ChanBeDu/relevant_section_length · Datasets at Hugging Face

1,746

107,267

16064+56727

Discharge summary

report+addendum

Admission Date: [**2146-1-14**] Discharge Date: [**2146-1-19**] Service: CCU HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 131**] is an 80-year-old woman who was in her usual state of health until approximately six weeks prior to admission when she fell and sustained a nose fracture. She then spent two weeks in a rehabilitation facility, went home for one week, and was then readmitted to an outside hospital Intensive Care Unit with a NSTEMI on [**2145-12-30**]. At this time, the patient was felt to be too debilitated to undergo cardiac catheterization, and she was therefore transferred to rehabilitation on medical management. After recovering, her PCP made arrangements for her transfer to the [**Hospital1 69**] for cardiac catheterization. Of note, on [**2145-12-30**], her electrocardiogram demonstrated T-wave inversions in leads V2 through V4, and the patient was given enoxaparin, aspirin, and a beta blocker. On the day of admission, the patient underwent cardiac catheterization. This study demonstrated very mild anterior hypokinesis, no mitral regurgitation, and a left ventricular ejection fraction of approximately 65%. Her coronary vasculature was found to be right dominant. She has a normal LMCA. There was a 90-95% elongated stenosis in the mid portion of her left anterior descending artery involving the take-off of a moderate sized first diagonal branch. There was 80-90% stenosis of the distal vessel. There is also 90% stenosis of the ostium of D1. There was 60-70% stenosis proximally in the LCX followed by a 50-60% stenosis. Stenoses 30-40% were also seen in the OM. Stenoses 50% were seen in the mid portion of the right coronary artery. The left anterior descending artery was successfully stented, and the first diagonal branch was rescued by wire. Late in the case, thrombus was noted in the left anterior descending artery stent. Eptifibide was then started, and then the stent was redilated with a 3 mm balloon. Shortly thereafter, the patient developed hematemesis necessitating discontinuation of the eptifibide. Also of note, the patient developed hypotension several times during the procedure, each time quickly responding to Dopamine. At the end of the case, a right heart catheterization demonstrated a low resting right and left heart filling pressures and low cardiac index, suggesting hypovolemia. There was no equalization of pressures. An echocardiogram demonstrated a tiny pericardial with no tamponade physiology. There was hypokinesis of the lateral wall with left ventricular ejection fraction of 45%. The patient was then transferred to the CCU in stable condition for further monitoring. PAST MEDICAL HISTORY: 1. Multiple prior falls with the most recent fall in [**2145**] while on lorazepam and Zolpidem. 2. Subdural hematoma in [**2141**]. 3. Right sided cerebrovascular accident complicated by upper and lower extremity spasticity and hemiparesis. 4. Hypertension. 5. Baseline confusion. 6. Hypercholesterolemia. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER TO THE CCU: 1. EC-ASA 81 mg po q day. 2. Atorvastatin 10 mg po q day. 3. Metoprolol 50 mg po tid. 4. Citalopram 10 mg po q day. 5. Clonazepam 1 mg po q day. 6. MVI one cap po q day. SOCIAL HISTORY: The patient lives with her daughter in a house with stairs. Of note, the patient lives on the [**Location (un) 13453**] of this house. The patient denies any history of tobacco, alcohol, or drug abuse. PHYSICAL EXAMINATION: On initial physical examination, the patient's temperature was 99.0 degrees, blood pressure 112/56, heart rate 97, respiratory rate 15, oxygen saturation is 98% on 3 liters nasal cannula, and her weight was 124 pounds. On Telemetry the patient was found to be in normal sinus rhythm with a rare PVC. In general, the patient was lying in bed and confused, although she was in no acute distress. Her heart was a regular, rate, and rhythm, there was a 3/6 systolic murmur at the left upper sternal border without rubs or gallops. She had bibasilar crackles on the left greater than on the right, and no wheezes. Her abdomen was soft, nontender, and nondistended and there were normoactive bowel sounds. She had left femoral sheaths present without evidence of hematoma. There was trace bilateral lower extremity pitting edema. Patient was moving all extremities without difficulty. She was alert and oriented to the hospital. Initial laboratory evaluation: The patient's white blood cells 13.4, hematocrit 24, platelets 405. Initial serum chemistries were remarkable for a bicarbonate of 19, but otherwise unremarkable. Initial CK was 165. Initial electrocardiogram demonstrated ectopic atrial activity with a rate in the 80s. There was evidence of early R-wave progression, and biphasic T waves were noted in leads V2 and V3. HOSPITAL COURSE BY SYSTEMS: 1. Cardiovascular: Quickly following her arrival to the CCU, the patient was weaned off Neo-Synephrine; this medication had been started in the Catheterization Laboratory given her hypotension. Her postprocedural hypotension was most likely secondary to a combination of a vagal reaction and hypovolemia. She was transfused a total of 4 units of packed red blood cells with a good hemodynamic response. She subsequently remained hemodynamically stable throughout the remainder of her admission. In terms of her coronary artery disease, the patient underwent PTCA and stenting of the left anterior descending artery complicated by transient D1 occlusion (restored with wire) and left anterior descending artery stent thrombosis. The patient was transiently started on Heparin and Epidifibitide with resolution of the thrombosis, although she subsequently developed gastrointestinal bleed. Her Heparin and eptifibitide were therefore discontinued. She was maintained on aspirin and Plavix throughout her hospitalization, although the Heparin and eptifibitide were not restarted. She was subsequently stabilized on a beta blocker and atorvastatin. An echocardiogram was performed on [**2146-1-17**]. This study demonstrated overall normal left ventricular systolic function with an ejection fraction of greater than 55%. No A-V stenosis was seen. Trace AR was seen. There was also evidence of trivial MR. There was no evidence of pericardial effusion. The patient was subsequently discharged on a stable medical regimen as noted below. Gastrointestinal: As noted above, the patient developed significant hematemesis, hypotension, and hypovolemia in the context of anticoagulation during her cardiac catheterization. The patient subsequently received a total of 4 units of packed red blood cells with an appropriate increase in her hematocrit. An abdominal CT scan was done on [**2146-1-14**] in order to evaluate for a possible retroperitoneal hematoma; this study was negative. She was initially started on an intravenous proton-pump inhibitor given her likely upper gastrointestinal bleed, and was subsequently transitioned to an oral proton-pump inhibitor prior to discharge. At the time of discharge, she was hemodynamically stable, her hematocrit had been stable for over 48 hours, and she had no evidence of active gastrointestinal bleeding. Neurology: The patient has baseline dementia and cognitive impairment. She was continued on risperidone as needed for agitation, as well as clonazepam 0.5 mg po bid. She was given acetaminophen as needed for her chronic right lower extremity pain. DISPOSITION: Prior to her discharge, the patient was evaluated by the Department of Physical Therapy. The physical therapist felt that the patient was currently functioning below her baseline, and therefore, a stay at a rehabilitation facility was recommended to maximize independence with functional mobility prior to returning home. DISCHARGE CONDITION: Stable. DISCHARGE PLACEMENT: To rehabilitation facility. DISCHARGE DIAGNOSES: 1. Recent NSTEMI ([**2145-12-30**]). 2. Coronary artery disease status post PTCA and stenting of the left anterior descending artery. 3. Upper gastrointestinal bleeding. 4. Baseline dementia. 5. Acute blood loss anemia status post cardiac catheterization. 6. Hypotension secondary to hypovolemia status post cardiac catheterization. 7. CT scan to rule out peritoneal bleed that was negative. DISCHARGE MEDICATIONS: 1. EC-ASA 325 mg po q day. 2. Clopidogrel 75 mg po q day x6 months. 3. Atorvastatin 20 mg po q day. 4. Metoprolol 50 mg po bid. 5. Pantoprazole 40 mg po q day. 6. Clonazepam 0.5 mg po bid. 6. MVI one cap po q day. 7. Citalopram 10 mg po q day. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Name8 (MD) 2507**] MEDQUIST36 D: [**2146-1-18**] 03:37 T: [**2146-1-18**] 04:11 JOB#: [**Job Number 45964**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 8447**] Admission Date: [**2146-1-14**] Discharge Date: [**2146-1-19**] Date of Birth: [**2065-6-11**] Sex: F Service: DISCHARGE MEDICATIONS: 1. Enteric coated aspirin 325 mg po q.d. 2. Clopidogrel 75 mg po q.d. times six months. 3. Atorvastatin 20 mg po q.d. 4. Metoprolol 50 mg po b.i.d. 5. Pantoprazole 40 mg po q.d. 6. Docusate 100 mg po b.i.d. 7. Calcium carbonate 1000 mg po b.i.d. 8. Clonazepam 0.5 mg po b.i.d. 9. Risperidone 1 mg po q.h.s. prn agitation. 10. Acetaminophen 325-650 mg po q. 4-6 hours prn pain. 11. Zolpidem 5 mg po q.h.s. prn insomnia. 12. Multivitamin 1 capsule po q.d. 13. Citalopram 10 mg po q.d. The patient was discharged to the [**Hospital3 8448**] in [**Hospital1 15**], [**State 1145**]. A copy of the complete discharge summary was faxed to the patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 8449**]. The patient was instructed to arrange for a follow-up appointment with Dr. [**Last Name (STitle) **] following her discharge from [**Hospital1 **]. [**First Name8 (NamePattern2) 77**] [**First Name8 (NamePattern2) 2448**] [**Name8 (MD) **], M.D. [**MD Number(1) 2449**] Dictated By:[**First Name3 (LF) **] MEDQUIST36 D: [**2146-1-19**] 04:41 T: [**2146-1-19**] 19:17 JOB#: [**Job Number 8450**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7853, 7913

7934, 8327

9143, 10396

4874, 7831

3506, 4846

118, 2686

2708, 3261

3278, 3483

9,054

165,488

3449+55476

Discharge summary

report+addendum

Admission Date: [**2103-9-17**] Discharge Date: [**2103-10-5**] Date of Birth: [**2031-8-15**] Sex: M Service: NEUROLOGY Allergies: Epinephrine / Lidocaine / Percocet / Imuran / Heparin Agents Attending:[**First Name3 (LF) 4583**] Chief Complaint: chest pressure and shortness of breath Major Surgical or Invasive Procedure: s/p esophageal dilation, s/p esophagogastroduodenoscopy [**9-18**] left internal jugular tunnelled catheter History of Present Illness: 72RH M h/o myasthenia [**Last Name (un) 2902**] managed by Dr. [**Last Name (STitle) **] initially admitted on [**2103-9-17**] breathing difficulty and constant chest pressure. He went to the Cardiothoracics service for EGD and balloon dilation of pylorus on [**9-18**] with improvement of chest pressure and tolerated PO diet without sxs. On [**2103-7-23**] Neurology was consulted due to increased somnolence and tachypneia. VBG 7.36/95/24 with bicarb >50. Despite Bipap, patient's VBGs/ABGs fluctuated and patient remained tachypneic 30-36 breaths/min with shallow breaths and inability to complete sentences from being so out of breath. He was subsequently transferred to MICU service for further management and Bipap. Patient reports that he has always had generalized weakness with his myasthenia; however, notes that this admission his breathing has been bothering him the most. He has difficulty having sustained conversdations since he feels constantly out of breath. However, he denied pain on inspiration. He does have double vision worse on lateral gaze R upper quadrant gaze. He also notes double vision worse with looking at near objects than looking at far objects. Denies difficulty swallowing, regurgitating as long as he takes small quanities or eyelid weakness. MICU c/b UTI Klebsiella tx'd 7D Ceftriaxone. Plasmapheresis D4/5 for myasthenic crisis. Of note, patient has history of vascular disease and in fact had MI when received IVIg last in [**7-4**]. Patient had baseline 1st degree heart block and developed 2 episodes of Wenckebach, HD stable and asx one resolved spontaneously other after fluid bolus. Patient now being called out to Neuro-stepdown for continued care of his myasthenia [**Last Name (un) 2902**]. Past Medical History: - Myasthenia [**Last Name (un) 2902**] dx'd [**2092**] p/w diplopia. EMG, tensilon test and anti-Ach R Ab +. Underwent thymectomy [**2095**]. - Diaphragmatic weakness with low insp & exp forces - H/o stroke, s/p R CEA - Esophageal Ca s/p resxn, rad & chemo - CAD w/MI status post Cypher DES of mid RCA 07/29/[**Numeric Identifier **]/05 normal EF 55% w/dCHF - Hyperchol - Sleep apnea requiring nighttime BiPAP - Malnutrition s/p J tube place & removal [**2-5**] - COPD(?) Social History: Lives at home with wife, no children. Retired steel warehouse worker. 15 pk/yr smoking hx but quit 25 years ago. Denies alcohol or illicit drug use. Family History: Notable for many family members with CAD. His brother had lung cancer. There is no myasthenia [**Last Name (un) 2902**] or other neurological problems in the family. Physical Exam: Physical Exam (at discharge): Vitals: T: 99.8 P: 99 1st AVB R: 22 BP: 134/60 SaO2: 96% 3L NC General: Awake, cooperative, NAD, elev RR, watching Pat's game on television sitting in recliner, slightly emaciated HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no JVD or carotid bruits appreciated. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: Mental Status exam: Alert Awake Oriented to self, place and date. Normal affect. Attentive, says [**Doctor Last Name 1841**] backwards. Speech is soft, fluent, and breathy with normal comprehension and repetition; naming intact. No dysarthria. [**Location (un) **] and writing intact. Registers [**3-2**], recalls [**1-2**] in 3 minutes [**3-2**] when given 3 choices. No right left confusion. Able to follow complex commands. No evidence of apraxia or neglect. No simultagnosia. Cranial Nerves: Olfaction not tested. Anisicoric pupils round and reactive to light bilaterally, R 4.5 mm->2 mm and L 6 mm->2 mm. No ptosis appreciated even after sustaied upgaze for 1 minute. Visual fields are full to confrontation. Extraocular muscles are full without nystagmus and diplopia only on sustained sustained lateral gaze R>L. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact. Motor: Normal bulk, decr'd tone throughout. No observed myoclonus or tremor. No pronator drift [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE IP H Q DF PF TE TF R 5 5 5- 5 5 5 5- 5- 5 5 5 5 4+ L 5 5 5- 5 5 5 5- 5- 5 5 5 5 4+ Sensory:Intact to light touch, proprioception throughout. Slightly decreased sensation to temperature (cold) on dorsum of R foot between big toe and 2nd toe and decreased vibratory sense (3 seconds long) in toes bilaterally. Coordination: No intention tremor. +Dysdiadochokinesia L>R. No dysmetria on FNF bilaterally. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response downgoing bilaterally. Gait: Deferred. Pertinent Results: pH 7.39 pCO2 70 pO2 33 HCO3 44 BaseXS 13 Na 140 Cl 98 BUN 13 Glc 180 AGap=6 K 3.6 CO2 40 Cr 0.4 Ca: 8.0 Mg: 1.9 P: 2.6 TSH:1.8 Vit-B12:525 Folate:11.3 102 WBC 5.9 HGB 9.2 PLT 157 MCV 102 HCT 28.4 N:89.6 L:7.0 M:3.2 E:0.2 Bas:0.1 Macrocy: 2+ PT: 13.1 PTT: 31.7 INR: 1.1 [**2103-9-29**] 04:29a CK: 29 MB: Notdone Trop-*T*: 0.25 Prealbumin 17L METHYLMALONIC ACID 249 H HEPARIN DEPENDENT ANTIBODIES NEGATIVE UCx (Final [**2103-9-19**]): KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML Radiologic data: CXR 1. Small peripheral wedge-shaped opacity. Differential diagnostic considerations include focus of early pneumonia, pulmonary infarction, or atelectasis. No pneumonia is seen Spirometry [**7-5**]- Impression: Results are consistent with a restrictive ventilatory defect. Since [**2103-1-26**], FVC has decreased 340cc (18%) and FEV1 has decreased 330cc (18%) ECHO [**9-29**]: 1. The left atrium is normal in size. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. 5. Compared with the prior study (images reviewed) of [**9-4**]/200, the aortic annular calcification is better visualized. Sinus tachycardia. Left atrial abnormality. A-V conduction delay. P-R interval 0.28. Right bundle-branch block. Compared to the previous tracing of [**2103-9-27**] no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 102 216 130 380/438.85 6 0 12 PCXR: 1. No definite evidence for aspiration. No new infiltrates in comparison to the prior study. 2. The previously noted opacity in the right lung has resolved PAXR: Progression of barium, with retained contrast now noted throughout the colon and rectum. Nonspecific bowel gas pattern. Chest CT c Contrast ([**2103-8-9**]): 1. Mixed progression/regression of multiple tiny pulmonary nodules as described above. 2. No change in size of mediastinal and hilar lymph nodes with no evidence of lymphadenopathy. 3. Small well defined ovoid fluid density medial to the lower pole of the right kidney of unclear significance. Comparison with prior studies is suggested. No comparisons are currently available on PACS. ECHO: 1. The left atrium is normal in size. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. 5. Compared with the prior study (images reviewed) of [**9-4**]/200, the aortic annular calcification is better visualized. Brief Hospital Course: 72 year old right handed man with myasthenia [**Last Name (un) 2902**] status post upper endoscopy and balloon dilation of the pylorus complicated by a increased difficulty breathing and extremity weakness consistent with a myasthenic crisis post procedure. He was transferred to the MICU for continued care and biPAP. Myasthenic crisis is usually precipitated by a variety of factors including infection, surgery, or tapering of immunosuppression. Although his past medical records state that the etiology of his difficulty breathing is multifactorial, upon inital evaluation by neurology, he had fatiguable weakness of the deltoid which was new. Patient was initiated on plasmaphersis and continued on biPAP. He was transferred to Neuro step-down unit for further neurologic care and to complete 5 cycles of plasmaphereis. Neurology: Patient was treated with IV solumedrol, mestinon and cellcept. IV solumedrol dose of titrated up to 24mg QD. Patient was evaluated by speech and swallow who recommended keeping patient NPO. As a result, his outpatient seroquel and celexa were held until he was re-evaluated and approved for a ground diet and thin liquids. Respiratory: Patient desaturated to 80% while conversing and was tachypneic at rest. He was continued on biPAP. Strict pulmonary toilet given increased secretions on cholinesterase inhibitor, mestinon to prophylax against developing pneumonia. CV: History of type 1 heart block. Patient had 2 episodes of Wenkebach which were asymptomatic and hemodynamically stable. Patient had NSTEMI likely secondary to increased myocardial demand with subsequent preserved ejection fraction. Cardiology was consulted regarding pre-operative risk for J tube replacement. Per cardiology, if stent more than 9 months from placement, reasonable to hold Plavix prior to surgery; however, would continue aspirin pre-operative. Given heart block did not recommend peri-operative beta blocker. At discharge, continued aspirin, statin and plavix (for history of CVA). Thrombocytopenia: Platelet count dipped to 67,000 from 215,000 on admission. Heparin products were held and HIT Ab was sent which was subsequently negative. However, platelet count recovered to 219,000 at discharge. Thrombocytopenia was either secondary to HIT 1 as heparin products were held and the platelet count recovered. However, on discussion with the plasmapheresis team, it may have been secondary to plasmapheresis technique. However, heparin was subsequently listed as an allergy to avoid recurrence of thrombocytopenia and risk of bleeding. Additionally, a pressurized PICC line was placed that only requires saline flushes. Nutrition: Receiving TPN with plan for J tube replacement when patient breathing more easily and more nutritionally replete. Since patient has not fully recovered, it was discussed with patient and his wife that there would be an increased risk of precipitating another myasthenic crisis with surgery so soon after this past one. Since he is DNI and is currently declining a tracheostomy, the risks would not outweigh the benefits of J tube placement this admission since he is already getting TPN can continue at rehab. Patient initally failed speech and swallow and is now able to take ground solids and thin liquids. CXR negative for silent aspiration. He will continue on TPN and PO diet until his J tube is placed. TPN will likely need some adjustments as he may be able to take more PO in the passing days. Plan for J tube placement in ~3 weeks if continues to recover from most recent myasthenic crisis. Anemia: baseline 34-38. Macrocytosis. Metylmalonic acid pending at discharge. TSH within normal limits. UTI: Status post 7 days of Ceftriaxone. Afebrile and asymptomatic. FEN: He developed a respiratory acidosis and metabolic alkalosis. Resolving. TPN as above with insulin additive. PPX: PPI, boots, aspiration precautions, strict pulm toilet. ACCESS: PICC line pressurized requires saline flushes only. Left internal jugular plasmapheresis line discontinued. CODE: DNR/DNI Medications on Admission: ASA 325 mg daily, Plavix 75 mg daily, Florinef 0.1 mg daily, Pravachol 20 mg daily, Mestinon 60 mg Q6hrs, CellCept [**Pager number **] mg [**Hospital1 **], Provigil 100 mg daily, Megace 400 mg daily, Prevacid 40 mg daily, Colace 100 mg daily, Senokot two tabs qhs, Alphagan 0.15% gtt q12hrs, Cosopt gtt q12hrs, Travatan 0.004% gtt qM/W/F, Celexa 30 mg daily, Seroquel 37.5 qhs, MVI Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb Solution Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal once a day as needed for constipation. 4. Brimonidine 0.15 % Drops Sig: One (1) Drop OU Ophthalmic every twelve (12) hours. 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 7. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 8. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop OU Ophthalmic every twelve (12) hours. 9. Anzemet 12.5 mg/0.625 mL Cartridge Sig: 12.5 mg Intravenous every eight (8) hours as needed for nausea. 10. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO once a day. 11. Insulin Regular Human 100 unit/mL Solution Sig: PER SLIDING SCALE UNITS Injection AS DIRECTED. 12. Methylprednisolone Sodium Succ 125 mg Recon Soln Sig: Twenty Four (24) mg Injection once a day. 13. Milk of Magnesia 7.75 % Suspension Sig: 15-30 ml PO every six (6) hours as needed for constipation. 14. Mupirocin 2 % Ointment Sig: One (1) Dab Topical once a day: Apply to the nose. 15. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution Sig: 1000 (1000) mg PO twice a day. 16. Pantoprazole 40 mg Recon Soln Sig: Forty (40) mg Intravenous once a day. 17. Pyridostigmine Bromide 5 mg/mL Solution Sig: Two (2) mg Injection every six (6) hours. 18. Quetiapine 50 mg Tablet Sig: 0.5 Tablet PO at bedtime. 19. Sodium Chloride 0.9 % Syringe Sig: One (1) Flush Injection once a day: 3ml Flush PRN. 20. Travatan 0.004 % Drops Sig: 1-2 drops OU Ophthalmic qMWF. 21. PICC line care PICC line care per protocol for HIT patients. Please flush with normal saline instead. PICC line is pressurized and does not require heparin products. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary diagnosis: s/p esophagogastroduodenoscopy and esophageal dilation myasthenic crisis NSTEMI malnutrition. Secondary diagnosis: myasthenia [**Last Name (un) 2902**] bilateral diaphragmatic impairment coronary artery disease history of esophageal cancer and TIA cervical spondylosis history of TB Discharge Condition: neurologically stable. RR 25-35 on 2L nasal cannula. Discharge Instructions: Please take your medications as prescribed. Please keep your follow-up appointments. Please call Dr.[**Name (NI) 1816**]/ Thoracic surgery office [**Telephone/Fax (1) 170**] to schedule your J tube surgery when your respiratory and nutritional status improves. Please confer with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] your neurologist as to the timing of this surgery. If you have any shortness of breath or difficulty breathing, chest pain, epigastric pain, fever, excessive nausea and vomitting, or diarrhea, please call your primary care physician or return to the emergency room. Ground diet, thin liquids, small meals throughout day as tolerated with Aspiration precautions. Sleep on wedge pillow, or [**2-2**] pillows Followup Instructions: Call Dr.[**Name (NI) 1816**]/ Thoracic surgery office [**Telephone/Fax (1) 170**] for an appointment. Future appointments: Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2103-10-4**] 11:00 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13647**]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2103-12-14**] 11:00 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2104-1-17**] 1:20 Completed by:[**2103-10-5**] Name: [**Known lastname 497**],[**Known firstname 33**] Unit No: [**Numeric Identifier 2528**] Admission Date: [**2103-9-17**] Discharge Date: [**2103-10-5**] Date of Birth: [**2031-8-15**] Sex: M Service: NEUROLOGY Allergies: Epinephrine / Lidocaine / Percocet / Imuran / Heparin Agents Attending:[**First Name3 (LF) 542**] Addendum: Please follow-up with your primary care physician [**Name9 (PRE) 2529**] [**Name8 (MD) 2530**], MD within 1-2 weeks of discharge. Phone: [**Telephone/Fax (1) 2531**]. Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] [**First Name11 (Name Pattern1) 194**] [**Last Name (NamePattern4) 544**] MD [**MD Number(1) 545**] Completed by:[**2103-10-5**]

