIES: Sulfa, Tolinase SOCIAL HISTORY: The patient lives alone in [**Hospital3 **]. Her daughter lives in the area, and helps to care for her. Her daughter has offered to have the patient move in with her, but the patient has been reluctant to do so for fear of becoming a burden to her daughter. The patient admits to multiple suicide attempts with pills in the last few years, most recently a few months ago. The patient also reports severe depression following the death of her husband from [**Name (NI) 2481**] disease last year. The patient also expresses extreme frustration with the intensive medical care which she has had to receive over the course of the last few years. PHYSICAL EXAMINATION: On admission to the Emergency Department, the patient had a temperature of 97.7, pulse of 70, blood pressure 105/54, respiratory rate 14, and oxygen saturation of 98% on 3 liters by nasal cannula. In general, she was comfortable, breathing rapidly, in no acute distress. Head, eyes, ears, nose and throat examination showed the patient to have severe facial edema, and her extraocular muscles were intact, pupils equal, round and reactive to light. On neck examination, there was no jugular venous distention, and no carotid bruits. On lung examination, she had decreased air movement in both lung fields, but no wheezes or rales. On heart examination, she had distant heart sounds, a regular rate and rhythm, with a II/VI systolic murmur, loudest at the right upper sternal border, with no gallops. On abdominal examination, she had normal active bowel sounds. Her abdomen was soft, nondistended and nontender. There was no hepatosplenomegaly, and no guarding or rebound. On extremity examination, her right leg (status post above the knee amputation), there was pitting edema in the thigh. In her left leg, there was pitting edema to the thigh. On neurological examination, she was alert and oriented x 3, extraocular muscles were intact, pupils equal, round and reactive to light, moved three extremities, 2+ patellar reflex on the left. LABORATORY DATA: CBC showed white blood cells of 7.4, hematocrit 33.7, platelets 245. Sodium 140, potassium 5.5, chloride 101, CO2 25, BUN 43, creatinine 0.9, glucose 260. Calcium 8.3, magnesium 4.7, phosphate 2.2. Ionized calcium 1.13. PT 14.9, PTT 25.6, INR 1.5. Arterial blood gas 77/58/7.4. CK was 81, troponin less than 0.3. Urinalysis showed glucose of 500, but otherwise normal. IMAGING: A chest x-ray showed a right pleural effusion and atelectasis vs. pneumonia in the right lower lobe. There were indistinct perihilar structures, but no overt pulmonary edema. An electrocardiogram showed normal sinus rhythm at 75 beats per minute, Q waves in II, III and AVF, right bundle branch block with ST depression in V2 to V3, with T wave inversion. HOSPITAL COURSE: In the Emergency Department, the patient was diuresed 1700 cc. She was admitted to the Medical Intensive Care Unit due to perceived respiratory distress. In the Medical Intensive Care Unit, she was ruled out for myocardial infarction, and diuresis was continued with symptomatic improvement. She was called out to the floor the next morning. On examination upon transfer to the floor, the patient was found to have signs of significant right heart failure greater than left heart failure, although prior records showed evidence of severe left ventricular dysfunction as well as right ventricular dysfunction. On the floor, she was aggressively diuresed with lasix and Zaroxolyn. The patient responded well to this diuresis, and overall was approximately 20 liters negative by the time of discharge to rehabilitation. Given her history of hyperkalemia, the patient was diuresed with lasix and Zaroxolyn without addition of an ACE inhibitor and Aldactone. She