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icd9cm

[ [ [] ] ]

[ "99.71", "42.92", "99.15", "38.93", "93.90", "45.13" ]

icd9pcs

[ [ [] ] ]

17190, 17429

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362, 473

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4,571

139,919

5993

Discharge summary

report

Admission Date: [**2162-12-6**] Discharge Date: [**2162-12-8**] Date of Birth: [**2085-10-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: pericardial effusion Major Surgical or Invasive Procedure: pericardiocentesis with drain placement in catheterization laboratory History of Present Illness: Patient is a 77 year-old gentleman with known CAD (R dominant system, prior stent to RCA, PTCA of D1) s/p recent off-pump CABG with Dr. [**Last Name (STitle) **] (Cath [**2162-11-9**] with 90% stenosis to mid-LAD, unsuccessful stenting complicated by dissection of vessel, revascularization with LIMA -> LAD [**2162-11-11**], [**Hospital **] hospital course significant for Afib, treated with amiodarone, dc'd home on POD5) who now presents with pericardial effusion noted in cardiology clinic on [**2162-12-6**]. Patient complained of increasing SOB over the last 5 days PTA. Also experiencing worsening orthopnea, sleeps in arm chair, decreased exercise tolerance -- now only able to ambulate across a room, previously ambulating between rooms. No chest pain or abdominal discomfort, occasional palpitations. . 1 day PTA patient went to Dr.[**Name (NI) 5452**] office for a regularly scheduled visit -- bedside echo was performed which revealed a pericardial effusion. Patient was admitted to [**Hospital Unit Name 196**] service. At night, had Aflutter on telemetry which broke spontaneously. lopressor 25 PO was started which was dc'd the following morning after consultation with patient's attending due to known side effects from drug. Past Medical History: 1. CAD - RCA stenting ([**2154**] and [**2159**]) and PTCA of diagonal [**2159**]; CABG [**2162-11-11**] after dissection of LAD during elective cath [**2162-11-9**] 2. HTN 3. Hyperlipidemia 4. Prostate CA with XRT/ seeding/ hormonal therapy 5. s/p appy [**2115**] Social History: retired lieutenant firefighter quit tobacco 15 years ago, smoked [**1-28**] cigars/day for 20 years drinks 2 glasses of wine per day lives with wife Family History: brother died of MI at age 82 Physical Exam: Vitals in ED: 96.2 127/60 76 22 97% on 2L Gen: pleasant, middle aged gentleman, NAD\ HEENT: NC, AT, anicteric, JVD + 12 cm, no carotid bruits, no LAD, CV: rrr, nl s1, loud s2, no extra HS Chest: faint crackles at bases, midline scar - c/d/i, healthy granulating tissue Abd: + BS, SNT, ND Ext: + femoral pulses, no bruits b/l, + 1 full DP/PT b/l Pertinent Results: ADMISSION CXR [**2162-12-6**]: IMPRESSION: Small bilateral pleural effusions and atelectasis within the left lung base. No evidence of CHF or pneumonia. . PERICARDIOCENTESIS PROCEDURE: Pericardiocentesis: was performed via the subxyphoid approach, using an 18 gauge thin-wall needle, a guide wire, and a drainage catheter. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. . ECHO [**2162-12-7**] Post pericardiocentesis there is a small somewhat echo dense pericardial region that likely represents a very small partially organized residual pericardial effusion; cannot exclude pericardial thickening. There is no echocardiographic evidence of tamponade. An interventricular septal bounce is noted. Brief Hospital Course: Patient is a 77 year-old gentleman with CAD, HTN, Hyperlipidemia with recent CABG [**2162-11-11**] who presented from cardiologist's office for pericardiocentesis after bedisde ECHO revealed pericardial effusion. The following issues were addressed during the [**Hospital 228**] hospital stay -- . 1. PERICARDIAL EFFUSION Etiology was patient's recent CABG. Patient underwent pericardiocentesis in the catheterization laboratory, and a temporary drain was placed. Patient tolerated procedure well. Portable CXR confirmed proper line placement and no pneumothorax. Repeat ECHO the following day showed drainage of effusion, and drain was subsequently removed. Patient to follow up with Dr.[**Name (NI) 5452**] office in 6 days. 2. CARDIAC (CAD, RHYTHM) Patient's outpatient cardiac medications were restored (ASA, Plavix, Lipitor, Cardizem, Cardura). On the evening of admission, patient had brief episode of Atrial Flutter, which reverted to sinus rhythm spontaneously. Patient was not on beta-blocker due to intolerable side effects including depression. In discussion with patient's cardiologist, patient had brief history of Afib post-operatively which was treated with Amiodarone -- he felt that anti-coagulation was not necessary as patient has been in sinus rhythm since, and Afib was attributed to routine post-operative event. During this hospital stay, patient's Amiodarone was increased to 400mg PO qd per Dr. [**Last Name (STitle) **], and patient will follow-up with him in 1 week to re-assess if this dosage and/or anticoagulation will be necessary. . 3. PUMP Patient with preserved EF per recent ECHO. Given shortness of breath, LE edema, elevated JVP on presentation, and pleural effusions on CXR, patient was started on Lasix 20mg PO qd, and will follow-up with cardiologist in 1 week. . 4. PPX Patient was kept on Heparin SC TID for DVT prophylaxis as inpatient, and outpatient vitamin supplements were continued. Medications on Admission: Docusate Sodium 100 mg Capsule [**Hospital1 **]; Aspirin 325 mg Tablet Daily; Clopidogrel 75 mg DAILY; Folic Acid 1 mg DAILY; Multivitamin Capsule DAILY ; Thiamine HCl 100 mg DAILY; Amiodarone 200 mg Tablet once a day; Protonix 20 mg Tablet Daily; Lipitor 80 mg Tablet Daily; Zetia 10 mg Tablet Daily; HCTZ 12.5mg Daily; Cardizem 300mg Daily; Cardura 2mg Daily. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amiodarone 200 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 12. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 13. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day. 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: Please continue taking until you see Dr. [**Last Name (STitle) **] next week. Disp:*30 Tablet(s)* Refills:*2* 15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp:*30 Capsule, Sustained Release(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary 1. Pericardial effusion s/p pericardiocentesis . Secondary 1. CAD s/p 3 PTCAs and recent CABG [**2162-11-11**] 2. HTN 3. Hyperlipidemia 4. Prostate CA s/p Rx Discharge Condition: clinically and hemodynamically stable, without chest pain or dyspnea, no oxygen requirement Discharge Instructions: 1. Please take all medications as prescribed - Lasix 20mg PO qd has been added to your regimen, and your Amiodarone has been increased to 400mg by mouth every day. Please continue these medications at the prescribed dosages until you see Dr. [**Last Name (STitle) **] in clinic in 1 week. 2. If you develop chest pain, shortness of breath, bleeding, or any other concerning signs/symptoms, please contact your PCP [**Name Initial (PRE) **]/or report to the nearest Emergency Medical facility 3. Please make all follow-up appointments Followup Instructions: Please make an appointment to see your PCP [**Last Name (NamePattern4) **] [**7-4**] days (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) **]). Please call your cardiologist Dr. [**Last Name (STitle) **] to schedule a follow-up appointment to be seen in his clinic in one week. Please keep your previously scheduled appointment with your cardiac surgeon -- Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Date/Time:[**2162-12-14**] 1:30 Completed by:[**2162-12-8**]

[ "401.9", "420.90", "997.1", "V45.81", "427.31", "272.4", "427.32", "V10.46" ]

icd9cm

[ [ [] ] ]

[ "37.0" ]

icd9pcs

[ [ [] ] ]

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337, 408

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38568

Discharge summary

report

Admission Date: [**2107-6-12**] Discharge Date: [**2107-6-18**] Date of Birth: [**2029-3-6**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8961**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: 78 year-old man with a history of lung adenocarcinoma s/p LUL lobectomy, DVT, afib on Coumadin, GI bleed, and nonverbal at baseline from severe dementia who is coming in from a nursing home with worsened altered mental status, fever, and hypoxic respiratory distress. He was recently admitted from [**Date range (1) 29475**]/11 for lethargy and fever. He was initially started on Vancomycin and Zosyn due to concern for sacral decubitus ulcer infection and possible osteomyelitis v. pneumonia. However, the CXR was without clear new infiltrate. The tachypnea was attributed to aspiration pneumonitis v. fever/stress response with the infected sacral ulcer thought to be the primary infectious process. The IV antibiotics were discontinued after 2 days as he underwent surgical debridement, which was felt to be the definitive treatment. He also was found to have C. diff colitis and started on oral flagyl. His mental status improved overall, and he was discharged back to his nursing home. . However, over the past day, he has had worsening altered mental status and shortness of breath. This evening at 7pm, he was found to have O2sats in the 70s on RA and was febrile to 101. He was still hypoxic when EMS arrived. They placed him on CPAP with improvement to the high 90s and brought him to the ED. . On ED arrival, initially vs were: T 99.1, P 88, BP 112/72, RR 32, O2sat 82% on NRB. He was tachypneic and minimally responsive on arrival so was intubated and sedated with fentanyl and midazolam. In the peri-intubation setting, he went into rapid afib with mild V4-V6 ST depressions captured on EKG; the RVR resolved with IV fluids. Labs were notable for a WBC 21 up from 12 on discharge (diff...). BNP was 1293 c/w prior admission during which he was not felt to be in CHF. CK was 115 but trop mildly elevated at 0.09, consistent with prior admission (0.08-1). Post-intubation CXR showed LLL infiltrates which were difficult to assess given his post-lobectomy changes. CTA chest showed no PE and bibasilar infiltrates mostly at the periphery consistent with pneumonia, less likely aspiration pneumonitis. Blood cultures were drawn, and patient started on vancomycin and Zosyn. During his ED course, he received a total of 3L IVF with SBPs ranging from 79 to low 100s. He remained afebrile. On transfer to the MICU, vs were: P 75, BP 105/66, O2sat 100% with ABG 7.60/27/130/27 on AC 500/16/5/100%. . On the floor, pt appeared comfortable, intubated and sedated. Past Medical History: - Severe dementia, unable to complete any ADL's on his own - S/p LUL lobectomy for spiculated mass: 3.3 cm adenocarcinoma with all regional lymph nodes negative, T2a, N0. Post op Afib. Then, L sided effusion s/p thoracocentesis [**8-/2106**] - Atrial fibrillation on Coumadin, h/o RVR on initial diagnosis - h/o DVT in RLE, [**4-/2106**] Tx'd with Lovenox - h/o TIA - colonic adenoma - hypothyroidism - Anemia - Osteoarthritis, s/p total L hip replacement, s/p total R knee replacement - h/o tibial fracture - spondylosis of the lumbosacral spine - h/o Gastric ulcer - h/o urinary retention requiring Foleys - h/o GIB in [**2-8**], presumed to be lower source, resolved on own. Social History: The patient lives at a nursing facility, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**]. His wife visits him, though she still lives at his prior home. Remote 10 pack year history. Denies current alcohol use, illicit substance use. Family History: No family history of lung cancers, prostate cancers or clotting disorders. Physical Exam: On admission: GENERAL: Intubated, sedated, not responding to command HEENT: NC/AT, PERRLA 3mm b/l, intubated and sedated, does not respond to voice or pain, grimaces to deep pain NECK: Supple LUNGS: clear to auscultation anteriorly, no wheezing or rales HEART: irregularly irregular, II/VI SEM, nl S1-S2. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding, clean stoma with no raw erythema, ostomy in place with soft brown stool; foley in place EXTREMITIES: WWP, no c/c, trace pretibial edema, with R leg with mild skin darkening and slightly more swelling, 2+ peripheral pulses. SKIN: No rashes LYMPH: No cervical LAD. NEURO: sedated, PERRLA, withdraws to deep pain RECTAL: decubitus (stage 4) on left presacral area, wound vac in place with no surrounding drainage . On discharge: GEN: arousable, not oriented to self, location, or time, comfortable HEENT: sclera anicteric, moist mucous membranes, oropharynx clear CV: irregularly irregular, + systolic murmur best at LUSB PULM: CTA anteriorly; however, exam limited by cooperation ABD: soft, non-tender, non-distended, + ostomy with soft, formed stool EXT: warm, trace edema, + boots NEURO: uncooperative with most of exam; however, strong hand grip b/l, able to move both upper extremeties DERM: stage IV decubitus ulcer on left presacral area Pertinent Results: Admission labs: =============== [**2107-6-12**] 05:35PM BLOOD WBC-21.0* RBC-3.57* Hgb-10.9* Hct-33.4* MCV-94 MCH-30.6 MCHC-32.7 RDW-15.8* Plt Ct-651* [**2107-6-12**] 05:35PM BLOOD Neuts-85* Bands-0 Lymphs-10* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2107-6-12**] 05:35PM BLOOD PT-24.2* PTT-27.7 INR(PT)-2.3* [**2107-6-12**] 05:35PM BLOOD Fibrino-773* [**2107-6-12**] 05:35PM BLOOD ESR-122* [**2107-6-12**] 05:35PM BLOOD UreaN-18 Creat-0.8 [**2107-6-13**] 03:42AM BLOOD Glucose-125* UreaN-14 Creat-0.6 Na-143 K-4.3 Cl-110* HCO3-24 AnGap-13 [**2107-6-12**] 05:35PM BLOOD ALT-36 AST-26 LD(LDH)-244 CK(CPK)-115 AlkPhos-72 TotBili-0.2 [**2107-6-12**] 05:35PM BLOOD CK-MB-2 cTropnT-0.09* proBNP-1293* [**2107-6-13**] 03:42AM BLOOD CK-MB-2 cTropnT-0.10* [**2107-6-12**] 05:35PM BLOOD Albumin-2.8* Calcium-8.5 Phos-4.7* Mg-2.2 [**2107-6-13**] 06:03PM BLOOD Ammonia-29 [**2107-6-12**] 05:35PM BLOOD CRP-102.5* [**2107-6-15**] 05:01PM BLOOD Vanco-23.6* [**2107-6-12**] 05:35PM BLOOD Digoxin-0.6* [**2107-6-15**] 05:01PM BLOOD Digoxin-0.7* [**2107-6-12**] 05:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Imaging: ======== CXR: 1. Endotracheal tube in standard position. 2. Left basilar opacity may representing a combination of pleural effusion and adjacent atelectasis, though infection is not excluded. 3. Minima patchy opacity in the right lung base could reflect additional area of infection. . CTA chest: 1. No pulmonary embolus. 2. Post-surgical changes of left upper lobectomy. 3. Diffuse peribronchovascular ground-glass nodular opacities compatible with and infectious process. Right sided pleural-based nodules and 5-mm nodule in the left lower lobe are likely part and parcel with the infectious process. Attention is recommended to these nodules on followup. 4. A 1-cm lymph node in the prevascular space is likely reactive. . CXR: As compared to the previous radiograph, the patient has received a nasogastric tube. The course of the tube is unremarkable. The tip of the tube projects over the middle parts of the stomach. No evidence of complications. Tip of the endotracheal tube is visible in unchanged location. Unchanged elevation of the left hemidiaphragm with left basal parenchymal opacity. . Brief Hospital Course: 78 year-old man with a history of lung adenocarcinoma s/p LUL lobectomy, DVT, afib on Coumadin, GI bleed, chronic stage IV sacral decubitus ulcer s/p diverting colostomy and surgical debridement, and mostly nonverbal at baseline from severe dementia who presents with worsened mental status, fever, and hypoxic respiratory distress. . # Goals of care: During his stay in the ICU, a family meeting was held and code status was changed to DNR/DN-reintubate. They did not wish for escalation of care. The patient was extubated on [**6-15**] with understanding that he may decompensate quickly or over several days/weeks and that readmission to the ICU or hospital is not consistent with goals. Upon transfer to the floor an additional family meeting was held with the help of Palliative Care and it was decided that goals of care would shift towards being comfort focused. The patient will eat small amounts of food for pleasure. He was discharged back to his extended care facility with transition to hospice care to provide comfort and increased quality of life for his remaining life. The rest of his hospital course is outlined below. . # Hypoxic Respiratory Distress (MICU course): On arrival to ED patient had O2 sats of 82% on NRB and was minimally responsive. He was intubated and in post-intubation setting went into rapid A fib with V4-6 ST depressions on ECG, which resolved with IVF. WBC elevated to 21 and BNP at 1293 (previous baseline), troponin mildly elevated to 0.09 (also at previous baseline). Post-intubation CXR showed bibasilar infiltrates and patient was started on vanco/zosyn for broad HCAP coverage given recent hospitalization. On transfer to the MICU, VS were: P 75, BP 105/66, O2sat 100% with ABG 7.60/27/130/27 on AC 500/16/5/100%. He was maintained on CMV and ultimately weaned down to PSV. Confirmed with family (nephew who is HCP) that patient is DNR and do not reintubate, and decision was made to extubate patient while accepting risk of subsequent respiratory failure. Patient is at great risk of aspiration and decompensation due to pneumonia. Sputum showed staph aureus coag + moderate growth, and yeast in sparce growth. He was ruled out for Influenza and Legionella. Family decided to continue antibiotics, but not to further escalate care and not to transfer back to the ICU. Patient was extubated on [**6-15**] and maintained adequate O2 sats on shovel mask. He was transferred to the medical floor for further management. . # Health-Care Associated Pneumonia: Confirmed on CT imaging. S/P intubation and mechanical ventilation and initially on broad antibiotics (Vancomycin and Zosyn); however, upon transfer to the Medicine floor the regimen was narrowed to Vancomycin alone given his endotracheal sputum culture grew coag + staph aureus. His leukocytosis resolved and he remained afebrile. He completed a 7 day course of antibiotics. Supplemental oxygen was provided as needed. . # Clostridium Difficile Colitis: C diff toxin positive on last admission on [**2107-6-6**]. Currently on 14 day course of Flagyl. Clinically, WBC improved and stool well-formed in colostomy. He was continued on Flagyl 500 mg TID (last day [**2107-6-20**]). . # Stage IV Sacral Decubitus Ulcer: Clinically probes to bone. On prior admission there was no xray evidence of osteomyelitis; however, MRI was not performed. He is s/p I&D, diverting colostomy, surgical debridement, antibiotic therapy, and repeat debridement last in 5/[**2107**]. Wound vac was removed in the ICU. Wound care consult provided recommendations regarding care. Given his current goals of care, surgical consult was deferred. -Contie wound care recs . # Altered mental status: Severe underlying dementia exacerbated by toxic-metabolic encephalopathy in the setting of infection. Digoxin level low. Mental status improved after transfer out of the intensive care setting. . # Afib with RVR: Most likely stress response in setting of sepsis; RVR resolved with IVF. Coumadin was held given therapeutic INR on admission and initiation of antibiotics. Given change in goals of care, anticoagulation was discontinued. . # Elevated troponin: Stable from prior admission with normal CK. [**Month (only) 116**] represent mild demand in the setting of Afib with RVR. Initially continued ASA 81 mg, simvastatin 20 mg and Metoprolol; however, given change in goals of care to focusing on comfort measures these medications were discontinued. . # Colostomy: Appears to be working appropriately, no evidence of infection around stoma, and patient making normal stool. Currently underway on 2-week course of Flagyl for positive C diff with resolution of symptoms. Medications on Admission: -Aspirin 81 mg daily -Simvastatin 20 mg daily -Senna 8.6 mg [**Hospital1 **] -Metoprolol succinate 200 mg daily -Diltiazem 240 mg daily -Digoxin 125 mcg daily -Warfarin 5 mg daily -Tamsulosin 0.4 mg qhs -Divalproex 250mg [**Hospital1 **] -Acetaminophen 650 mg q6h prn pain -Multivitamin 1 tab daily -Metronidazole 500 mg q 8h Discharge Medications: 1. other ok to screen and admit to hospice 2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days: last day is [**2107-6-20**]. Disp:*9 Tablet(s)* Refills:*0* 3. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Five (5) mg PO q1h as needed for mild pain. Disp:*30 cc* Refills:*0* 4. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Ten (10) mg PO q1h as needed for moderate pain. Disp:*30 cc* Refills:*0* 5. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Fifteen (15) mg PO q1h as needed for severe pain. Disp:*30 cc* Refills:*0* 6. Lorazepam Intensol 2 mg/mL Concentrate Sig: 0.5 mg PO every four (4) hours as needed for agitation/restlessness. Disp:*30 cc* Refills:*0* 7. Lorazepam Intensol 2 mg/mL Concentrate Sig: One (1) mg PO every four (4) hours as needed for agitation/restlessness. Disp:*30 cc* Refills:*0* 8. Atropine-Care 1 % Drops Sig: Two (2) drops Ophthalmic every four (4) hours as needed for excess secretions. Disp:*30 cc* Refills:*0* Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 730**] [**Last Name (NamePattern1) 731**] Discharge Diagnosis: health-care associated pneumonia clostridium difficile colitis chronic stage IV sacral decubitus ulcer chronic indwelling foley atrial fibrillation coronary artery disease dementia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname 8071**], You were initially admitted to the ICU (intensive care unit) for treatment of worsening respiratory status, likely secondary to a pneumonia. We provided you with antibiotics and you improved. We had a family meeting and all agreed that it is best to focus our goals on improving the quality of your life. You are being discharged back to your extended care facility where you will be able to receive hospice services. . We are making a few changes to your current medication regimen. We are discontinuing medications that are not necessary and we are adding medications to address your symptoms and focus on providing comfort. Followup Instructions: You will be followed by providers at the extended care facility . The following appointments were scheduled in our system. You may cancel the ones you do not wish to attend. Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2107-6-23**] at 1:30 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 2359**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RADIOLOGY When: MONDAY [**2107-8-29**] at 10:15 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2107-9-13**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

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8209

Discharge summary

report

Admission Date: [**2190-10-20**] Discharge Date: [**2190-10-22**] Date of Birth: [**2123-7-4**] Sex: F Service: MEDICINE Allergies: Paxil / Benadryl / Buspar / Levaquin / Adhesive Tape Attending:[**First Name3 (LF) 7651**] Chief Complaint: L sided chest pain Major Surgical or Invasive Procedure: Pericardial drain History of Present Illness: 67-year-old lady with history of breast and bladder cancers, history of L lateral bypass tract-mediated SVT, with a recent CCU admission from [**Date range (1) 29177**] for elective EPS with ablation for SVT. . During the procedure she developed hypotension to SBP of 77 mm HG. This responded to IVF and dopamine infusion to SBP of 130s. TTE showed noncircumferential pericardial effusion with mild RA collapse without RV collapse. PA catheterization showed preserved CO, no equalization of filling pressures, and preserved Y descent on RA tracing, suggesting nonhemodynamically significant effusion. She was monitored in the CCU overnight and discharged on [**10-10**]. . . Since that time, she has continued to feel L sided pleuritic chest pain, that is worse with deep inspiration and lying on her left side. She also feels weak, with decreased appetite. She says over the past 10 days she gets fatigued after 2-3 hours. She has been taking several naps per day due to fatigue. On [**10-12**], she had a repeat echocardiogram that showed again stable pericardial effusion measuring no more than 1.3-cm circumferentially without any other cardiac abnormalities. Her Cardiologist started her on lasix 20mg po daily due to significant dyspnea and respiratory findings on examination attributed to a fluid-overloaded state. After the lasix, her dyspnea improved, but she continued to feel L sided discomfort and generalized weakness. She has not had any episodes of presyncope or syncope. Her event monitor has only shown stable sinus rhythm in the 90??????s. . She has been taking Vicodin for chest pain, which has been helping. Echo from Dr.[**Name (NI) 1912**] office on [**10-19**] showed increase size of effusion (no less than 2.0cm) with no frank diastolic collapse. She had an elective pericardial drain placed this morning. . The procedure was uncomplicated. Pericardial tap with elevated pericardial pressure of 25mmHg. Drained 400mL of fluid. Pressure dropped to 4mmHg. . On arrival patient feels well. She has some mild L sided pleuritic chest pain. She denies shortness of breath or palpitations. . REVIEW OF SYSTEMS: The patient denies fever, chills, headaches, blurred vision, constipation, nausea, vomitting, shortness of breath, PND, orhtopnea, lower extremity edema. No history of pulmonary embolus, DVT, stroke, melena, BRBPR, blood in urine. All other review of systems negative in detail. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: -CABG: N/A -PERCUTANEOUS CORONARY INTERVENTIONS: N/A -PACING/ICD: N/A 3. OTHER PAST MEDICAL HISTORY: - Total abdominal hysterectomy and salpingoophrectomy [**2164**] r/t endometriosis - Left breast cancer diagnosed [**2180**] s/p Left lumpectomy and radiation therapy - Papillary bladder cancer diagnosed [**2180**] s/p multiple resections and chemotherapy, finished [**2190-4-28**] - [**2190-3-5**] s/p right ureteral stent, ? transitional cell cancer of the right ureteral orifice - Anxiety . Social History: Lives with: husband Occupation: retired ETOH: no Tobacco: 35 years/ 1ppd, quit in [**2180**] Contact person upon discharge: Husband and son: [**Telephone/Fax (1) 29176**] Home Services: NO . Family History: Unremarkable for any cardiac disease, sudden cardiac death, arrhythmias . Physical Exam: VS: T=97.1 BP 130/63 HR 83 RR 17 95% on RA GENERAL: Pleasant lady, in NAD. Lying down, Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Unable to assess JVP appropriately given the patient's position. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Tenderness to palpation over sternum and L costal margin. Pericardial drain in place, draining a small amount of serosanguinous fluid. LUNGS: Resp were unlabored, no accessory muscle use. CTAB in anterior lung fields, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis. PULSES: Right: DP 2+ Left: DP 2+ Pertinent Results: [**2190-10-20**] 10:55AM BLOOD WBC-13.5* RBC-3.58* Hgb-9.4* Hct-30.2* MCV-84 MCH-26.3* MCHC-31.2 RDW-15.1 Plt Ct-733*# [**2190-10-21**] 03:44AM BLOOD WBC-8.9 RBC-3.37* Hgb-8.9* Hct-27.9* MCV-83 MCH-26.4* MCHC-31.8 RDW-14.8 Plt Ct-664* [**2190-10-22**] 06:30AM BLOOD WBC-9.8 RBC-3.64* Hgb-9.2* Hct-30.4* MCV-84 MCH-25.2* MCHC-30.2* RDW-14.8 Plt Ct-729* [**2190-10-20**] 10:55AM BLOOD PT-15.3* INR(PT)-1.3* [**2190-10-22**] 06:30AM BLOOD PT-14.4* PTT-26.0 INR(PT)-1.2* [**2190-10-20**] 10:55AM BLOOD Glucose-124* UreaN-15 Creat-0.7 Na-138 K-5.2* Cl-101 HCO3-28 AnGap-14 [**2190-10-21**] 03:44AM BLOOD Glucose-108* UreaN-13 Creat-0.6 Na-140 K-4.3 Cl-105 HCO3-29 AnGap-10 [**2190-10-22**] 06:30AM BLOOD Glucose-98 UreaN-11 Creat-0.6 Na-141 K-5.2* Cl-106 HCO3-28 AnGap-12 [**2190-10-21**] 03:44AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.2 Iron-18* [**2190-10-22**] 06:30AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.2 [**2190-10-21**] 03:44AM BLOOD calTIBC-237* Ferritn-659* TRF-182* . Pericardial Fluid: [**2190-10-20**] 12:45PM OTHER BODY FLUID TotProt-4.9 Glucose-96 LD(LDH)-1569 Amylase-35 Albumin-3.1 [**2190-10-20**] 12:45PM OTHER BODY FLUID WBC-600* RBC-[**Numeric Identifier 29178**]* Polys-48* Lymphs-37* Monos-15* [**2190-10-20**] 12:45 pm FLUID,OTHER PERICARDIAL. GRAM STAIN (Final [**2190-10-20**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2190-10-23**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2190-10-21**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Cytology: Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS. . Blood Cx [**10-20**] NGTD (pending final) . Imaging: TTE [**10-20**]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a moderate sized circumferential pericardial effusion with mild right ventricular diastolic collapse and accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling/tamponade physiology. Compared with the prior study (images reviewed) of [**2190-10-9**], the pericardial effusion is larger with hemodynamic compromise now suggested (increased pericardial pressure). . Pericardiocentesis [**2190-10-20**] (not final report): 1. Pericardiocentesis performed from the subxiphoid approach yielded 400 cc of serosanguinous fluid. The inital pericardial pressure mean was 25 mmHg consistent with early tamponade. After drainage, the mean pericardial pressure decreased to 4 mmHg. The fluid was sent for culture, chemistry, cbc, and cytology. FINAL DIAGNOSIS: 1. Successful pericardiocentesis with removal of 400 cc fluid and decrease of pericardial pressure. . TTE [**10-20**]: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a very small circumferential pericardial effusion without evidence of hemodynamic compromise. A catheter is suggested in the pericadial space (clip [**Clip Number (Radiology) **]). Compared with the prior study (images reviewed) of the morning of [**2190-10-20**], the pericardial effusion has largely resolved. . TTE [**10-21**]: Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is a very small circumferential pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2190-10-20**], the small size of the pericardial effusion is unchanged. . TTE [**10-22**]: Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is a small pericardial effusion. There is an anterior space which most likely represents a fat pad. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. Compared with the findings of the prior study (images reviewed) of [**2190-10-21**], no major change. Brief Hospital Course: 66 year old female with a history of Left lateral bypass tract-mediated SVT s/p recent EPS ablation procedure complicated by pericardial effusion, who presented with an interval increase in effusion with impaired ventricular filling, treated with pericardiocentesis and pericardial drain placement. . # Pericardial Effusion/PUMP: Pericardial effusion was iatrogenic after previous EP study. Outpatient TTE [**10-19**] showed moderate pericardial effusion with impaired ventricular filling. Pericardial drain was placed without complication and 400 cc of fluid drained. Pericardial fluid was sent for analysis, and did not show any indication of infection. The patient was observed in the CCU and remained hemodynamically stable. Serial Echos were performed which did not show any reaccumulation of pericardial fluid, and the drain was removed without complications. The patient's pleuritic chest pain improved with drainage, but did not completely resolve and was felt to be an indication that her effusion had resulted in mild pericarditis. She was started on colchicine for treatment of pericarditis. Attempted removal of pericardial drain by EP fellow was complicated by a suspected adhesion of the drain to the hear. As a result, the patient was transferred to the operating room so as to have cardiac surgery available in case of problems during removal of tube. In the end, the drain was removed without incident. . . # RHYTHM: History of SVT with evidence of left lateral bypass tract and pre-excitation. Incomplete ablation procedure on last admission. The patient remained in sinus rhythm throughout her hospitalization. She had one episode of 6 beats NSVT, which was self terminated. She was monitored on telemetry and continued . . # CORONARIES: No known CAD, but a history of hyperlipidemia. She was continued on ASA and home dose simvastatin. . # Leukocytosis: Thought to be secondary to inflammatory state from pericardial effusion. Remained afebrile throughout stay and leukocytosis resolved. All pericardial and blood cultures have been negative to date. . # Anxiety: Continued Xanax per outpatient regimen and ambien for insomnia. . # H/o breast CA and papillary bladder CA: Stable. Patient advised to continue outpatient follow-up per primary oncologist. Medications on Admission: 1. Simvastatin 30 mg po daily 2. Multivitamin po daily 3. Atenolol 25 mg po daily 4. Cholecalciferol (Vitamin D3) 400 unit po daily 5. Cyanocobalamin 50 mcg po daily 6. Omega-3 Fatty Acids po daily 7. Aspirin 81 mg po daily 8. Alprazolam 0.25 mg po daily 9. Ibuprofen 400 mg 1-2 Tablets PO tid PRN pain 10. Lunesta 2 mg po qhs 11. Lasix 20mg po daily -stopped by Cardiologist on [**10-19**] 12. Vicodin PRN pleuritic CP Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: Do not drive after taking this medication. It makes you sedated. . 10. Lunesta 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Please take for chest pain. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Pericardial effusion Secondary diagnosis: Superventricular tachycardia Discharge Condition: Stable. Normal echo. 96% on room air. Discharge Instructions: You were admitted with a pericardial effusion. You had a drain placed to remove the fluid around your heart. You had multiple echos of your heart thereafter that showed no more fluid around your heart. You were started on colchicine to treat the pain around your heart. If you have any shortness of breath, worsening chest pain, lightheadedness, or any other symptoms that concern you, please call your doctor or go to the emergency department. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2190-10-26**] 10:40

[ "V10.51", "285.9", "E878.8", "427.0", "272.4", "997.1", "420.99", "401.9", "288.60", "V10.3", "300.00" ]

icd9cm

[ [ [] ] ]

[ "37.0", "88.72" ]

icd9pcs

[ [ [] ] ]

13254, 13260

9506, 11791

333, 353

13394, 13434

4535, 5979

13930, 14061

3625, 3700

12261, 13231

13281, 13281

11817, 12238

7687, 9483

13458, 13907

3715, 4516

2901, 2974

6159, 6159

6192, 7670

2511, 2791

275, 295

3540, 3609

381, 2492

13342, 13373

13300, 13321

6015, 6123

3005, 3400

2813, 2881

3416, 3524

28,686

199,524

33072

Discharge summary

report

Admission Date: [**2183-12-18**] Discharge Date: [**2183-12-27**] Date of Birth: [**2121-7-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5893**] Chief Complaint: metastatic cancer Major Surgical or Invasive Procedure: CT guided needle biopsy of RUL mass History of Present Illness: The patient is a 62 year old man with history of COPD who developed neck spasms in [**Month (only) **], PCP [**Name9 (PRE) 8019**] revealed lung tumor, with inconclusive results biopsy x 2 (via bronch). Per PCP C/T-spine CT done, and C-spine CT shows C6 tumor. He reports that approximately two weeks ago he developed R shoulder weakness, tingling, and pain that would radiate to his right hand. At the same time he developed R buttock pain, with intermittent R leg pain. Patient was transferred to [**Hospital1 18**] from [**Hospital **] hospital for further C-spine work-up and treatment. He was initially admitted to the Neurosurgical service for the concern of spinal cord compression. He had MRI c/t/l spine that showed diffuse infiltration of the vertebral bodies w/o frank cord compromise. He was transfered to oncology for further management. . Currently he denies pain in his arm. He states that he is weak in the shoulder and elbow on the right side. He has no numbness or tingling of his right hand. The left shoulder is also weak but not as much as the right. His legs feel strong to him. . ROS: no chest pain. no shortness of breath. no cough. no nausea/vomiting/diarrhea. he feels constipated. no bowel or bladder incontinence. no jaundice. no fever/chills/sweats Past Medical History: Hyperlipidemia Social History: Non-smoker x 2 years (previously smoked 1.5 ppd x 20 years), rare EtOH intake, lives with wife of 14 years. Has 2 children from prior marriage. Works full time at his dental lab. Family History: Brother with MI in mid 60s. father died of dementia at 93. mother died of MI at 73. no cancers. Physical Exam: Vitals: 97.3 18 106/62 78 98%RA pain 0/10 Gen: thin Caucasian male in NAD HEENT: PERRL, EOMI, anicteric sclera. MMM. Neck: no cervical lymphadenopathy. no thyromegaly Chest: clear on left. bronchial breath sounds on right upper fields. no dullness. no I:E prolongation CV: RRR no m/r/g Abd: flat, soft. NT, active bowel sounds. small but prominent pulsation of abdominal aorta Ext: thin. mild digital clubbing. no edema. full ROM to both shoulders and elbows. Neuro: -MS: alert and oriented x3 coherent response to interview. no extinction -CN: II-XII intact -Motor: normal hand grip. [**2-3**] at right deltoid. [**4-3**] right bicep. normal finger abduction. [**5-3**] hip flex, knee flex/ext, ankle flex/ext -DTR: 2+ biceps, patellars, ankles. toes downgoing bilat. -[**Last Name (un) **]: light touch intact to face/hands/feet -Coord: [**Doctor First Name **] intact. FTN limited by shoulder strength Pertinent Results: LABS on admission: LABS on discharge: IMAGING: Brief Hospital Course: 62yo M w/ COPD admitted with right shoulder pain and weakness found to have large lung mass, with lesions to brain (5 solitary lesions), spine (C5 and T11) and possibly the kidney, unknown primary. 1.Lung Mass and HYPOXIA: Lung mass presumed to be the primary lesion, given the multiple lesions in ipsilateral and contralateral lung consistent with advanced disease. Previous biopsies only obtained necrotic tissue, so unable to identify primary malignancy prior to patients death. Throughout the course of his admission he became progressively more hypoxic and tachycardic due to diffuse cancerous involvement of lungs bilaterally as well as associated emphysematous changes. In addition, he likely developed a post obstructive pneumonia. He was intubated on [**12-25**] for hypoxic respiratory failure according to the patient and his wife's wishes. He was treated with vancomycin and zosyn for post obstructive pneumonia. Given the massive involement of his lungs by tumor it was very unlikely that he would ever come off of ventillatory support. In addition given the late stage and wide spread metastasis of his cancer his prognosis was very poor. This was discussed with the patient and his wife prior to intubation. Following his intubation, the decision was made to make him comfort measures only and withdraw ventillatory support on [**12-27**]. He died within one hour of withdrawing ventillatory support. He will have a post mortem autopsy according to the family's wishes. 2. METASTATIC DISEASE: Pt has metastatic disease to brain, contralateral lung, and spine (C5 and T11). Also possible that he has disease in his kidney, given the abnormal 4.5 x 3.4cm L renal mass seen on CT. Also has rising LFTs and RUQ tenderness, raising concern for liver mets. Most likely etiologies are metastatic lung ca vs. metastatic RCC. Neurologic status began to progress to involve bilateral arms so he was initially started XRT to C-spine, however this was stopped once his condition progressed to respiratory failure. He was continued on dexamethasone for brain/spinal mets and seizure prophylaxis. 3. LEUKOCYTOSIS: Most likely due to combination of steroids and post-obstructive pneumonia. He was treated with vancomycin and zosyn. 4. TRANSAMINITIS: Elevated LFTs and RUQ pain are concerning for liver metastases. INR 1.4 so may have synthetic dysfunction as well (though pt's nutritional status is also poor which could be contributing). This was not evaluated further due to decline in patient quality of life and change of goals of care to comfort measures only. Medications on Admission: Insulin SC Sliding Scale Lorazepam 0.5 mg IV Q8H:PRN anxiety Acetaminophen 325-650 mg PO Q6H:PRN Morphine Sulfate 1-3 mg IV Q4H:PRN pain Atorvastatin 10 mg PO DAILY Ondansetron 4 mg IV Q8H:PRN n/v Bisacodyl 10 mg PO/PR DAILY Oxycodone-Acetaminophen [**12-31**] TAB PO Q4H:PRN pain Dexamethasone 4 mg PO Q6H Pantoprazole 40 mg PO Q24H Docusate Sodium 100 mg PO BID Senna 1 TAB PO BID Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "272.0", "162.3", "995.91", "198.3", "038.9", "276.3", "197.7", "518.81", "276.2", "348.30", "276.1", "492.8", "198.5", "486", "723.4", "198.0" ]

icd9cm

[ [ [] ] ]