was continued on her beta blocker and Digoxin. During the admission, the patient's standing insulin dose was increased from baseline, and her blood sugars decreased from the high 200s on admission to the low 100s prior to discharge. The patient was changed back to her baseline insulin regimen prior to discharge in the context of a steroid taper. Her hemoglobin A1c was found to be 11.3, indicating poor chronic control of her diabetes mellitus. During the admission, her triglycerides were 91, HDL 44, LDL 111. During this admission, the patient expressed great dissatisfaction with her current quality of life, feeling degraded by a lack of motility and a lack of autonomy. Psychiatry was consulted, and they concluded that the patient was capable of making decisions about whether and how aggressively to pursue standard medical care. The palliative care team was also consulted to discuss with the patient her goals for treatment. The patient decided to pursue medical treatment despite her ambivalence about her goals--she desires to be alive, to enjoy her family, while at the same time she sees how difficult it is to lose her independence. After extensive discussion with the palliative care team, Ms. [**Known lastname **] decided to continue medical treatment for now, and opted for discharge to [**Hospital 3058**] rehabilitation before moving in with her daughter at her home. Physical Therapy has seen the patient, and has decided that she is a good candidate for physical rehabilitation. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: Discharged to [**Hospital 3058**] rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Worsened ascites DISCHARGE MEDICATIONS: 1. Albuterol two puffs inhaler every four hours as needed 2. Aspirin 325 mg by mouth once daily 3. Digoxin 0.125 mg by mouth every other day 4. Divalproex sodium 250 mg by mouth every morning, 500 mg by mouth every evening 5. Docusate sodium 100 mg by mouth twice a day 6. Lasix 120 mg by mouth once daily 7. Hydrocodone/acetaminophen one tablet by mouth every eight hours as needed 8. Regular insulin sliding scale 9. Ipratropium bromide two puffs inhaled every four hours as needed 10. Metolazone 5 mg by mouth once daily 11. Metoprolol 25 mg by mouth twice a day 12. Pantoprazole 40 mg by mouth once daily 13. Prednisone 20 mg by mouth once daily 14. Senna two tablets by mouth twice a day 15. Temazepam 15 mg by mouth daily at bedtime 16. Warfarin 4 mg by mouth every other day 17. Potassium chloride 20 mEq by mouth once daily DISCHARGE PLAN: The patient plans to move to [**Hospital 3058**] rehabilitation for approximately ten days before moving in at her daughter's residence. The goals for treatment at [**Hospital 3058**] rehabilitation include: 1. Diuresis with a goal of 1 to 2 liters negative per day. Will need to check BUN, creatinine, potassium, HCO3 daily for the first three to four days of rehabilitation. Lasix and potassium chloride doses will need to be adjusted as necessary. 2. The patient will need physical therapy for moving out of bed to chair. 3. The patient will need to begin a prednisone taper beginning with prednisone 20 mg by mouth once daily for three days, prednisone 10 mg by mouth once daily for three days, and then prednisone 5 mg by mouth once daily for three days, and then no prednisone. 4. The patient will need to be continued on home oxygen (2 to 3 liters via nasal cannula). 5. If potassium remains stable on current regimen, can consider reinstituting ACE inhibitor and Aldactone at a later time. [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 4200**], M.D. [**MD Number(1) 4201**] Dictated By:[**Last Name (NamePattern1) 4202**] MEDQUIST36 D: [**2196-7-4**] 02:02 T: [**2196-7-4**] 03:40 JOB#: [**Job Number 4203**]