[ "33.26", "96.04", "96.71", "38.91" ]

icd9pcs

[ [ [] ] ]

6097, 6106

3045, 5631

335, 372

6165, 6175

2971, 2976

6231, 6242

1930, 2027

6065, 6074

6127, 6144

5657, 6042

6199, 6208

2042, 2952

278, 297

3011, 3022

400, 1680

2991, 2991

1702, 1718

1734, 1914

83,430

186,677

49419

Discharge summary

report

Admission Date: [**2171-2-15**] Discharge Date: [**2171-2-21**] Date of Birth: [**2099-5-19**] Sex: F Service: MEDICINE Allergies: Flexeril / Percocet / Compazine Attending:[**First Name3 (LF) 1145**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: none History of Present Illness: This is a 71 yo female with long-standing coronary disease s/p CABG in [**2143**] and redo in [**2156**] who presented with chest pain refractory to nitroglycerin who was admitted to CCU for concern for STEMI. She began experiencing left-sided non-radiating [**8-19**] chest pain last night, for which she took 325mg aspirin and 9 sublingual nitroglycerins with minimal relief. She then called EMS, who administered another sublingual nitroglycerin which also did not provide substantial relief. She was brought to the emergency room where she was noted to have ST segment deviations in V1-V2. Cardiac catheterization was discussed and patient declined due to presence of non-intervenable disease on prior catheterizations and she opted for medical management. She was continued on home clopidogrel 75mg, and given a heparin bolus, and admitted to CCU for further evaluation and management. She also received morphine 4mg IV and hydromorphone IV which rendered her pain free. Eptifibatide was deferred on admission due to renal insufficiency. Of note, patient was also noted to be guaiac positive in the emergency room. . Of note, patient was admitted to the hospital during [**Month (only) 1096**] [**2170**] with CHF exacerbations and cellulitis. She had been sent home on torsemide and metolazone and was changed back to furosemide on [**2170-2-10**] since her weight had come down to 176 lbs. She reports that her weight has been stable since then and she denies any worsening dyspnea or worsening oedema. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for orthopnea, increasing ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS:: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: -CABG: s/p CABG x 2; [**2143**] (SVG-LAD after PTCA of LAD), re-do CABG in [**2156**] (LIMA-LAD, SVG-OM, SVG-D1). 3. OTHER PAST MEDICAL HISTORY: #. Left ventricular systolic heart failure: last echo in [**12/2170**] showing global LV hypokinesis 40-50%, depressed RV fx, mod-severe AS, 3+TR #. Atrial fibrillation. The patient has declined coumadin in the past #. Hypertension #. Chronic renal failure, creatinine baseline 1.4-1.7 #. Morbid obesity #. S/P appendectomy, cholecystectomy (combined; at age 20) #. H/O keloid right ear s/p surgeries #. H/O ectopic gestation s/p tubal ligation #. Dyslipidemia Social History: She lives by herself, although her son has been staying with her recently. Has visiting nurse. Retired. No tob/etoh/drugs. She has two adult children still living. Two of her children died in their 40's due to heart disease. She does her best to follow a low salt diet and has been inspired by her son who is on salt free diet as he awaits heart transplant. Family History: The patient has significant family history of CAD: daughter died at 43 MI, son died 48 of MI, sister 60 died of MI, brother died at 27 of MI, father died at 56 of MI. One sister and one niece died of cancer(unkown type). Patient also reports family h/o colon cancer in her sister and ? in her niece diagnosed ages 40s-50s. She has one son and one daughter who are living. Both have heart disease. Her son is on the heart transplant list. Physical Exam: T:98.3 HR:89 BP:117/41 RR:16 O2Sat97% on RA GENERAL: Elderly, overweight female, pleasant, NAD HEENT: MMM, OP Clear NECK: Supple with JVP of 18cm. CARDIAC: PMI diffuse, + RV Heave. LUSB mid-peaking systolic murmur. Holosystolic murmur at Apex. S1 and normal S2. No gallops. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, obese, NT, ND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ peripheral oedema, stable. SKIN: Stage II Sacral decubitus noted on admission PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [**2171-2-15**] 08:55AM BLOOD WBC-5.3 RBC-3.36* Hgb-9.4* Hct-28.5* MCV-85 MCH-28.1 MCHC-33.1 RDW-16.7* Plt Ct-221 [**2171-2-15**] 08:55AM BLOOD Neuts-66.2 Lymphs-25.2 Monos-5.7 Eos-2.3 Baso-0.7 [**2171-2-15**] 08:55AM BLOOD PT-14.4* PTT-24.0 INR(PT)-1.3* [**2171-2-15**] 08:55AM BLOOD Glucose-114* UreaN-129* Creat-1.5* Na-135 K-4.5 Cl-97 HCO3-23 AnGap-20 [**2171-2-15**] 08:55AM BLOOD ALT-19 AST-31 LD(LDH)-142 CK(CPK)-355* AlkPhos-76 Amylase-126* TotBili-0.8 [**2171-2-15**] 08:55AM BLOOD Lipase-154* [**2171-2-17**] 02:17PM BLOOD Lipase-76* [**2171-2-19**] 04:47AM BLOOD Lipase-64* [**2171-2-15**] 08:55AM BLOOD cTropnT-0.02* [**2171-2-15**] 05:32PM BLOOD CK-MB-16* MB Indx-3.9 cTropnT-0.36* [**2171-2-16**] 04:29AM BLOOD CK-MB-19* MB Indx-4.3 cTropnT-0.58* [**2171-2-17**] 04:41AM BLOOD CK-MB-16* MB Indx-4.1 cTropnT-0.59* [**2171-2-18**] 07:03AM BLOOD CK-MB-15* MB Indx-4.1 cTropnT-0.72* [**2171-2-19**] 04:47AM BLOOD CK-MB-16* MB Indx-4.3 cTropnT-1.05* [**2171-2-15**] 08:55AM BLOOD Albumin-4.8 Calcium-10.2 Phos-3.9 Mg-2.7* Iron-65 [**2171-2-15**] 08:55AM BLOOD calTIBC-378 VitB12-625 Folate-19.3 Ferritn-260* TRF-291 [**2171-2-15**] 08:55AM BLOOD Digoxin-1.0 . PICC placement - IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 4Fr PICC line placement via the right brachial venous approach. Final internal length is 33 cm, with the tip positioned in SVC. The line is ready to use. . EKG [**2171-2-18**] - Atrial fibrillation. There are small R waves in the anterior leads consistent with probable prior anterior myocardial infarction. Diffuse ST-T wave changes which are non-specific but may represent ischemia or infarction. Low voltage in the precordial leads. Compared to the previous tracing the rate is slightly slower. . Chest x-ray - FINDINGS: A single AP semi-upright view of the chest was obtained. The patient is status post median sternotomy with median sternotomy wires identified. The heart is stably enlarged. There is atherosclerotic disease of the aorta. The lungs are clear bilaterally. There are no pleural effusions or pneumothorax identified. The osseous structures are intact. IMPRESSION: Marked stable cardiomegaly with clear lungs. . Echo - The left atrium is elongated. The right atrium is moderately enlarged. The estimated right atrial pressure is 0-10mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the anterior septum and anterior walls. The apex is mildly dyskinetic. The remaining segments contract normally (LVEF = 40%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is moderately increased with moderate global free wall hypokinesis. The aortic valve leaflets are moderately thickened. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, inferolaterally directed jet of moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD. Right ventricular cavity enlargement with free wall hypokinesis. Moderate aortic valve stenosis. Moderate pulmonary artery systolic hypertension. Moderate mitral regurgitation. Compared with the prior study (images reviewed) of [**2170-12-21**], right ventricular cavity size is slightly smaller with improved free wall motion. Septal motion was abnormal on the prior study but considered due to RV overload, but there was no septal thickening. Anterior and apical dysfunction are now apparent. The severity of tricuspid regurgitation is similar. Brief Hospital Course: ASSESSMENT AND PLAN: 71 yo female with severe coronary artery disease, systolic CHF presents with chest discomfort in setting of atrial fibrillation with rapid ventricular response. . # Chest pain: ST segment deviations may have been related to old-infarcts and changes have now resolved. Some contribution related to atrial fibrillation with RVR, given that recurrent episodes associated with CP. Initially treated with Bblockers but SBPs have not been high enough to tolerate this. Did well with NTG drip and MS IV, limited again by hypotension. Troponin elevation may be related to demand in setting of atrial fibrillation with RVR versus NSTEMI. Likely former, since CK was stable near 400, which was the same level during her last admission. Initially treated for suspected NSTEMI with Lovenox 80mg SC q24h for creatinine clearance < 30. Now off anticoagulation and doing well. Essentially this is a patient with end-stage, non-intervenable coronary disease, also patient declined cardiac cath. Symptoms are controlled with MS contin with MS IR for breakthrough pain. Rate control is tantamount, increased BB to 37.5 TID, rate well-controlled with this. ASA, Plavix, statin (lowered dose per pt request). ACEI on hold for elevated Cr and low BPs. Patient refused cardiac catherization, prefers palliative approach. Pt did not appear to be getting significant benefit from imdur, so DCed and increased BB as above. Started on MS contin with very good effect. . # RHYTHM: Atrial fibrillation with rapid ventricular response. Uptitrated beta blockers as above. Cont. BB as above. Continue digoxin, level appropriate at 1.0. Pt refused long term anticoagulation, completed lovenox x 3days for ACS. . # Chronic systolic CHF - Leg edema is at baseline and patient is not any more dyspneic than baseline. Chest x-ray is clear. Elevated JVP may be secondary to tricuspid regurgitation. Medications on Admission: 1. Atorvastatin 20 mg daily 2. Aspirin 81 mg daily 3. Clopidogrel 75 mg daily 4. Multivitamin daily 5. Furosemide 40mg daily 6. Omeprazole 20 mg daily 7. Cephalexin 250 mg for 8 days. 8. Metoprolol Tartrate 25 mg [**Hospital1 **] 9. Metolazone 5 mg Daily 10. Hydrocodone-Acetaminophen 5-500 mg One [**Hospital1 **] prn pain 11. Digoxin 125 mcg EVERY OTHER DAY 12. Lisinopril 2.5 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day as needed for lower extremity edema or worsening sob. Disp:*30 Tablet(s)* Refills:*1* 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*240 Tablet(s)* Refills:*2* 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please hold for BM > 2. Disp:*60 Tablet(s)* Refills:*2* 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily): please hold for BM greater than 2 per day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 12. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO twice a day as needed for nausea. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0* 13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*20 Tablet, Sublingual(s)* Refills:*0* 14. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours): please hold for sedation or RR < 12. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 15. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: please hold for sedation or RR < 12. Disp:*60 Tablet(s)* Refills:*0* 16. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 17. Miralax 17 gram (100 %) Powder in Packet Sig: Seventeen (17) grams PO once a day: Hold for >2BM per day. Disp:*qs gram* Refills:*1* 18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*5* Discharge Disposition: Home With Service Facility: [**Hospital 269**] Hospice Care Discharge Diagnosis: Primary: NSTEMI, atrial fibrillation with RVR . Secondary: CABG: s/p CABG x 2; [**2143**] (SVG-LAD after PTCA of LAD), re-do CABG in [**2156**] (LIMA-LAD, SVG-OM, SVG-D1). Chronic systolic Heart failure Atrial fibrillation. The patient has declined coumadin in the past Hypertension Chronic renal failure, creatinine baseline 1.4-1.7 Obesity S/P appendectomy, cholecystectomy (combined; at age 20) H/O keloid right ear s/p surgeries H/O ectopic gestation s/p tubal ligation Dyslipidemia Discharge Condition: afebrile, chest pain free, vital signs stable with HR largely in 80-90s, BP systolic in 90s-100s Discharge Instructions: You were admitted to the hospital with chest pain and found to have a non-ST elevation myocardial infarction. You declined repeat cardiac catherization. You were evaluated by our pain and palliative care service and are being discharged home with visiting nurse services, with possible bridge to hospice services. . Medication changes: 1) You were started on MS Contin for pain control 2) You were started on morphine IR for breakthrough cardiac pain 3) Your standing daily lasix was discontinued. You should weigh yourself and if you notice 3-lb weight gain or shortness of breath, take a dose of 20mg. 4) You were started on aggressive bowel regimen in the setting of standing morphine. It is VERY important that you take these medications because the opiods are very constipating. 5) Your aspirin was changed to full strength 325 mg daily from 81 mg daily 6) Your lisinopril was stopped due to worsening renal function 7) Your beta blocker dose was changed to metoprolol 50mg twice per day 8) You were started on Zofran as needed for nausea/vomiting 9) You were started on allopurinol for your gout . You should adhere to [**2162**] mg sodium diet. . Please call your PCP if you experience any worsening chest pain that cannot be managed with your current medications or if you experience worsening shortness of breath or abdominal pain. Followup Instructions: Please follow up with Dr. [**First Name (STitle) 437**] and Dr. [**Last Name (STitle) 9764**]. [**Hospital1 18**] Cardiology office number is ([**Telephone/Fax (1) 2037**]. We would recommend that you follow up within 1 month. . In addition, please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9006**] within 1 month of discharge. You can call ([**Telephone/Fax (1) 1300**] to schedule at your convenience. . You have the following appointments already scheduled for you: Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2171-3-12**] 1:00 Completed by:[**2171-8-7**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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62,412

194,418

35419

Discharge summary

report

Admission Date: [**2147-3-15**] Discharge Date: [**2147-3-21**] Date of Birth: [**2072-12-12**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest tightness Major Surgical or Invasive Procedure: [**2147-3-16**] Five Vessel Coronary Artery Bypass Grafting(left internal mammary artery to left anterior descending artery with vein grafts to the diagonal, first obtuse marginal, second obtuse marginal, and PDA) History of Present Illness: Mr. [**Known lastname **] is a 74 year old male with known coronary artery disease. He presented to [**Hospital **] Hospital with a six week history of chest tightness and heaviness. He underwent cardiac catheterization which revealed 70% left main lesion including severe three vessel coronary artery disease. He was subsequently transferred to the [**Hospital1 18**] for cardiac surgical intervention. Past Medical History: Coronary Artery Disease - Prior PTCA/stenting to RCA in [**2135**] Type II Diabetes Mellitus Hypertension Dyslipidemia Benign Prostatic Hypertrophy, s/p TURP [**2131**] Degenerative Joint Disease Diverticular Disease Sigmoid Resection [**2145**] Cataract Surgery Right Knee Operation [**2144**] Social History: Performs office work part time. 30 pack year history of tobacco but quit smoking in [**2122**]. Denies ETOH. Family History: Father died of MI at age 62. Physical Exam: BP 126/69, P 62, RR 12 Ht 70 inches Wt 80 kg General - WDWN male in NAD Skin - unremarkable HEENT - oropharynx benign, EOMI, sclera anicteric Neck - supple, no JVD Chest - lungs CTA bilaterally Heart - regular rate and rhythm, normal s1s2, no rub or murmur Abdomen - benign Ext - warm, no edema Neuro - alert and oriented, CN 2-12 grossly intact, FROM, [**5-23**] strength Pertinent Results: [**2147-3-15**] 01:32PM BLOOD WBC-6.0 RBC-3.98* Hgb-12.7* Hct-35.3* MCV-89 MCH-32.0 MCHC-36.0* RDW-13.0 Plt Ct-196 [**2147-3-15**] 01:32PM BLOOD PT-14.4* PTT-29.8 INR(PT)-1.3* [**2147-3-15**] 01:32PM BLOOD Glucose-149* UreaN-10 Creat-0.8 Na-141 K-4.0 Cl-108 HCO3-30 AnGap-7* [**2147-3-15**] 01:32PM BLOOD ALT-12 AST-16 LD(LDH)-131 AlkPhos-67 TotBili-0.7 [**2147-3-15**] 01:32PM BLOOD Albumin-3.9 Calcium-8.9 Phos-2.7 Mg-1.9 [**2147-3-15**] 01:32PM BLOOD %HbA1c-7.9* [**2147-3-15**] Carotid Ultrasound 1. Mild plaque in the right internal carotid artery with less than 40% stenosis. 2. No stenosis in the left internal carotid artery. This is a baseline examination at the [**Hospital1 18**]. [**2147-3-15**] Echocardiogram The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the intensive care unit given his critical coronary anatomy. He underwent routine preoperative evaluation - please see result section for preoperative study results. He remained pain free on medical therapy and was cleared for surgery. The following day, Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting surgery. Please see operative note for details. Following the operation, he was transferred to the surgical intensive care unit for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. His unit course was otherwise routine and he transferred to the step down floor on postoperative day one. His chest tubes and epicardial wires were removed. He was seen in consultation by the physical therapy service. His beta blockade was titrated up as tolerated. By post-operative day five he was ready for discharge to home. Medications on Admission: Aspirin 81 qd, Enalapril 10 qd, Fexofenadine 180 qd, Levemir 23 units, Novolog sliding scale, Lopressor 50 [**Hospital1 **], Lovastatin 40 qd, Omeprazole 20 qd, Terazosin 4 qd, Viagra prn Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 5. Terazosin 1 mg Capsule Sig: Four (4) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*2* 7. Levemir Flexpen 100 unit/mL Insulin Pen Sig: Twenty Three (23) units Subcutaneous at bedtime. Disp:*qs * Refills:*2* 8. Novolog Flexpen 100 unit/mL Insulin Pen Sig: see sliding scale Subcutaneous three times a day. Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Coronary Artery Disease - s/p CABG Type II Diabetes Mellitus Hypertension Dyslipidemia Prior PTCA/stenting to RCA in [**2135**] Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**4-23**] weeks, call for appt ([**Telephone/Fax (1) 11763**] Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Sanan (PCP) in [**2-21**] weeks, call for appt ([**Telephone/Fax (1) 80746**] Dr. [**Last Name (STitle) 8579**] or Caligan (cardiology) in [**2-21**] weeks, call for appt Completed by:[**2147-3-21**]

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icd9cm

[ [ [] ] ]

[ "39.61", "36.15", "36.14" ]

icd9pcs

[ [ [] ] ]

5273, 5336

3141, 4080

292, 508

5508, 5515

1840, 3118

6314, 6693

1402, 1432

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237, 254

536, 941

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1276, 1386

16,022

184,709

7152

Discharge summary

report

Admission Date: [**2185-10-19**] Discharge Date: [**2185-10-31**] Date of Birth: [**2119-4-16**] Sex: M Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 30**] Chief Complaint: Creatinine of 7.0. Nausea and vomiting. Major Surgical or Invasive Procedure: PICC line placement [**2185-10-21**]. History of Present Illness: ON ADMISSION TO MEDICAL FLOOR: . 66 year old male with Type II NIDDM, CAD, recent discectomy complicated by right sided embolic CVA, who presented to the [**Hospital1 18**] with nausea/vomiting x 2 weeks at which point he was found to have a creatinine of 7 (baseline of 1). . Patient has had nausea since his [**8-14**] surgery (see below for history of recent hospitalizations). He reports that he has been unable to tolerate food as just the smell makes him nauseated. He has lost 54 pounds since his surgery. On [**10-6**] he was started on 4 week course of ciprofloxacin for E. Coli prostatitis. Though his urinary symptoms resolved, since that time his nausea and vomiting have worsened. He was not been able to tolerate full meals, only ginger ale. His vomitus has been non-bloody, non-bilious and he has had no abdominal pain or cramping. He has been feeling weak and lightheaded. At his [**10-19**] PCP visit with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], he was directed to the [**Hospital1 18**] ED due to persistent vomiting and dehydration. While there his creatinine was found to be 7.0 and he was admitted to the MICU. . During his ICU course he was followed by the renal team (attending Dr. [**First Name (STitle) 805**] who thought his renal failure to be multi-factoral ATN due to volume depletion w/ ACE and hypotension. Patient showed some improvement with maitenance IVF, his lisinopril, metformin and NSAID were held. At no point did the patient need HD. His nausea and vomiting improved somewhat on scopalamine patch and anti-emetics, but patient continued to have vomiting. His bradycardia and hypotension were thought to be secondary to beta blocker toxicity in setting of ARF; atenolol, lisinopril, glucagon and dopamine were held. Patient began to receive ceftriaxone on [**10-20**] for his prostatitis. Patient has had a sore throat for two days, was strep negative. He was transferred to the medical floor on [**10-23**] in stable condition. . REVIEW OF SYSTEMS: Weak and fatigued, feels lightheaded when he stands up, but resolves when he lies down. He sleeps a great deal. No loss of consiousness. No fevers or sweats. 54 pound weight loss since [**8-14**] surgery. No rash, pruritus, bruising, change in hair or nails. No headaches or trauma. No eye irritation or change in vision (though initially diminished on left after CVA). Wears glasses for [**Location (un) 1131**] and distance. No change in hearing. No epistaxis. No mouth sores or difficulty swallowing. Has had sore throat with associated cough for two days. No chest problems or difficulty breathing. No chest pain or pressure, no palpitations. No abdomenal pain or cramping. Occassional loose stools, but generally regular bowel movements. As above, patient has had nausea and vomiting. No dysuria, though patient was not able to urninate in the ED, has had Foley catheter since this admisison. Patient has had erectile dysfunction for several years. Patient has osteoarthritis with tender finger, toe and left knee joints. Patient has some calf pain on exertion - he has had claudication, he is unable to walk more than a block without pain. He has some abnormal sensation in his fingers and toes, things often feel "wet." He has had no nervousness, depression or change in memory. He often feels cold. . Past Medical History: RECENT HOSPITALIZATIONS: *[**Date range (1) 26594**]: Elective C5-C6 disectomy due right HNP with compression of exiting nerve root. Episode of hemiparesis, with continued motor dysfunction. *[**Date range (1) 26595**]/06: "difficulty dressing and personality changes." Assumed to be post operative left hemiparesis, found to be from right MCA CVA due to a PFO. Had loose stools, c-diff negative. *[**Date range (1) 26596**]/06: "watery diarrhea." C-diff negative, but improved with empiric flagyl, planned 2 week empiric treatment. Assumed diarrhea worsened by Omega 3 fatty acids and Aggrenox, both discontinued with associated improvement in symptoms. *[**Date range (1) 26597**]: "fevers, dysuria, urgency and pelvic pain." Ultrasound showed prostatic hypertrophy, PSA elevated at 24.9, E.coli in urine culture = prostatitis; treated with IV ceftriaxone, discharged with 4 week course of ciprofloxacin and Flomax. Had loose stools on admission and discharge, c-diff negative. . MEDICAL HISTORY: 1) Adenoma, most recent colonoscopy in [**5-/2185**] with adenoma. Followup recommended in one year. 2) Coronary artery disease status post PTCA of RCA in [**2173**]. 3) Atrial fibrillation on amiodarone, s/p cardioversion (summer [**2184**]), currently off coumadin. 4) Peripheral vascular disease status post bilateral femoral PTCA in [**2159**]; chronic claudication. 5) History of Osteoarthritis in the hands, feet, C-spine, left knee. 6) Hyperlipidemia, predominantly elevated triglycerides and low HDL. 7) Diabetes type 2, managed with metformin. 8) Obesity and Obstructive Sleep Apnea. 9) Kidney stones 10) Radiculitis diagnosed in 07/[**2185**]. MRI with foraminal narrowing C5-C6. 11) Recent E. coli prostatitis: diagnosed on [**10-3**] admission. 12) Recent Diarrhea: [**2185-9-14**] admission negative for C-Diff but tx with Flagyl, taken off Aggrenox and symptoms improved. 13) Hypothyroid: diagnosed < 1 year ago. . SURGICAL HISTORY: 1) Cervical Radiculopathy s/p discectomy [**2185-8-25**] 2) Cholecystectomy 3) History of left knee surgery. 4) acromioplasty, arthoscopic debridement, rotator cuff tear repair . Social History: Patient is married (wife [**Name2 (NI) 17486**]), has 6 children (4 from previous marriage, 2 from current marriage), and four grandchildren. Patient lives with his wife, daughter and son. [**Name (NI) **] worked for 40 years at [**Last Name (un) **] in purchasing department, waiting to return to work. Habits: 40 pack year smoking history, quit 10 years ago. Heavy drinker for 40 years, quit 10 years ago after elevated bilirubin, now occassional wine. Denies use of any other drugs. Patient is no longer sexually active due to erectile dysfunction of several years. Family History: Diabetes mellitus, peripheral vascular disease, coronary artery disease, lung and breast cancer Physical Exam: ON ADMISSION TO MEDICAL FLOOR: GENERAL: pale appearing man in no acute distress, lying in bed. VITALS: T: 98.2 BP: 134/70 P: 50 RR:18 96% on RA Fingerstick 148 HEENT Exam: Head normocephalic, atraumatic; conjunctivae clear, sclerae anticteric, pupils equally round and reactive to light. Extraocular muscles intact. Visual acuity testing was deferred. Oropharynx clear, moist mucus membranes, no posterior oropharyngeal erythema or exudate. NECK: Trachea midline. Neck supple. Thyroid not palpable. No cervical, axillary or supraclavicular lymphadenopathy noted. LUNG: Clear to auscultation bilaterally on anterior exam. Good breath sounds, decreased air movement. No crackles, wheezes or rhonchi throughout. Some pain to palpation on left costal border. CARDIAC: regular rate and rhythm, 1/6 systolic murmur, no rubs or gallops, JVP not appreciated, no carotid bruits. ABDOMEN: Scars from previous cholecystectomy, active bowel sounds in all four quadrants. Non tender, no palpable masses, no hepatosplenomegaly, no guarding or rebound. RECTAL: no tenderness or pain. EXTREMITIES: warm, well-perfused. No clubbing, cyanosis, edema. 1+ dorsalis pedis pulses bilaterally. SKIN: skin warm and moist. No suspicious nevi, rashes, petechiae or ecchymoses. NEUROLOGY: Alert and oriented x3. CN II-XII intact to direct testing. Preserved sensation throughout. Resting tremor in upper and lower left extremity. Motor on right [**5-13**], on left [**4-13**]. Finger to nose and rapid alternating movements intact on right side, diminished and with tremor on left. No pronator drift. Gait assessment deferred. Pertinent Results: CHEST X-RAY ([**10-19**]): No evidence of intrathoracic pathology. . ECG ([**10-19**]): Sinus bradycardia. Prolonged QTc interval. Since previous tracing of [**2185-10-5**] diffuse low amplitude T wave changes have decreased. . RENAL US ([**10-20**]): No evidence of hydronephrosis or obstruction. Bilateral renal cysts. . ECG ([**10-21**]): Sinus rhythm with rightward axis, low limb lead QRS voltages, Q-Tc interval appears prolonged but is difficult to measure. Since previous tracing of [**2185-10-19**], sinus bradycardia rate faster. . [**2185-10-28**] 06:49AM BLOOD WBC-4.6 RBC-3.13* Hgb-9.3* Hct-27.7* MCV-89 MCH-29.6 MCHC-33.4 RDW-15.0 Plt Ct-166 [**2185-10-23**] 03:00AM BLOOD WBC-4.0 RBC-2.94* Hgb-8.8* Hct-27.7* MCV-94 MCH-30.1 MCHC-31.9 RDW-14.7 Plt Ct-157 [**2185-10-19**] 10:05AM BLOOD WBC-9.0# RBC-4.02* Hgb-12.1* Hct-35.4* MCV-88 MCH-30.0 MCHC-34.1 RDW-14.8 Plt Ct-380 [**2185-10-19**] 10:05AM BLOOD Neuts-80.9* Lymphs-15.4* Monos-2.8 Eos-0.5 Baso-0.4 [**2185-10-28**] 06:49AM BLOOD PT-13.3* PTT-28.6 INR(PT)-1.2* [**2185-10-26**] 04:57AM BLOOD PT-14.4* PTT-30.3 INR(PT)-1.3* [**2185-10-19**] 10:37AM BLOOD PT-15.8* PTT-27.3 INR(PT)-1.4* [**2185-10-28**] 06:49AM BLOOD Glucose-87 UreaN-24* Creat-4.0* Na-147* K-3.7 Cl-114* HCO3-25 AnGap-12 [**2185-10-27**] 06:55AM BLOOD Glucose-106* UreaN-27* Creat-4.4* Na-147* K-3.8 Cl-115* HCO3-26 AnGap-10 [**2185-10-26**] 04:57AM BLOOD Glucose-98 UreaN-35* Creat-5.0* Na-145 K-3.9 Cl-115* HCO3-22 AnGap-12 [**2185-10-25**] 05:57AM BLOOD Glucose-92 UreaN-42* Creat-5.7* Na-145 K-4.0 Cl-114* HCO3-23 AnGap-12 [**2185-10-24**] 05:45AM BLOOD Glucose-113* UreaN-47* Creat-5.8* Na-144 K-4.0 Cl-115* HCO3-20* AnGap-13 [**2185-10-23**] 04:14AM BLOOD Glucose-130* UreaN-54* Creat-6.0* Na-143 K-4.0 Cl-115* HCO3-20* AnGap-12 [**2185-10-21**] 03:57AM BLOOD Glucose-193* UreaN-55* Creat-6.4* Na-136 K-3.7 Cl-107 HCO3-18* AnGap-15 [**2185-10-20**] 02:07PM BLOOD Glucose-137* UreaN-56* Creat-6.4* Na-138 K-3.8 Cl-109* HCO3-18* AnGap-15 [**2185-10-20**] 04:24AM BLOOD Glucose-81 UreaN-53* Creat-6.6* Na-143 K-4.0 Cl-112* HCO3-19* AnGap-16 [**2185-10-19**] 08:00PM BLOOD Glucose-58* UreaN-47* Creat-6.4* Na-148* K-4.1 Cl-113* HCO3-18* AnGap-21* [**2185-10-20**] 02:07PM BLOOD CK(CPK)-37* [**2185-10-19**] 10:05AM BLOOD ALT-17 AST-31 CK(CPK)-38 AlkPhos-78 Amylase-34 TotBili-1.0 [**2185-10-20**] 02:07PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2185-10-19**] 05:38PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2185-10-19**] 10:05AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2185-10-28**] 06:49AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.7 [**2185-10-19**] 08:00PM BLOOD Calcium-8.2* Phos-4.8* Mg-2.1 [**2185-10-19**] 10:05AM BLOOD TotProt-7.4 Calcium-9.5 Phos-5.1*# Mg-2.2 [**2185-10-23**] 03:00AM BLOOD calTIBC-168* Ferritn-543* TRF-129* [**2185-10-20**] 04:24AM BLOOD [**Month/Day/Year 8675**]-0.36 [**2185-10-23**] 03:00AM BLOOD PTH-48 [**2185-10-19**] 05:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . Stool culture ([**2185-10-21**]): Negative. . Urine culture ([**2185-10-19**]): Negative. . Blood culture ([**2185-10-19**]): Negative. Brief Hospital Course: Patient is a 66-year-old male with non-insulin dependent diabetes type 2, coronary artery disease status post PTCA, peripheral vascular disease, hypercholesterolemia, status post C-spine surgery [**2185-8-9**], with postop course complicated by left hemiparesis likely due to right MCA CVA in the setting of patent foramen ovale, who presented with creatinine of 7.0 and hypotension in the setting of several weeks of of nausea and vomiting. . 1) Renal failure: Patient was likely dehydrated secondary to prolonged nausea/vomiting and poor PO intake. He continued to take lisinopril and atenolol which would further decrease his renal perfusion, leading to supratherapeutic levels of both and more hypoperfusion, likley resulting in acute tubular necrosis. On admission FENa was 3.3%, consistent with intrinsic renal failure and acute tubular necrosis. Renal ultrasound ([**10-19**]) showed no evidence of hydronephrosis or obstruction. Urinalysis and urine culture both negative. Patient had foley catheter inserted on admission and continued to make urine throughout hospitalization (foley was removed on [**10-26**]). Patient received IVF throughout hospital stay. Ace inhibitor, atenolol and metformin were held, medications were renally dosed. On admission ([**10-19**]) patient's creatinine was 7.0 (baseline creatinine is 1.0), was 6.0 on [**10-23**] when transfered to medical floor, and 3.5 on [**10-30**]. - Patient's creatinine will be monitored every other day at skilled nursing facility, results will be sent to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office. Follow up appointment with renal (Dr. [**First Name (STitle) 805**] 10:30 am on [**2185-11-7**]). . 2) Bradycardia: On admission patient was taking atenolol and amiodarone, but was likely supratherapeutic due to renal failure. He was symptomatic with dizziness and light headedness with ambulation. ECG showed long QTc and no ST changes. Cardiac enzymes were normal. Patient's blood pressure medications were all held. While in the MICU patient received glucagon to attempt to reverse the effects of his beta-blocker. Heart rate remained in the 50-60bpm range. - Patient was discharged without his home medications of atenolol, amiodarone and lisinopril, due to prolonged bradycardia. Will need to be restarted in future once bradycardia resolves. . 3) Blood Pressure: Patient was hypotensive on admission. During MICU stay patient had no fever or evidence of infection. Urine, blood, stool cultures are negative to date. Hypotension was likely secondary to bradycardia and multiple BP meds on board in addition to dehydration. Patient received IV fluids throughout hospital course. Most likely the result of medications supratherapeutic concentrations in setting of renal insufficency. Once transfered to the medical floor his blood pressures trended up with SBPs in the 150s. -Patient was started on amlodipine 5mg on [**10-28**]. Patient will be discharged on this medication. . 4) Nausea/vomiting: Patient has had nausea and decreased appetite since disectomy on [**2185-8-25**], and severe vomiting for several weeks PTA. Patient had been unable to tolerate most foods, with the exception of ginger ale. Patient has had a 54 pound weight loss over the last several months. Per patient, his nausea worsened when he received ciprofloxacin for prostatitis, but did improve once ciprofloxacin was discontinued (last dose 10/10). Ciprofloxacin was held. Patient's diet was slowly advanced - at time of discharge he was able to tolerate his meals without vomiting, though he still had some baseline nausea. Patient received antoprazole throughout his hospital course, as well as multiple combinations of anti-emetics. - Patient will be discharged on scopalamine, promethazine and metoclopramide for his anti-emetic regimen. He will also continue to receive pantoprazole. . 5) Prostatitis: Patient was diagnosed with E. Coli prostatatis on [**10-3**] admission (PSA was 25, enlarged prostate seen on ultrasound) and was treated with IV ceftriaxone. At that time he was discharged with tamsulosin and 4 week course of ciprofloxacin. He received 2.5 weeks of ciprofloxacin, which was changed by his PCP on the day PTA to bactrim due to concern for patient's nausea and vomiting, his tamsulosin was also stopped. As Bactrim can cause increased creatinine levels, Ceftriaxone 1gm daily was started on admission ([**10-20**]) and continued throughout the hospital course. Urology team consult recommended continued tamsulosin and antibiotics treatment, tamsulosin was restarted. Additionally, on admission patient was not able to void and received a Coude catheter. This was removed on [**10-26**], patient was successfully able to void with post void residual of 118cc. - Patient will continue to receive ceftriaxone for a full four week course (until [**11-3**]). - Patient has follow up urology appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] on [**11-23**] at 3:30 pm. . 6) Anemia: Patient's hematocrit was 35 on admission, but persisted in the 28-30 range (baseline of 40). Iron studies ([**10-23**]) showed: Iron (40), TIBC (168), Transferrin (129) and Ferritin (543) consistent with anemia of chronic disease and his renal failure. Patient was started ([**10-25**]) on Epoetin 3000 units M/W/F (increased to 4000 units on [**10-30**]) and ferrous sulfate 325mg. - Patient will continue to receive Epoetin and ferrous sulfate at skilled nursing facility. . 7) Type II DM: Home medications include metformin, which was held due to concern for increased risk of lactic acidosis in setting of renal failure. Patient's glucose was monitored and he was kept on an insulin sliding scale. Euglycemic over the past week. [**Month (only) 116**] be due to decreased weight. - Metformin should continue to be held until patient's renal function has improved. Will need to reassess as outpatient with PCP. . 8) Hypercholesteremia: Patient continued to receive atorvastatin. Fenofibrate was held. . 9) Hypothyroid: Patient's [**Month (only) 8675**] was 0.36 on [**10-20**]. He continued to receive levothyroxine Sodium 100 mcg PO DAILY. . 10) CAD: Coronary artery disease status post PTCA of RCA in [**2173**]. Troponins were negative on admission. Patient received 81 mg aspirin daily during hospital stay. - Patient will need to continue ace-inhibitor once creatinine stabilizes, as cardioprotective in diabetics; will need to be reassessed with PCP. . 11) Atrial Fibrillation: Patient's rate is controlled with atenolol and amiodarone for PAF status post cardioversion in [**6-12**] and has been persistently in sinus rhythm since that time. Coumadin has been deferred as patient has a Chads score of 2 (1 point for HTN and 1 point for diabetes). Per his cardiologist Dr. [**Last Name (STitle) 1445**], his hisory of post-operative stroke does not enhance his current CVA risk. Anti-coagulation was deferred during this hospitalization. - Amiodarone and atenolol were held at discharge. - Patient has follow up appointment with his cardiologist, Dr. [**Last Name (STitle) 1445**], on [**2186-1-11**] at 10:00am. . 12) PPx: Patient received pantoprazole, heparin SC, and pneumoboots. Patient walked with PT and received OT as well. . 13) FEN: Patient received IV fluids. Patient was hypophosphatemic and responded well to NeutraPhos. . 14) Access: patient received PICC during on [**10-21**]. . 15) Code: FULL . 16) DISPO: Patient did not qualify for acute rehab as his PT needs were not sufficient. Patient was discharged to West Acres skilled nursing facility where he will continue to receive PT, OT and monitoring of his creatinine. . Medications on Admission: 1. Atenolol 12.5 mg once a day. 2. Amiodarone 200 mg once a day. 3. Aspirin 81 mg a day. 4. Fenofibrate 48 mg a day. 5. Levothyroxine 100 mcg a day. 6. Atorvastatin 40mg PO daily. 7. Metformin 500 mg p.o. b.i.d. 8. Fluticasone 50 mcg/Actuation Aerosol Spray Nasal DAILY (Daily). 9. Lisinopril 2.5 mg PO daily. 10. Loperamide 2 mg Capsule Sig: [**1-10**] Capsules PO QID 11. Ciprofloxacin 500 mg p.o. b.i.d. (patient was switched from ciprofloxacin to Bactrim on [**10-18**] an attempt to control his nausea) Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Sliding scale will be attached. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. 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. 13. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal every seventy-two (72) hours. 14. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday). 15. Ceftriaxone 1 g Recon Soln Sig: One (1) gram Intravenous once a day for 3 days. 16. Nystatin 100,000 unit/g Powder Sig: One (1) Topical once a day for 10 days. 17. Cepacol 2 mg Lozenge Sig: [**1-10**] Lozenges Mucous membrane PRN (as needed). Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Acute Renal Failure. Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating without assistance. Discharge Instructions: **You were admitted with acute renal failure. You were treated with IV fluids and some of your medications were held. Your creatinine levels have continued to improve. **In addition, your nausea and vomiting have improved. **You should continue the medications that have been newly prescribed. You will need to discuss restarting some of these medications with your PCP in the next week. **Please call your doctor or return to the emergency room if you continue to have persistent vomiting and weight loss, weakness, lightheadedness, or if you have difficulty or stop producing urine. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19779**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2185-11-2**] 1:00 Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone: [**Telephone/Fax (1) 3637**] Date/Time: [**2185-11-7**] 10:30am Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2185-11-23**] 3:00 Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2186-1-11**] 10:00 Completed by:[**2185-10-31**]

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icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "00.17" ]

icd9pcs

[ [ [] ] ]