[ "496", "276.5", "443.9", "250.01", "428.0", "311", "414.01", "V49.76", "V45.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8157, 8999

8112, 8134

5502, 7988

3367, 5483

8003, 8091

189, 2164

9016, 10302

2186, 2679

2697, 3343

2,937

145,662

51177

Discharge summary

report

Admission Date: [**2184-4-28**] Discharge Date: [**2184-5-2**] Date of Birth: [**2105-4-14**] Sex: M Service: CARDIOTHORACIC Allergies: Ciprofloxacin / Nifedipine / Percocet Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest and abdominal pain Major Surgical or Invasive Procedure: Cardiac Catheterization [**2184-4-29**] History of Present Illness: This is a 79 year old gentleman with a notable past medical history of hypertension and a repair of an infrarenal abdominal aortic aneurysm in [**2176**] who presents with acute onset [**5-10**] diffuse abdominal pain that several hours prior to admission. He has mild epigastric pain as well. He has no fevers/diarrhea/constipation/shortness of breath. His last bowel movement was yesterday and he is passing gas. He has a mild cough. Past Medical History: Hypertension Atrial Fibrilation Infrarenal abdominal aortic aneurysm s/p repair '[**76**] Throat Cancer Partial Small Bowel Obstruction Hodgkin's disease COPD Social History: The patient is married and lives with his wife. [**Name (NI) **] is a prior world war 2 veteran. He has a prior smoking history of 1 pack/day for 55 years. He occasionally drinks alcohol. Family History: Non-contributory. Physical Exam: On admission: Afebrile, BP 150s/60s, pulse 70s sinus, 20, sat 98% on room air Gen: anxious, no acute distress, slightly underweight HEENT: MMM, EOMI Neck: no masses/lymphadenopathy CV: RRR, no murmur Pulm: CTAB Abd: soft, mild epigastric tenderness, palpable mid-abdominal pulse, old surgical scars Extr: no edema Neuro: grossly intact Pertinent Results: SEROLOGIEs: [**2184-4-28**] 05:20AM BLOOD WBC-4.7 RBC-3.28*# Hgb-8.5*# Hct-26.6*# MCV-81* MCH-26.0*# MCHC-32.0 RDW-16.0* Plt Ct-281 [**2184-4-28**] 01:14PM BLOOD Hct-23.1* [**2184-4-28**] 09:19PM BLOOD Hct-26.5* [**2184-4-29**] 02:56AM BLOOD WBC-6.0 RBC-3.66* Hgb-10.6* Hct-29.9* MCV-82 MCH-29.0# MCHC-35.6*# RDW-15.7* Plt Ct-264 [**2184-4-29**] 02:11PM BLOOD Hct-32.4* Plt Ct-256 [**2184-4-29**] 08:23PM BLOOD Hct-31.7* [**2184-4-30**] 03:16AM BLOOD WBC-6.1 RBC-4.32* Hgb-11.6* Hct-35.0* MCV-81* MCH-26.9* MCHC-33.2 RDW-16.1* Plt Ct-252 [**2184-4-28**] 05:20AM BLOOD PT-14.8* PTT-28.7 INR(PT)-1.3* [**2184-4-28**] 01:14PM BLOOD PT-15.1* PTT-32.7 INR(PT)-1.4* [**2184-4-29**] 02:56AM BLOOD PT-14.8* PTT-30.4 INR(PT)-1.3* [**2184-4-28**] 05:20AM BLOOD Glucose-100 UreaN-24* Creat-2.3*# Na-137 K-3.8 Cl-102 HCO3-25 AnGap-14 [**2184-4-28**] 01:14PM BLOOD Glucose-97 UreaN-22* Creat-1.9* Na-135 K-3.4 Cl-104 HCO3-22 AnGap-12 [**2184-4-29**] 02:56AM BLOOD Glucose-131* UreaN-20 Creat-1.7* Na-134 K-3.8 Cl-103 HCO3-22 AnGap-13 [**2184-4-30**] 03:16AM BLOOD Glucose-83 UreaN-21* Creat-1.9* Na-134 K-4.1 Cl-102 HCO3-24 AnGap-12 [**2184-4-28**] 05:20AM BLOOD ALT-11 AST-16 LD(LDH)-189 AlkPhos-125* TotBili-0.4 [**2184-4-28**] 01:14PM BLOOD ALT-8 AST-14 LD(LDH)-164 AlkPhos-106 Amylase-63 TotBili-0.3 [**2184-4-28**] 05:20AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.5* [**2184-4-28**] 01:14PM BLOOD Albumin-3.0* Calcium-7.7* Mg-1.9 [**2184-4-29**] 02:11PM BLOOD Calcium-8.3* Mg-2.2 [**2184-4-30**] 03:16AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.2 RADIOLOGY: CT TORSO [**2184-4-28**]: Within the ascending aorta is a 9 cm saccular aneurysm with contained rupture into the middle mediastinum. There is no evidence of aortic dissection. Additionally, within the descending thoracic aorta is an 8 cm saccular aneurysm versus pseudoaneurysm with mural thrombus. On this contrast-enhanced study it does not appear that there is acute hemorrhage into the wall of the aorta within the descending thoracic aneurysm. The caliber of the aorta at the arch and inferior to the thoracic aneurysm is normal. Again, the lung fields show diffuse emphysematous changes bilaterally. There is minimal atelectasis within the left lower lung lobe. The airways are patent to the segmental level bilaterally. There is no pleural effusion or pneumothorax. There is no pathologically enlarged axillary, hilar, or mediastinal lymphadenopathy. There is moderate calcified atherosclerotic disease within the visualized thoracic aorta. CT ANGIOGRAM OF THE ABDOMEN WITH CONTRAST: The abdominal aorta is normal in caliber. A graft is seen within the infrarenal portion of the aorta extending to the right and left iliac arteries. There is heavy atherosclerotic calcification within the iliac arteries and their branches, however, contrast is seen within the femoral arteries distal to the bypass bilaterally. Metallic clips are seen in the region of the aortic graft. The liver contains a rounded 1 cm low density focus in the posterior aspect of the right lobe of the liver, which likely represents a simple renal cyst. A calcified focus in the anterior aspect of the right lobe of the liver may represent a hepatoartery pseudo aneurysm versus a granuloma. The gallbladder, pancreas, spleen, and right adrenal gland are unremarkable. Again, the left kidney is not seen, however, the right kidney contains multiple exophytic and intraparenchymal cysts, the largest measuring 10 cm and is located in the upper pole. The stomach and intra-abdominal loops of small and large bowel are unremarkable. There is no evidence for bowel dilatation. There is no pathologically enlarged mesenteric or retroperitoneal lymphadenopathy. There is no free fluid within the abdomen. There is no free air. CT OF THE PELVIS WITH CONTRAST: The rectum, sigmoid colon, and intrapelvic loops of small and large bowel are normal in appearance and caliber. There is an enhancing mass in the anterior aspect of the bladder measuring 2.5 x 3.4 cm. There is no pathologically enlarged inguinal or pelvic lymphadenopathy. The visualized aortic branches are heavily calcified. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. Degenerative changes are seen within the thoracolumbar spine. CT REFORMATS: Coronal, sagittal, volume rendered images were essential in delineating the anatomy and pathology of this case. Value grade V. IMPRESSION: 1. Ascending saccular aortic aneurysm measuring 9 cm and demonstrating a contained acute hemorrhagic rupture into the middle mediastinum. 2. Additional descending thoracic aortic saccular aneurysm versus pseudo- aneurysm without evidence for acute intramural hematoma. 3. Moderate atherosclerotic calcifications throughout the aorta with infrarenal aortoiliac bypass graft, demonstrating patency to the femoral arteries bilaterally. 4. Very atrophic left kidney with multiple intraparenchymal and exophytic cysts of the right kidney. 5. Enhancing small anterior bladder mass which could represent a polyp or mass CARDIOLOGY: [**2184-4-28**] TTE: The left atrium is moderately dilated. The right atrium is moderately dilated. A left-to-right shunt across the interatrial septum is seen at rest consistent with the presence of a small secundum type atrial septal defect. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [**2184-4-29**] Catheterization: 1. Three vessel coronary artery disease. 2. Severe systolic ventricular dysfunction. COMMENTS: 1. Selective coronary angiography showed a right dominant system with LMCA that had a 50-60% lesion. The LAD had sequential 70% proximal and 50% lesions with post-stenotic dilatations and was severely calcified. LCX had a high OM1 with 50% stenosis and a mid-vessel 70% lesion. 2. Left ventriculography was deferred. 3. Hemodynamic assessment was limited and showed normal aortic systemic Brief Hospital Course: This is a 79 year old gentleman who presented to the emergency department with abdominal pain and was found to have a contained rupture of ascending and descending components of a large saccular thoracic aortic aneurysm. He was admitted to the cardiac surgery service in the intensive care unit shortly after his presentation where central venous access was placed and the patient was started on Nipride and Esmolol for blood pressure control. He was transfused with 2 units of blood with an appropriate rise in hematocrit and was hemodynamically stable throughout his hospital course. On hospital day 2 he underwent cardiac catheterization in preparation for surgery and was found to have significant multi-vessel disease. After discussing the complicated surgery and possible prolonged hospital course, as well as high comorbid state given his coronary disease, the patient opted for no operative intervention and asked to be DNR/DNI with comfort measures only on [**2184-4-30**]. He was then transferred to the intensive care unit with lopressor for blood pressure control. He was discharged to home with resumption of his home medications in addition to the lopressor. All questions were answered to his satisfaction upon discharge. Medications on Admission: Diltiazem Protonix Terazosin Lopressor Flovent Sertraline Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:*20 Tablet(s)* Refills:*0* 2. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* Diltiazem Protonix Terazosin Flovent Sertraline Discharge Disposition: Home Discharge Diagnosis: Primary: contained rupture of thoracic ascending and descending Aortic Aneurysm Secondary: Multi-vessel coronary artery disease, hypertension Discharge Condition: Stable. Tolerating POs. Good pain control Discharge Instructions: You may resume your preadmission medications in addition to the medications we have given you-- please note that we have increased the dosage of Lopressor, your blood pressure medication. You should meet with your primary care physician to discuss continuation of your blood pressure medications. You should return to the ER with any worsening pain/shortness of breath/light-headedness. Followup Instructions: Follow-up with your primary care physician [**Last Name (NamePattern4) **] 1 week to discuss maintenance of your blood pressure medications. Completed by:[**2184-5-2**]

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icd9cm

[ [ [] ] ]

[ "37.22", "88.56", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

9694, 9700

8054, 9292

328, 370

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1629, 8031

10365, 10536

1238, 1257

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