21354, 21409

11429, 19153

318, 358

21474, 21553

8275, 11406

22189, 22862

6510, 6607

19720, 21331

21430, 21453

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21577, 22166

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2421, 3754

239, 280

386, 2402

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5920, 6494

32,410

179,874

34674

Discharge summary

report

Admission Date: [**2131-8-29**] Discharge Date: [**2131-9-4**] Date of Birth: [**2058-1-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: congestive heart failure Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname **] is a 73 year old white male who underwent aortic valve replacement in [**2129**] in [**State 108**]. He had a urinary tract infection in the past requiring a suprapubic tube due to prostatic enlargement. This led to a prostatectomy and a chronic enterococcus urinary infection. This summer he was found to have a creatinine increased to 3. He was found at that time to have a periprosthetic valvular leak. He developed congestive heart failure and was found to have blood cultures positive for VRE. Vegetations were found by echocardiogram on his prosthetic aortic and native mitral valves. He was flown here for surgical evaluation. As well he has radiographic evidence of discitits at T4-5 and L1-2,[**12-31**]. He subsequently underwent reoperative aortic valve replacement, mitral valve replacement and repair of an aorta to [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. Postoperatively he required pressors briefly as well as CVVH. He failed the first extubation btu subsequently was extubated and did well. His renal function stabilized and CVVH was changed to hemodialysis which was soon discontinued discontinued. He briefly had some atrial fibrillation and also required bronchcoscopy for mucous plugging. His sternum developed some drainage at the xiphoid was was opened at the bedside and later had a woundvac applied. Cultures of this grew nothing. His Daptomycin was continued and Meropenum was discontinued during the postoperative period after treating a pseudomonas urinary infection. A closed thoracostomy was necessary for a large right pleural effusion. He remained stable and was transferred to a rehabilitation facility for recovery prior to discharge home to [**State 108**]. A week prior to readmission his Lasix dose was halved and three days later he developed progressive shortness of breath. He was seen in clinic for routine followup the day of admission and was dyspneis at rest. He was admitted. Past Medical History: s/p aortic valve replacement [**8-5**] hypertension chronic renal insufficiency abdominal aortic aneurysm sleep apnea benign prostatic hypertrophy hypercholesterolemia s/p bilateral cataract extractions cardiomyopathy sp/ redo sternotomy, redo aortic valve replacement, mitral valve replacement, closure aorto-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] Social History: Lives with his wife in [**Name (NI) 108**] Retired engineer Cigs: 70 pk. yr., quit 20 yrs. ago ETOH: occasionally Family History: Unremarkable Physical Exam: awake and alert VSS, afebrile sternal wound- clean and healing wet to dry dressing lungs- decresed BS right base cor- reg rhythm exts- 4+ peripheral edema Pertinent Results: [**2131-9-4**] 05:43AM BLOOD WBC-10.8 RBC-3.23* Hgb-8.8* Hct-27.0* MCV-84 MCH-27.3 MCHC-32.7 RDW-20.1* Plt Ct-256 [**2131-9-4**] 05:43AM BLOOD Plt Ct-256 [**2131-9-3**] 04:03AM BLOOD PT-17.5* INR(PT)-1.6* [**2131-9-3**] 04:03AM BLOOD Glucose-99 UreaN-80* Creat-3.2* Na-134 K-3.6 Cl-94* HCO3-31 AnGap-13 [**2131-8-29**] 02:41PM BLOOD ALT-69* AST-53* LD(LDH)-524* AlkPhos-159* TotBili-0.8 Brief Hospital Course: Upon admission to the ICU his diuretics were increased to 80mg IV BID as at discharge from here and he was cultured. His CXR revealed an unchanged left pleural effusion and a creatinine was 2.9, essentially as at discharge. A TTE showed a significant perivalvular of the aortic valve with a mitral valve vegetation. A TEE was performed revealed 2+ paravalvular aortic leak, 1+ mitral. There was a 1cm vegetation on the aortic valve and a possible abscsee at the confluence of the mitral leaflet and posterioraortic root. Urine grew greater than 100,000 e. coli which was treated with Cipro. Blood cultures on [**8-29**] had no growth. Daptomycin was continued empirically. A repeat MRI of the spine was performed which was essentially unchanged from previously. He is not felt to be a candidate for further surgical therapy and with his heart failure controlled, he is discharged back to a rehabilitation facility prior to returning home. He is to continue on Daptomycin and to followup with the [**Hospital **] clinic in one week. Medications on Admission: Amiodarone 200mg/D Daptomycin 500mg/D Lasix 40mg [**Hospital1 **] Metalozone 5mg [**Hospital1 **] Lopressor 37.5mg TID KCl 20meq/D Zantac 15omg/D Zocor 80mg/D trazadone 50mg HS Coumadin daily ASA 81mg/D Colace 100mg [**Hospital1 **] Discharge Medications: 1. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-29**] Drops Ophthalmic PRN (as needed). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 10. Furosemide 10 mg/mL Solution Sig: 120mg Injection Q12H (every 12 hours). 11. Sodium Chloride 0.45 % 0.45 % Parenteral Solution Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 16. Daptomycin 900 mg Recon Soln Sig: 500 mg Recon Solns Intravenous Q48H (every 48 hours). 17. Linazolid 600mg IV Q12 hours Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Prosthetic valve endocardititis s/p reoperative aortic valve replacement, mitral valve replacement and closure of aorta to LV fistula benign prostatic hypertrophy abdominal aortic aneurysm hypercholesterolemia s/p cataract extractions chronic renal insufficiency hypertension sleep apnea cardiomyopathy Discharge Condition: good Discharge Instructions: no lifting more than 10 pounds for 10 weeks from surgery date no driving for 4 weeks from surgery report any fever greater than 100.5 report any redness of, or discharge from incisions report any weight gain of more than 2 pounds in a day or 5 pounds in a week shower daily, no baths or swimming no lotions, creams or powders to incisions take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) **] as previously scheduled ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) 976**] as scheduled [**Hospital **] clinic in a week- Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111**] [**Telephone/Fax (1) 457**] Completed by:[**2131-9-4**]

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icd9cm

[ [ [] ] ]

[ "88.72", "38.93" ]

icd9pcs

[ [ [] ] ]

6418, 6484

3516, 4557

344, 351

6831, 6838

3105, 3493

7258, 7552

2899, 2913

4840, 6395

6505, 6810

4583, 4817

6862, 7235

2928, 3086

280, 306

379, 2359

2381, 2751

2767, 2883

12,263

101,509

3587

Discharge summary

report

Admission Date: [**2147-4-17**] Discharge Date: [**2147-4-24**] Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 4232**] Chief Complaint: mental status change Major Surgical or Invasive Procedure: central venous catheter placement History of Present Illness: This is a [**Age over 90 **] year-old man with coronary artery disease, diabetes mellitus, chronic renal insufficiency and dementia presenting from [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] rehab with altered mental status. As per report there, patient noted to be shivering and moaning earlier tonight. (Baseline as per report is alert, verbal but confused and completely dependent for ADL's.) Vital signs largely unremarkable at that time. CBC/chem-10 sent and patient noted to be hyperglycemic to 800's, hypernatremic to 149, potassium of 7. 2, creatinine 3.6 and crit of 30 (unknown baselines). He was given levoquin and transferred to [**Hospital1 18**] for further management. . In the ER, patient afebrile, tachycardic to 102, tachypneic to 20's, bp's 130's to 140's, patient moaning, responsive to pain, moving all four extremities. Above lab abnormalities confirmed, lactate of 3.3, cxr revealed RML pneumonia, dirty U/A with apparent UTI, treated with 10 units insulin followed by drip, bicarbonate, calcium gluconate, 2 liters NS, vancomycin, levoquin and flagyl. Urine output not recorded but by report, good. Past Medical History: 1. Coronary Artery Disease 2. Diabetes Mellitus 3. Chronic Renal insufficiency 4. Dementia 5. UTI's 6. Suprapubic prostatectomy/catheter 7. S/p right nephrectomy? 8. hypertension Social History: lives at [**Hospital3 **]. former cook at [**Last Name (un) 16356**] [**Location (un) 16357**] in [**Location (un) 7349**], travelled extensively with the merchant marines, ? tobacco history. Family History: unavailable Physical Exam: On Admission- VS: Temp: 98.4/98.2 BP:122/58 HR:105 RR:24 95%rm airO2sat . general: responds to pain, moves all four extremities, intermittenly responds to name, cachectic HEENT: EOMI, anicteric, no sinus tenderness, MMdry, op without lesions, no jvd lungs: crackles at right base, left lung field clear heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: nd, +b/s, multiple scars, suprapubic catheter in place without surrounding erythema, soft, nt extremities: no edema skin/nails: no rashes/no jaundice/ neuro: unable to follow commands, intermittently responds to voice, moves all four extremities . Pertinent Results: [**2147-4-17**] 01:05AM BLOOD WBC-20.6*# RBC-3.26* Hgb-10.3* Hct-31.5* MCV-97# MCH-31.6 MCHC-32.7 RDW-15.4 Plt Ct-473* [**2147-4-23**] 07:05AM BLOOD WBC-15.3* RBC-3.69* Hgb-11.2* Hct-34.4* MCV-93 MCH-30.3 MCHC-32.5 RDW-15.3 Plt Ct-510* [**2147-4-23**] 07:05AM BLOOD Glucose-32* UreaN-41* Creat-2.5* Na-144 K-4.7 Cl-113* HCO3-17* AnGap-19 [**2147-4-18**] 03:52AM BLOOD ALT-19 AST-25 AlkPhos-93 Amylase-296* TotBili-0.4 [**2147-4-19**] 06:50AM BLOOD Lipase-57 [**2147-4-23**] 07:05AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.3 [**2147-4-19**] 06:50AM BLOOD calTIBC-183* Ferritn-421* TRF-141* [**2147-4-18**] 03:52AM BLOOD %HbA1c-7.5* . RENAL U.S. [**2147-4-20**] 4:08 PM RENAL ULTRASOUND: Study is limited due to patient cooperativity. No gross abnormality seen in the right renal bed. The left kidney measures 9.7 cm. There is no hydronephrosis. There is a small cyst in the mid-to-lower pole measuring up to 14 mm. There is no overt solid mass. Probable extrarenal pelvis. No hydronephrosis. . CHEST PORTABLE [**2147-4-17**] 2:02 AM FINDINGS: Placement of right internal jugular venous catheter is identified in the expected region of the mid SVC. No pleural effusion or pneumothorax identified. Again noted is airspace opacity within the right lower lobe. IMPRESSION: 1. Normal placement of right internal jugular venous catheter without pneumothorax identified. 2. Right lower lobe pneumonia as described previously. . Brief Hospital Course: This is a [**Age over 90 **] year-old man with history of dementia, cad, diabetes mellitus, chronic renal insufficiency who presented with mental status change, work up remarkable for HONK, hypernatremia, pneumonia, UTI. 1)Mental Status change: Multifactorial in secondary to hyperglycemia, hypernatremia, pneumonia, metabolic derangements. The patient's mental status returned to baseline once metabolic derangements and infections were treated. 2)Endocrine: The patient has an unclear history of DM, but not presently on medications. Hyperosmolar state (HONK) likely precipitated by pneumonia/UTI. He was given aggressive fluids with NS initially, then changed to D5W since hypernatremia was not improving. Briefly required an Insulin drip, added D5 when sugar <200, converted to long-acting insulin on [**4-17**]. He was tapered to standing NPH insulin, then later became hypoglycemic with treatment of his infection. He was discharged on Humalog sliding scale. Treatment with an oral antidiabetic [**Doctor Last Name 360**] should be considered as an outpatient as Pt's Hgb A1C was 7.5 on admission. 4)Acute on Chronic Renal Failure: Pt is s/p L nephrectomy. Likely secondary to ATN in setting of hypotension, hypovolemia. Pt's baseline Creatinine is 1.9 according to PCP. [**Name10 (NameIs) **] improved from 3.8 to 3.0 with IV fluids, but was in plateau phase for several days. Renal service was consulted, renal ultrasound did not reveal hydroureter. Gentle intravenous fluids continued to improved pt's Cr clearance leading up until discharge. His medications were renally dosed. 5) Heme: Anemia consistent with AKD in combination with chronic kidney disease. Guaiac negative. Renal recommended starting EPO q M,W,F. Hematocrit was stable on serial checks. 6) Infectious Disease: a) Pneumonia: required ICU admission --vancomycin, ceftriaxone, levoquin initially - was changed to vanc/zosyn on [**4-17**] for a health care associated pneumonia. He should complete a full 14 day course of Vancomycin as his sputum grew MRSA. b) UTI--grew cipro and bactrim resistant E. Coli- 14 day course of ceftriaxone for complicated UTI c) [**Name (NI) 1069**] Pt developed copius diarrhea on HD #4, was started on empiric Flagyl PO, C. diff x 2 negative. His stools normalized following initiation of treatment. He should complete a 14 day course following the last day of Vancomycin and Ceftriaxone. 7) Suprapubic Catheter: Pt was noted to have copious urine drainage from around his suprapubic catheter, without evidence for skin infection. Urology was consulted and recommended Tolteridine 1mg [**Hospital1 **] for potential bladder spasm. He has a 24 Fr foley. There is no further role for intervention except for continued monitoring to assure his catheter flushed, dressed properly for good position within the bladder. 8) Speech and Swallowing evaluation: Recommended PO diet of soft solids with thin liquids, pills crushed as allowable. Aspiration precautions with 1:1 assist at meals. Code Status: DNR/DNI per discussion with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] [**Telephone/Fax (1) 16358**] or [**Telephone/Fax (1) 16359**](lives in [**State 2690**]) and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] [**Telephone/Fax (1) 16360**](lives in [**Location 86**]) Pt's grandchildren and HCP. At this time, Ms. [**Name13 (STitle) 284**] expressed that they would not be opposed to dialysis should Mr. [**Known lastname 16361**] eventually require it. Medications on Admission: (As [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] notes): 1. omeprazole 20mg daily 2. felodipine 10mg daily 3. MVI 4. MOM 5. bisacodyl 6. tylenol prn 7. levoquin started [**4-16**] Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: [**11-15**] PO BID (2 times a day). 2. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 5. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 6. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Day 1 is [**4-19**]. continue for two weeks once vancomycin and ceftriaxone is given. 8. Acetaminophen 650 mg Suppository Sig: [**11-15**] Suppositorys Rectal Q6H (every 6 hours) as needed. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Humalog 100 unit/mL Solution Sig: per sliding scale protocol Subcutaneous four times a day. 11. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 4 days. 12. Tolterodine 2 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 4 days. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: hyperosmolar nonketotic hyperglycemia delirium hospital acquired pneumonia urinary tract infection clostridium dificile colitis hyponatremia anemia acute renal failure Secondary 1. Coronary Artery Disease 2. Diabetes Mellitus 3. Chronic Renal insufficiency 4. Dementia 5. chronic UTI's 6. Suprapubic prostatectomy/catheter 7. S/p right nephrectomy? 8. hypertension Discharge Condition: Stable Discharge Instructions: Take all medications as prescribed. Do not stop or change any medications without first speaking to your physician. Follow up as outlined below. Please contact your primary care physician if you experience any pain, shortness of breath, fever, chills, or any other concerning symptoms. Followup Instructions: You have an appointment with [**Doctor First Name 2951**] Sedo, the Nurse Practitioner who works with your primary care doctor Dr. [**Last Name (STitle) **] at 1:30 PM on [**5-1**]. Call [**Telephone/Fax (1) 608**] if you have any questions about thsi appointment. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**] Completed by:[**2147-4-24**]

[ "276.7", "285.21", "403.90", "599.0", "707.07", "008.45", "482.41", "276.0", "V09.0", "276.50", "707.09", "294.8", "584.5", "707.03", "585.9", "250.12" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9190, 9263

3994, 7509

236, 271

9673, 9682

2555, 3971

10019, 10408

1880, 1893

7799, 9167

9284, 9652

7535, 7776

9706, 9996

1908, 2536

176, 198

299, 1452

1474, 1655

1671, 1864

41,119

165,214

8599

Discharge summary

report

Admission Date: [**2119-11-29**] Discharge Date: [**2119-12-2**] Date of Birth: [**2053-2-22**] Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 6440**] Chief Complaint: fevers Major Surgical or Invasive Procedure: Cystoscopy, left retrograde pyelogram, attempted [**Last Name (un) 938**] bladder stones History of Present Illness: 66 y/o male w/hx of uric acid bladder stones presents with 5 hours of fevers, chills, left flank pain, dysuria. He was in his normal state of health until last night at 11PM, when he first had fevers/chills and then onset of left flank pain. He had nausea, without emesis. His pain improved with 4mg IV morphine here. He passed a tiny (approx 1-2mm) stone since admission to the ED, which was sent for analysis. He denies hematuria, chest pain, dyspnea. He was given Zosyn in the ED. Past Medical History: PMH: HTN Hyperlipidemia ADHD Elevated PSA [**Doctor Last Name 1726**] Syndrome Hx of uric acid nephrolithiasis and bladder stones PSH: Cystoscopy, [**Last Name (un) 938**] bladder stones, [**2115**] Multiple foot surgeries as child Social History: SOC: Chair of family medicine at [**Hospital3 **], No tobacco/EtOH Family History: FH: No family hx of GU Cancer Father: uric acid stones Physical Exam: VS: 101.2 89 126/68 18 97%2L NAD, A&Ox3 No respiratory distress Abd: Obese, soft, nondistended, nontender No CVAT bilaterally Ext: No cyanosis/clubbing/edema. Pertinent Results: [**2119-11-29**] 08:59PM URINE HOURS-RANDOM UREA N-1180 CREAT-205 SODIUM-30 CHLORIDE-48 [**2119-11-29**] 08:59PM URINE OSMOLAL-741 [**2119-11-29**] 08:59PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022 [**2119-11-29**] 08:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-MOD [**2119-11-29**] 08:59PM URINE RBC-1 WBC-27* BACTERIA-FEW YEAST-NONE EPI-0 [**2119-11-29**] 08:59PM URINE MUCOUS-RARE [**2119-11-29**] 03:00PM TYPE-[**Last Name (un) **] TEMP-36.1 COMMENTS-COLLECTION [**2119-11-29**] 03:00PM LACTATE-3.7* [**2119-11-29**] 03:00PM O2 SAT-75 [**2119-11-29**] 02:52PM TYPE-MIX COMMENTS-GREEN TOP [**2119-11-29**] 02:52PM LACTATE-4.1* [**2119-11-29**] 02:25PM GLUCOSE-201* UREA N-29* CREAT-1.4* SODIUM-141 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-22 ANION GAP-15 [**2119-11-29**] 02:25PM ALT(SGPT)-52* AST(SGOT)-44* LD(LDH)-209 ALK PHOS-72 TOT BILI-0.4 [**2119-11-29**] 02:25PM cTropnT-<0.01 [**2119-11-29**] 02:25PM CALCIUM-7.7* PHOSPHATE-3.6# MAGNESIUM-1.3* [**2119-11-29**] 02:25PM WBC-16.6* RBC-4.12* HGB-12.1* HCT-35.6* MCV-87 MCH-29.3 MCHC-33.9 RDW-15.2 [**2119-11-29**] 02:25PM PLT COUNT-148* [**2119-11-29**] 12:06PM URINE HOURS-RANDOM CREAT-136 SODIUM-88 POTASSIUM-70 CHLORIDE-86 [**2119-11-29**] 12:06PM URINE OSMOLAL-598 [**2119-11-29**] 09:26AM LACTATE-4.4* [**2119-11-29**] 08:57AM GLUCOSE-140* UREA N-31* CREAT-1.5* SODIUM-141 POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-23 ANION GAP-14 [**2119-11-29**] 08:57AM CALCIUM-8.2* PHOSPHATE-2.0* MAGNESIUM-1.3* [**2119-11-29**] 08:57AM WBC-11.6*# RBC-4.24* HGB-12.6*# HCT-37.0* MCV-87 MCH-29.7 MCHC-34.0 RDW-15.2 [**2119-11-29**] 08:57AM NEUTS-79* BANDS-12* LYMPHS-3* MONOS-1* EOS-0 BASOS-0 ATYPS-3* METAS-2* MYELOS-0 [**2119-11-29**] 08:57AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2119-11-29**] 08:57AM PLT SMR-LOW PLT COUNT-145* [**2119-11-29**] 08:57AM PT-15.6* PTT-25.7 INR(PT)-1.4* [**2119-11-29**] 03:07AM PT-13.5* PTT-19.3* INR(PT)-1.2* [**2119-11-29**] 02:23AM LACTATE-4.1* [**2119-11-29**] 02:10AM URINE HOURS-RANDOM [**2119-11-29**] 02:10AM URINE GR HOLD-HOLD [**2119-11-29**] 02:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2119-11-29**] 02:10AM URINE BLOOD-NEG NITRITE-POS PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2119-11-29**] 02:10AM URINE RBC-0-2 WBC-[**11-4**]* BACTERIA-MANY YEAST-NONE EPI-0-2 [**2119-11-29**] 02:10AM URINE EOS-POSITIVE [**2119-11-29**] 12:49AM LACTATE-4.2* [**2119-11-29**] 12:45AM GLUCOSE-109* UREA N-28* CREAT-1.3* SODIUM-143 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-27 ANION GAP-19 [**2119-11-29**] 12:45AM estGFR-Using this [**2119-11-29**] 12:45AM ALT(SGPT)-53* AST(SGOT)-47* ALK PHOS-154* TOT BILI-0.6 [**2119-11-29**] 12:45AM LIPASE-61* [**2119-11-29**] 12:45AM WBC-1.6*# RBC-5.43 HGB-15.7 HCT-46.0 MCV-85 MCH-29.0 MCHC-34.2 RDW-15.6* [**2119-11-29**] 12:45AM NEUTS-69 BANDS-1 LYMPHS-24 MONOS-2 EOS-3 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2119-11-29**] 12:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2119-11-29**] 12:45AM PLT SMR-NORMAL PLT COUNT-170 Brief Hospital Course: Patient was admitted to the ICU due to concern for urosepsis. He was given ceftriaxone. His blood pressure remained stable and he was afebrile during the hospitalization. He was taken to the operating room on [**11-30**] for cystoscopy, left retrograde pyelogram, and attempted [**Last Name (un) 938**] of bladder stone. Please see operative note for full detail. He was extubated the following day and transferred to the floor in stable condition. His foley was removed but he was only able to void small volumes with large post-void residual. Therefore, a foley was replaced. His WBC trended to 9.9 at discharge. His urine grew <10,000 organisms, and his blood cultures were no growth to date at discharge. He was given 10 days of ciprofloxacin at discharge to complete a total 14 day course. His blood pressure medications were also held since it was well controlled throughout hospitalization. He will follow up with his PCP regarding this. He will call Dr.[**Name (NI) 6444**] office on Monday AM to confirm surgery appointment that day for an open simple prostatectomy. Medications on Admission: Meds: ALLOPURINOL - 300 mg Tablet - 1 Tablet(s) by mouth once a day AZELASTINE - 137 mcg Aerosol - 2 (Two) sprays [**Hospital1 **] PRN DEXEDRINE SPANSULES SR - 10MG - [**Hospital1 **] DEXTROAMPHETAMINE - 5 mg Tablet - 2 Tablet(s) by mouth QID DIAZEPAM - 5 mg Tablet - 1 Tablet(s) by mouth [**Hospital1 **] PRN FEXOFENADINE - 180 mg Tablet Daily HYDROCHLOROTHIAZIDE - 25 mg Tablet Daily LISINOPRIL - 40 mg Tablet - 1 (One) Tablet Daily METOPROLOL SUCCINATE - 200 mg Tablet SR by mouth once a day SIMVASTATIN - 40 mg Tablet - by mouth once a day ASPIRIN - 81 mg Tablet, by mouth once a day Discharge Medications: 1. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Fever or pain. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for Anxiety. 5. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Bladder stones Discharge Condition: Stable A+Ox3 Ambulates independently Discharge Instructions: -No vigorous physical activity. -Expect to see occasional blood in your urine. -Tylenol should be your first line pain medication -Make sure you drink plenty of fluids to help keep yourself hydrated. -You may shower and bathe normally. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -Resume all of your home medications, can hold blood pressure medications if blood pressure remains stable. -Call Dr.[**Name (NI) 6444**] office for follow-up AND if you have any questions. -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: Call Dr.[**Name (NI) 6444**] office for follow up.

[ "478.75", "274.11", "600.91", "038.9", "401.9", "579.8", "995.91", "594.1", "458.29", "996.39", "E878.8", "272.4", "314.01", "790.93", "V64.1", "790.4", "788.29", "518.5" ]

icd9cm

[ [ [] ] ]

[ "87.74", "57.32", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

7455, 7461

4849, 5938

311, 402

7520, 7559

1536, 4826

8352, 8406

1280, 1337

6580, 7432

7482, 7499

5964, 6557

7583, 8329

1352, 1517

265, 273

430, 922

944, 1179

1195, 1264

11,018

104,650

215

Discharge summary

report

Admission Date: [**2148-12-2**] Discharge Date: [**2148-12-11**] Date of Birth: [**2084-12-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2145**] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: BiPAP History of Present Illness: 64 yo AA male with HIV/AIDS (VL: 570; CD4: 251 on [**11-27**]'[**48**] currently treated with Combivir and Bactrim SS Mon, Wed, Fri for ppx as well as a flu shot for [**2147**]-[**2148**]) and COPD on home oxygen (FEV1/FVC: 34%; FEV1 26%; FVC: 77%) comes in with dyspnea for 6 days. The pt reports development of sob similar to his previous episodes of COPD/PNA. 2-3days ago, he subsequently developed cough productive of yellow-green sputum along with subjective fevers, chills, and diaphoresis. He also developed some pleuritic chest pain several days ago. The chest pain was located in the left side of the chest below the nipple line and occurred with deep inspiration. The pt reports these are all similar to previous episodes of COPD exacerbation. The pt had tried nebulizers Q4hours in addition to 2L NC one day PTA without any improvement. The pt uses oxygen at home 40% of the time, mostly when he is active. The pt noted inc. DOE even with the oxygen prior to this episode. The pt does admit to one episode of vomiting in the ED, which was thought to be secondary to meds he received in the ED. The pt denies HA, abd pain, diarrhea. In the ED, the pt was febrile to 101 rectally, requiring 5liters oxygen to keep sats >96%. He was given ceftriaxone, azithromycin, bactrim and solumedrol with continuouos nebs for PNA vs. COPD flare. He had one episode of emesis in ED. The pt also received a CTA which ruled out a PE (given the concern for pleuritic chest pain). ABG in the ED was: 7.44/40/81--> 7.49/40/67. The pt reports improvement in his sob after receiving solumedrol and nebs in the ED. Past Medical History: 1. HIV/AIDS: CD4: 251; VL: 570 ([**2148-11-27**])- on combivir and bactrim 2. COPD: intermittently on oxygen at home, followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2146**]/[**First Name8 (NamePattern2) 2147**] [**Last Name (NamePattern1) 496**]. FVC: 77%; FEV1: 26%; FEV1/FVC: 34%. 3. GERD 4. HTN 5. CRI 6. h/o GI bleed- w/u negative [**2142**] 7. Leukopenia- followed by [**Doctor Last Name 2148**]- plan is for BM bx 8. Anemia 9. Inguinal hernia 10. Homocysteinemia 11. Chronic back pain- failed spinal cord stimulator, requires injections from pain management. MR [**9-21**]. Herniated discs. 12. Granulmatous disease in spleen- seen on ct scan 13. Esophagitis- egd [**11-20**] 14. Schatzki's ring- seen on egd [**7-/2143**] 15. SBO obstruction in past 16. H/o of drug use- narcotics contract PAST SURGICAL HISTORY: 1. Basilar artery clipping [**2134**] 2. Status post several lumbar discectomies in the past. 3. Status post right inguinal hernia repair. 4. Status post right colectomy for benign disease. Social History: Disabled. Lives in [**Location 669**] by himself. EtOH: former heavy etoh, quit [**2135**] Tob: quit tobacco in [**2135**], 2ppd between [**2100**]-93. Illicit drugs: smoked crack [**2135**] Family History: 1. Father: deceased, EtOH 2. Mother: deceased, CVA in 60s 3. Brother: lung cancer 4. Sister: HTN 5. Sister: CVA in 60s Brothers x7 (now only two), Sister x2 (both still alive) Physical Exam: VS in ED: 100.8, 95, 159/95, 21, 98% on neb, 150cc emesis, 200cc urine in ED VS in [**Hospital Unit Name 153**]: 91, 126/70, 21, 97% on FM at 7L Gen: thin, almost cachectic AA male in NAD. Conversing fluently in full sentences. No accessory muscle use HEENT: EOMI, anicteric, mmm, op clear Neck: no retractions, supple, full ROM Chest: poor air movement posteriorly, soft wheezing bilaterally, no crackles, no pain on palpation of chest. CV: RRR, S1, S2, no m/r/g Abd: soft, suprapubic tenderness, neg [**Doctor Last Name 515**] sign, no rebound, guarding. Ext: wwp, no c/c/e, DP +1 bilaterally Pertinent Results: EKG: NSR, nml axis, peaked and widened P waves, ?ST elevations in V3 (vs. artifact) CXR [**2148-12-2**]: emphysematous changes CTA [**2148-12-2**]: No PE, +bronchiectasis and emphysema, granulmatous disease MIBI: [**11/2142**]: normal ECHO: [**9-21**]: hyperdynamic EF>75%, trivial MR [**Name13 (STitle) 2149**] [**11-20**]: normal EGD [**11-20**]: esophagitis Labs on Admission [**2148-12-2**] 05:50AM BLOOD WBC-3.2* RBC-2.94* Hgb-11.0* Hct-31.7* MCV-108* MCH-37.3* MCHC-34.6 RDW-13.8 Plt Ct-134* [**2148-12-2**] 05:50AM BLOOD PT-11.7 PTT-27.3 INR(PT)-0.9 [**2148-12-2**] 05:50AM BLOOD Glucose-105 UreaN-14 Creat-0.9 Na-138 K-3.7 Cl-101 HCO3-29 AnGap-12 [**2148-12-2**] 05:50AM BLOOD CK-MB-4 [**2148-12-2**] 05:50AM BLOOD cTropnT-0.03* [**2148-12-2**] 05:50AM BLOOD LD(LDH)-222 CK(CPK)-144 [**2148-12-3**] 05:15AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.0 Labs on Discharge [**2148-12-10**] 06:15AM BLOOD WBC-5.6 RBC-2.78* Hgb-9.6* Hct-29.4* MCV-106* MCH-34.5* MCHC-32.6 RDW-13.5 Plt Ct-286 [**2148-12-10**] 06:15AM BLOOD Plt Ct-286 [**2148-12-10**] 06:15AM BLOOD Glucose-91 UreaN-32* Creat-1.1 Na-137 K-4.2 Cl-101 HCO3-28 AnGap-12 [**2148-12-10**] 06:15AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0 Blood Gases [**2148-12-2**] 06:09AM BLOOD Type-ART FiO2-40 pO2-81* pCO2-40 pH-7.44 calHCO3-28 Base XS-2 [**2148-12-2**] 08:44AM BLOOD Type-ART O2 Flow-2 pO2-67* pCO2-40 pH-7.49* calHCO3-31* Base XS-6 [**2148-12-3**] 10:43AM BLOOD Type-ART pO2-26* pCO2-55* pH-7.35 calHCO3-32* Base XS-1 [**2148-12-3**] 01:36PM BLOOD Type-ART pO2-99 pCO2-33* pH-7.50* calHCO3-27 Base XS-2 [**2148-12-3**] 11:12PM BLOOD Type-ART pO2-73* pCO2-40 pH-7.46* calHCO3-29 Base XS-4 [**2148-12-4**] 01:23PM BLOOD Type-ART pO2-104 pCO2-46* pH-7.43 calHCO3-32* Base XS-4 Intubat-NOT INTUBA [**2148-12-6**] 05:19AM BLOOD Type-[**Last Name (un) **] Temp-36.6 O2 Flow-2 pO2-44* pCO2-44 pH-7.44 calHCO3-31* Base XS-4 Intubat-NOT INTUBA Brief Hospital Course: A/P: 64yo M with COPD (FEV1 of 26%), HIV/AIDS (VL: 570; CD4: 251 treated with Combivir and Bactrim ppx p/w respiratory distress. . #. Respiratory distress: The patient was originally admitted to the [**Hospital Unit Name 153**]. During this time he was treated for positive influenza A and COPD exacerbation. He received 5 days of tamiflu. After a 5 day course in the ICU his respiratory status improved. Respiratory status stabilzed with supprot over the course of a 5 day stay in the ICU. He was started on a prednisone taper. He was transferred to the medicine floor service. Initially per PT/OT evals the patient qualified for rehab. However he quickly improved and his O2 sats were stable on room air. The patient felt safe to go home with PT and oxygen. He was discharged on a prednisone taper. He had follow up scheduled with his PCP and pulmonology. . #. HIV: The pt has HIV/AIDS with VL of 570 and CD4 of 251. He was maintained on Combivir and Bactrim SS Mon, Wed, Fri for ppx . #. HTN: The patient was maintained on HCTZ 25 daily . #. Pain: The pt has known chronic LBP and is on a narcotics contract. He was continued on tramadol and Tylenol #3 as well as tizanidine 2mg [**11-18**] PRN (for spasticity). Given his end stage HIV has was treated liberally with IV morphine for respiratory comfort while in the ICU. . #. Dispo: The patient was discharged home with PT, supplemental O2 and instructed to follow up with his health care providers. . #. Code Status: DNR/DNI. confirmed by MICU resident, intern and Pulm fellow. . #. Communications: HCP #1: Son: [**Name (NI) **] [**Name (NI) **] [**Known lastname 2150**]: [**Telephone/Fax (1) 2151**] HCP #2: Friend: [**Name (NI) 2152**] [**Name (NI) 2153**]: [**Telephone/Fax (1) 2154**] HCP #3: Sister: [**Name (NI) 2155**] [**Name (NI) 2156**] (moved to VA): [**Telephone/Fax (1) 2157**] Medications on Admission: 1. Combivir 2. Bactrim- Mon, Wed, Friday 3. Azmacort- 10 puffs [**Hospital1 **] 4. Albuterol nebs and inhaler prn 5. Atrovent nebs prn 6. HCTZ 25 daily 7. Protnix 40 daily 8. Trazadone- 50 qhs prn 9. Doxazosin 2mg qhs 10. Tizanidine 2mg- one to 2 prn 11. tramadol 50 1-2 tabs q4-6 hours prn 12. APAP #3- ONE TID- Narcotics contract 13. Vitamin B12- 2000mcg daily 14. Folic acid 15. Aspirin 16. colace, senna 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. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 4. Azmacort 100 mcg/Actuation Aerosol Sig: Ten (10) puffs Inhalation twice a day. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 15. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 16. Prednisone 10 mg Tablet Sig: AS DIR Tablet PO DAILY (Daily) for 4 days: [**2148-12-12**] 30 mg qd [**2148-12-13**] 20 mg qd [**2148-12-14**] 10 mg qd [**2148-12-15**] 5 mg qd. Disp:*6 Tablet(s)* Refills:*0* 17. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. COPD exaccerbation 2. Influenza Secondary: 1. HIV 2. GERD 3. HTN 4. Chronic back pain Discharge Condition: afebrile, satting well on room air Discharge Instructions: If you have fevers, chills, shortness of breath, chest pain, nausea/vomiting, please call Dr [**Last Name (STitle) **] for evaluation or come to the ED. 1. Take medications as directed 2. You will be on a prednisone taper on discharge for your COPD 3. Use oxygen as needed for you shortness of breath. Followup Instructions: Already scheudled: . Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2148-12-17**] 6:00 . Pulmonary: Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2149-1-3**] 9:10 Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **]/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2149-1-3**] 9:30 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2149-5-4**]

[ "585.9", "491.21", "042", "285.29", "112.0", "487.1", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9934, 9992

5994, 7855

338, 345

10126, 10163

4077, 5971

10514, 11080

3268, 3446

8314, 9911

10013, 10105

7881, 8291

10187, 10491

2851, 3043

3461, 4058

278, 300

373, 1980

2002, 2828

3059, 3252

19,033

122,880

28703

Discharge summary

report

Admission Date: [**2193-2-20**] Discharge Date: [**2193-2-26**] Date of Birth: [**2141-6-11**] Sex: M Service: CARDIOTHORACIC Allergies: Compazine Attending:[**First Name3 (LF) 2969**] Chief Complaint: Peumatocele Major Surgical or Invasive Procedure: left upper lobe segmentectomy via thoracotomy w/ latisamus flap History of Present Illness: 51 y/o male who was admitted for a thoracotomy on [**2-20**] for repair of a pneumatocele that formed as a complication of a radical resection of a mass in his left upper back . Past Medical History: Testicular carcinoma treated about 26 years ago at the former [**Location (un) 511**] [**Hospital **] Hospital - radical orchiectomy and chemoradiation, Mild hypertension, asthma, Rupture of the right biceps tendon and the left quadriceps tendon during his activities as a weight lifter. HTN Asthma PSH: Radical Sarcoma resection left back. right total hip replacement requiring revision. Social History: He does not smoke or drink. Family History: [**Known firstname **] has an extensive family history of cancer, although none of the individuals were first degree relatives. [**Name (NI) **] states that various aunts and uncles had leukemia, pancreatic cancer, and other carcinomas. There is no history of sarcoma or any other connective tissue or neural sheath lesion. Physical Exam: Gen: NAD CV: RRR: Chest : CTA Bilat. Abd: soft ,NT Ext + pulses Pertinent Results: [**2193-2-20**] 11:30PM GLUCOSE-160* UREA N-23* CREAT-1.8* SODIUM-136 POTASSIUM-6.2* CHLORIDE-104 TOTAL CO2-25 ANION GAP-13 [**2193-2-20**] 11:30PM CALCIUM-7.4* PHOSPHATE-4.3# MAGNESIUM-1.5* Brief Hospital Course: Patient tolerated the procedure well. Patient's diet was advanced to regular without complcations. His pain was well controlled and he was discharged home in stable condition. Medications on Admission: Albuterol INH Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 3 weeks. Disp:*84 Capsule(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*75 Tablet(s)* Refills:*0* 5. Albuterol 90 mcg/Actuation Aerosol Sig: [**11-27**] Inhalation q4hrs prn. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*40 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Home Health And Hospice Care Discharge Diagnosis: mild asthma, Aortic stenosis PSH: radical sarcoma resection left back, R hip replacement, partial left chest wall resection, orchiectomy for testicular CA Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) **] office [**Telephone/Fax (1) 170**] if you develop chest pain shortness of breath, fever, chills, redness or drainage from your incision sites or drain sites. Empty your drains as instructed. Continue taking your antibiotics as scheduled. you may need a mild laxative to avoid constipation while taking pain medication. Followup Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] for a follow up appointment. call Dr.[**Name (NI) 1745**] office for a follow up appointment and drain removal. Call Dr.[**Name (NI) 69409**] office for a follow up appointment and drain removal. Completed by:[**2193-3-6**]

[ "285.1", "585.9", "403.90", "584.9", "998.13", "425.1", "V10.47", "997.3", "493.90", "518.89", "424.1" ]

icd9cm

[ [ [] ] ]

[ "34.79", "83.82", "33.22", "32.3" ]

icd9pcs

[ [ [] ] ]

2542, 2601

1681, 1858

288, 354

2802, 2809

1462, 1658

3201, 3499

1036, 1363

1922, 2519

2623, 2781

1884, 1899

2833, 3178

1378, 1443

237, 250

382, 561

583, 974

990, 1020

48,868

170,469

38260

Discharge summary

report

Admission Date: [**2115-6-3**] Discharge Date: [**2115-6-10**] Date of Birth: [**2041-7-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 603**] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: PICC line punch biopsy of penile lesion History of Present Illness: 73 y/o M with hx of schizoaffective, lives in a nursing home and guardian is a state appointed guardian who has an indwelling foley and presented today after being found with AMS and lethargy. He had been in his usual state of health (reportedly) until the 2nd, when he was noted to have some foul smelling urine. He had a urine culture drawn on [**5-31**] which grew >100,000 GPCs and GNRs. It was likely thought to be a contaminant or colonization as he wasn't treated. Today, he was found lethargic and hypoxic in his nursing home. He had poor appetite but was drinking fluids. His VSs at the [**Hospital1 1501**] were 80/60, p 145, 4 28, and 84% on RA. At baseline, he is not very communicative. Has tardive dyskinesia. . In the ED, initial vitals were Tm 103, P 107, BP 87/43, R 32, 91% on RA. He was placed on a NRB and had an Xray that was unremarkable His pressures were as low as SBPs in the 60s. His legal guardian was [**Name (NI) 653**] and confirmed his [**Name (NI) **]/DNI status and said no aggressive measures like lines or pressors. The patient received Levofloxacin 750 mg IV x1, flagyl 500 mg IV x1 and vanco 1 gm x1. He also received tylenol 1000 mg PR x1. There was concern for either urosepsis vs. c.diff based on his labs and clinical scenario. Patient was admitted to the MICU for sepsis. . Past Medical History: Schizoaffective Disorder Personality Disorder Indwelling foley for urinary retention DJD of hip tardive dyskinesia venous stasis L2 compression fracture Social History: Lives at skilled nursing facility and has a court-appointed legal guardian. Unknown tobacco, alcohol or drug history. Family History: Non-contributory. Physical Exam: Vitals - T: 96.4 BP: 104/60 HR: 80 RR: 29 02sat: 98% 4L NC GENERAL: pt slumped over to the right side in bed with eyes closed, minimally responsive HEENT: NCAT, PERRL (minimally reactive to light) CARDIAC: RRR, no M/R/G, normal S1, S2 LUNG: poor respiratory effort, unable to assess breath sounds clearly ABDOMEN: soft, unable to assess tenderness, nondistended, normoactive bowel sounds GU: foley catheter in place, purulent drainage from urethral meatus with ulceration surrounding the meatus EXT: 2+ PT pulses bilaterally, no clubbing, cyanosis or edema NEURO: non-verbal, unable to assess orientation, baseline bilateral upper extremity tremor ?tardive dyskinesia DERM: warm, dry, intact MSK: diffuse muscle wasting Pertinent Results: [**2115-6-9**] 05:38AM BLOOD WBC-7.3 RBC-3.45* Hgb-9.8* Hct-30.1* MCV-87 MCH-28.3 MCHC-32.4 RDW-13.8 Plt Ct-104* [**2115-6-9**] 05:38AM BLOOD Glucose-103* UreaN-11 Creat-0.7 Na-145 K-3.9 Cl-109* HCO3-27 AnGap-13 CHEST (SINGLE VIEW) Study Date of [**2115-6-7**] 5:26 PM The heart is somewhat enlarged. There is continued LLL consolidation with small left-sided pleural effusion and probable atelectasis. There is also atelectasis at the right lung base. There is patchy air space opacity in the right mid lung zone/perihilar region. This is not substantially changed from the prior study. Brief Hospital Course: # Hypoxia: Patient has persistent O2 requirement. CXR shows LLL atelectasis vs. consolidation. Patient remains afebrile with WBC wnl. Patient was discharged on supplemental oxygen . # Urethral lesion: Patient had punch biopsy [**6-7**]. Evaluated by urology - differential diagnosis includes reactive inflammation from the chronic indwelling foley catheter vs. fungal infection vs. malignant lesion. Urology will contact the patient/gaurdian regarding biopsy results and appropriate follow up . # Sepsis/UTI: Patient was initially admitted to the ICU and treated with vancomycin, cefepime and flagyl. Leukocystosis, tachycardia, hypotension and fever resolved. Blood cultures revealed E. Coli sensitive to ceftriaxone. Patient was switched to IV ceftriaxone and treatement was planned for a 14 days course. . # Pain control: Patient was treated with scheduled tylenol and oxycodone prn. As patient was refusing PO meds, he was also given IV morphine prn for pain. . # ARF: Cr back to wnl and stable. Had new ARF, unclear of baseline. Urine lytes not consistent with pre-renal etiology, likely ATN from hypotension. This resolved without intervention. . # Hypernatremia: Patient was initially hypernatremic after leaving the ICU. He was given D5W and this corrected. . # Home HTN: Patient was treated with his home hypertension regimen. . # Schizoaffective disorder: Per group home, baseline mental status is very poor with minimal response and essentially non-verbal status. This remained stable throughout his stay. . # Goals of Care: Given patient poor functional status, and difficulty taking PO, a goals of care discussion was had with his legal guardian. It was decided that he should be comfort care/DNR, with a goal of transitioning to hospice on discharge. . # CODE STATUS: Comfort Care/DNR/DNI Medications on Admission: Omeprazole 20 mg daily Cranberry tab 450 mg daily Vitamin D 400 u daily Tums 500 mg TID Propranolol 10 mg TID Fluticasone nasal spray qHS Clozapine 50 mg qHS Mirtazapine 15 mg qHS Milk of Magnesium PRN Tylenol PRN Maalox PRN Guiatuss PRN Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Clozapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical TID (3 times a day). 7. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 8. Morphine 2 mg/mL Syringe Sig: One (1) mg Injection Q4H (every 4 hours) as needed for pain. 9. PICC care 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. 10. PICC Please remove PICC after last dose of ceftraixone. 11. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 9 days. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) 86**] Discharge Diagnosis: sepsis due to urinary tract infection penile lesion hypoxia Discharge Condition: Mental Status: Confused (Patient has baseline cognitive impairment and is mostly non-verbal). Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: It was a pleasure treating you at [**Hospital1 1170**]. You were admitted for treatment of septic shock caused by a urinary tract infection. We gave you antibiotics and followed your blood tests and chest xray to ensure resolution of the infection. You also had a biopsy of the lesion on your penis; you will follow up the results with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office as an outpatient. On discussion with your guardian, it was decided to change the goals of your care to promote your comfort, rather than to cure any possible disease. We made the following changes to your medications: STARTED ceftriaxone for a total of 14 days Followup Instructions: You will be [**Last Name (NamePattern1) 653**] with the results of your biopsy by the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (urology). If you have not heard from them in two weeks, please call [**Telephone/Fax (1) 4537**].

[ "459.81", "707.04", "276.2", "799.02", "995.92", "715.95", "038.42", "785.52", "301.9", "607.89", "788.20", "792.1", "287.5", "276.0", "295.70", "599.0", "707.21", "584.5", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "64.11" ]

icd9pcs

[ [ [] ] ]

6696, 6781

3435, 5245

320, 362

6885, 6885

2822, 3412

7779, 8047

2048, 2067

5533, 6673

6802, 6864

5271, 5510

7079, 7683

2082, 2803

7712, 7756

273, 282

391, 1721

6900, 7055

1743, 1897

1913, 2032

25,329

161,784

49959

Discharge summary

report

Admission Date: [**2122-1-15**] Discharge Date: [**2122-1-20**] Date of Birth: [**2079-7-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1974**] Chief Complaint: Hemetemesis, dyspnea. Major Surgical or Invasive Procedure: Upper endoscopy. History of Present Illness: 42 year-old male with Type I diabetes, ESRD on HD, poorly controlled HTN, diastolic CHF and multiple hospitalizations for chronic left flank pain with negative work-up, recently admitted for hypertensive crisis, now presents with hemetemesis, guaiac positive stool and dyspnea. . Patient initially presented to the ED with his usual complaint of left flank pain and also nausea/vomiting. Initial vital signs were T 97.9 P 114 BP 230/122 R 20 O2sat 95% on RA. He was given 2 mg ativan, 4 mg morphine. He then started to have hemetemesis about 20 cc and was noted to have guaiac positive stool. Patient could not tolerate NG lavage. His O2 sat dropped to 85% on RA and 92% on NRB with CXR showing pulmonary edema. Urgent dialysis was planned. Central line was intially attempted on right groin with no success. Left groin SCV was finally placed. Patient was started on nitro gtt. Initial K was 5.3 without EKG changes. . MICU COURSE: The patient was dialyzed on [**1-15**] with 2L fluid removed. The patient was dialyzed [**1-16**], UF 2L. The patient was dialyzed [**1-17**], UF 2L. The patient had improvement in shortness of breath. There were no further episodes of hematemesis. The patient's groin site was noted to bleed but this resolved with DDAVP [**1-16**]. . Currently denies fevers, chills. Denies chest pain, shortness of breath, cough. Denies abdominal pain, nausea, vomiting, diarrhea. Denies melena, hematochezia. Past Medical History: 1. Diabetes mellitus, type I x 17 years, HbA1c 5.8 [**2121-12-26**] 2. ESRD on HD T/Th/Sa at [**Location (un) **] Dialysis 3. Hypertension, poorly controlled 4. Right foot operation with bone excision "few months ago" 5. Right foot ulcer "3-4 years ago" 6. Depression with history of SI and psychiatric hospitalizations, currently no SI 7. Esophagitis on EGD [**10-21**] with H. Pylori negative 8. History of left flank pain since [**2119**] with extensive work-up and no organic etiology for pain Social History: Lives with mother in subsidized housing. Has four children. Former floor tech, quit 2 years ago and dialysis-dependent starting 1 year ago. No smoking, EtOH, drugs. Family History: Diabetes in multiple relatives on both sides Physical Exam: On admission to the MICU: VITAL SIGNS: T 98.4 P 95 BP 180/97 RR 25 O2 sat 95% on 4L GENERAL: Lying in bed, clutching head in pain, looks fatigued HEENT: Anicteric, PERRLA, headache too painful to follow other commands, moist mucus membrane, neck supple, no JVD HEART: Regular, tachycardic, no r/m/g LUNGS: Rales bilaterally, tachypneic, mild neck accessory muscle use, speaking in full sentences ABDOMEN: Soft, nontender, nondistended, no hepatosplenomegaly EXTREMITIES: No edema, left groin line still oozing blood, right groin in pressure dressing NEUROLOGIC: Alert, hard to assess orientation because of headahce, PERRLA, does not cooperate with neuro exam, move all 4 extremities . On transfer to the floor: VITAL SIGNS: T 99.6 P 97 BP 151/80 RR 20 O2sat 95%RA GENERAL: Lying in bed, breathing comfortably, speaking full sentences HEENT: Anicteric, PERRLA, moist mucus membrane, neck supple, no JVD HEART: Regular rate and rhythm, no r/m/g LUNGS: Crackles at bases ABDOMEN: Soft, nontender, nondistended, no hepatosplenomegaly EXTREMITIES: No edema, left groin c/d/i NEUROLOGIC: Alert, oriented x 3, moving all extremities well Pertinent Results: Labwork on admission: [**2122-1-15**] 08:38PM WBC-6.8 RBC-4.69 HGB-12.5* HCT-37.6* MCV-80* MCH-26.7* MCHC-33.2 RDW-16.2* [**2122-1-15**] 08:38PM PLT COUNT-192 [**2122-1-15**] 08:38PM NEUTS-66.5 LYMPHS-22.5 MONOS-6.8 EOS-3.9 BASOS-0.3 [**2122-1-15**] 08:38PM GLUCOSE-260* UREA N-27* CREAT-6.8*# SODIUM-138 POTASSIUM-6.2* CHLORIDE-98 TOTAL CO2-28 ANION GAP-18 [**2122-1-15**] 10:20PM TYPE-ART PO2-72* PCO2-45 PH-7.44 TOTAL CO2-32* BASE XS-5 [**2122-1-15**] 10:45PM PT-13.0 PTT-51.3* INR(PT)-1.1 . CHEST (PORTABLE AP) [**2122-1-15**] IMPRESSION: Findings consistent with pulmonary edema/fluid overload. No free air under the diaphragms or pneumothorax identified. . US EXTREMITY NONVASCULAR PORT LEFT/RIGHT [**2122-1-16**] IMPRESSION: No evidence of hematoma. . CHEST (PORTABLE AP) [**2122-1-16**] FINDINGS: There is mild cardiomegaly. Small bilateral pleural effusions and perihilar congestion persist. There is no pneumothorax. IMPRESSION: Moderate CHF. . EGD [**2122-1-19**] Esophagus: Mucosa: Normal mucosa was noted. Stomach: Mucosa: Diffuse patchy erosive gastritis was noted in the stomach. Cold forceps biopsies were performed for histology at the stomach antrum and stomach body. Duodenum: Mucosa: Normal mucosa was noted. Impression: Normal mucosa in the esophagus Normal mucosa in the duodenum Abnormal mucosa in the stomach (biopsy) . Labwork on discharge: [**2122-1-20**] 12:03PM BLOOD WBC-6.9 RBC-4.00* Hgb-10.5* Hct-31.2* MCV-78* MCH-26.3* MCHC-33.8 RDW-16.1* Plt Ct-228 [**2122-1-20**] 04:45AM BLOOD Glucose-44* UreaN-51* Creat-11.6*# Na-135 K-4.7 Cl-96 HCO3-25 AnGap-19 Brief Hospital Course: 42 year-old male with ESRD on HD, chronic left flank pain, Type I diabetes, uncontrolled hypertension who presents with hemetemesis, guaiac positive stool and hypoxia. . 1. Hypoxia. Resolved soon after admission. CXR on admission consistent with pulmonary edema. The patient's presentation was likely secondary to flash pulmonary edema from hypertension and fluid overload from dietary indiscretion. The patient's last echocardiogram [**9-20**] showed mild diastoic dysfunction; mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF >55%). This was unlikely ischemic with troponins trending down. The patient was dialyzed during admission with removal of ~6 liters. The patient was maintained on fluid restriction and low sodium diet. The patient was continued on BB and ACEI. . 2. Hematemesis/guaiac positive stool. The patient had no further episodes of hematemesis during hospitalization. The patient's hematocrit dropped slightly as above. The patient had grade III esophagitis on EGD [**10-21**] likely secondary to vomiting from uremia and diabetes. The patient underwent endoscopy prior to discharge which showed diffuse patchy erosive gastritis. The patient's guaiac positive stools were thought secondary to this upper GI source. The patient was tolerating a regular diet prior to discharge. The patient's protonix was changed from daily to twice daily. The patient tolerated a regular diet prior to discharge. The patient's aspirin was discontinued for now; the patient will follow-up with his primary care doctor regarding future use of aspirin. . 3. Anemia/hematocrit drop. The patient's baseline hematocrit is mid-30s; hematocrit was 40 on admission and was 30 at the time of discharge. The drop was likely secondary to groin bleeds and hemetemesis. The patient likely has a component of anemia from chronic renal failure and iron studies in the past have been consistent with anemia of chronic disease. . 4. Groin bleed. The patient was status post multiple CVL attempts in the ED. Hematocrit fell to 30 from baseline mid-30s. Bleeding stopped status post DDAVP [**1-16**]. Bilateral US negative for hematoma [**1-16**]. . 5. Diabetes, type I. Hemoglobin A1C 5.8 [**12-22**]. Complicated by nephropathy, neuropathy. The patient's evening NPH was decreased prior to discharge for hypoglycemia. The patient was continued on reglan for nausea/vomiting thought secondary to diabetic gastroparesis. The patient will follow-up with [**Last Name (un) **] after discharge. . 6. ESRD secondary to diabetes. The patient was followed by renal throughout admission. The patient's usual dialysis is T/Th/Sat. The patient was dialyzed with removal ~6 liters. The patient was continued on calcium acetate and lanthanum. The patient's calcium acetate was increased prior to discharge per renal recommendations. . 7. Left flank pain. Patient has been hospitalized multiple times in the past with extensive work-up including CT abdomen, MRI, and ultrasound without clear etiology for pain. Psychiatric and medicine teams felt pain was psychosomatic in nature. The patient was given pain control with morphine prn, neurontin, klonopin, glycopryrolate, and doxepin. . 8. Hypertension. The patient was continued on metoprolol, lisinopril, and nifedipine. There were no changes made to the patient's regimen on this admission. . 9. Depression. The patient was continued on celexa and doxepin. Medications on Admission: Lisinopril 40 mg Calcium Acetate Metoclopramide 10 mg PO QIDACHS Docusate Sodium 100 mg PO DAILY Aspirin 325 mg Tablet PO DAILY Metoprolol 150 [**Hospital1 **] Pantoprazole 40 mg PO Q24H Simethicone 80 mg QID Citalopram 20 mg Mirtazapine 15 PO HS Gabapentin 300 mg Capsule DAILY Clonazepam 0.5 mg PO TID Doxepin 50 mg PO HS Glycopyrrolate 2 mg PO TID Nifedipine 120 mg QD Insulin NPH 20 units qAM/12 QHS Lanthanum 1000 mg PO TID W/MEALS Oxycodone 5 mg prn Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). 5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Glycopyrrolate 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Lanthanum 250 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO TID (3 times a day). 8. 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* 9. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*270 Capsule(s)* Refills:*2* 10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 13. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Hematemesis, likely from erosive gastritis seen on EGD 2. Hypoxia, likely flash pulmonary edema in the setting of hypertension . Secondary: - DM1 x 17 years, HbA1c 5.8 [**2121-12-26**] - ESRD on HD normally T/Th/Sa at [**Location (un) **] Dialysis, MWSa the week of admission [**3-20**] holidays - HTN, poorly controlled - R foot operation with bone excision "few months ago" - R foot ulcer "3-4 years ago" - Depression with h/o SA and psych hospitalizations, currently no SI - Esophagitis on EGD [**10-21**] with H. Pylori negative - History of L flank pain as above since [**2119**] with extensive work-up and no organic etiology for pain. Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: Please contact a physician if you experience fevers, chills, chest pain, shortness of breath, nausea, vomiting, black stools or blood in your stools, or any other concerning symptoms. . Please take your medications as prescribed. It is very important you take all your medications. - You should take protonix 40 mg twice daily instead of once daily. - You should hold aspirin for now and speak with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 9533**] aspirin. - Your insulin was decreased to 10 units at night. Your morning insulin is the same. You should measure your finger stick sugars four times daily. - Your calcium acetate was increased to three tablets three times daily. . Please keep your follow-up appointments as below. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2122-1-21**] 1:30 Provider: [**Name10 (NameIs) **] PROCEDURE Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2122-1-21**] 1:30 . Please call your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], at [**Telephone/Fax (1) 65441**] to arrange follow-up within two weeks. You should follow-up your biopsy results with him at this time. . Please call [**Last Name (un) **] Diabetes Center to arrange follow-up regarding your diabetes. . Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-3-16**] 1:00

[ "789.09", "276.7", "404.93", "428.0", "285.21", "311", "998.11", "250.01", "285.1", "585.6", "799.02", "338.29", "535.41" ]

icd9cm

[ [ [] ] ]

[ "45.16", "39.95" ]

icd9pcs

[ [ [] ] ]

10570, 10576

5372, 8800

337, 356

11273, 11305

3746, 3754

12115, 12817

2533, 2579

9307, 10547

10597, 11252

8826, 9284

11329, 12092

2594, 3727

5130, 5349

276, 299

384, 1813

3768, 5116

1835, 2334

2350, 2517

29,035

115,770

17957

Discharge summary

report

Admission Date: [**2153-5-14**] [**Year/Month/Day **] Date: [**2153-5-16**] Date of Birth: [**2089-12-13**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Indomethacin / Actonel / Reglan Attending:[**First Name3 (LF) 3561**] Chief Complaint: Hypoxia and hypotension s/p thoracentesis Major Surgical or Invasive Procedure: None History of Present Illness: 63 F with NASH cirrhosis, recurrent pleural effusions, DM, ESRD on TTS schedule who was sent to the ER after 2 liter thoracentesis done by radiology. Her oxygen saturation dropped to the high 80s and she was transiently hypotensive to 80s systolic. She denied lightheadedness, dizziness, chest pain, nausea, diaphoresis, her only complaint was of pleurisy on inspiration. In the ER her blood pressure was stable in the 90s systolic (b/l 90-100s), CXR with no PTX, 99% 4L/NC. Clinically without complaints, asking for food. Guiaic negative. No other complaints. No fluids given. Admitted to MICU for close observation of hemodynamics. . Review of systems is otherwise negative other than HPI. In the ICU she had no complaints other than pleurisy. Past Medical History: NASH cirrhosis: Liver bx [**2152-9-6**] = Stage IV cirrhosis, Grade 2 inflammation, complicated by portal HTN --Esophageal varicies (grade I and II, s/p banding), s/p TIPS in [**9-15**] --History of encephalopathy --History of ascites - Anemia - Thrombocytopenia - ESRD on HD due to diabetes and contrast-induced nephropathy - Type 2 diabetes with retinopathy, nephropathy, and neuropathy - History of C. difficile infection - History of seizures - Small left frontal meningioma - Hypertension - GERD - OSA - Leg cramps/? RLS - DJD of neck - History of dermoid cyst - Right adrenal mass . Past Surgical History: - Status post cholecystectomy followed by tubal ligation - Status post left oopherectomy - Status post appendectomy . Past Psychiatric History: Depression first experienced in high school. First hospitalization in [**2131**] (after husband's death). History of cutting and burning self. History of overdose. One course of ECT in past that was helpful. Social History: Social History: Widowed, lived in [**Hospital3 **] although most recently has been at rehab. Has 4 children, several in MA. Smoking: None EtOH: Never Illicits: None Family History: Family History: Mom: CAD, stroke Dad: HTN, DM Physical Exam: Tmax: 36.7 ??????C (98 ??????F) Tcurrent: 36.7 ??????C (98 ??????F) HR: 58 (56 - 62) bpm BP: 98/34(49) {76/34(47) - 100/47(59)} mmHg RR: 15 (11 - 15) insp/min SpO2: 97% General Appearance: No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : RLL), (Breath Sounds: Diminished: RLL) Abdominal: Soft, Non-tender, Bowel sounds present, Distended, ascites present Extremities: Right: 1+, Left: 1+ Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed Pertinent Results: COMPARISON: [**2153-4-29**]. FINDINGS: There is no pneumothorax. There is small residual pleural effusion on the right. Left lung is clear. There is no left effusion. Heart and mediastinal contours are stable. Right-sided tunneled catheter is again noted, and the tip is situated within the right atrium. A tip is noted, and projects over the expected location within the liver. Osseous structures are stable. IMPRESSION: No pneumothorax. ------------ [**5-15**] CHEST PORTABLE AP REASON FOR EXAM: 63-year-old woman with re-expansion pulmonary edema, assess change. Since yesterday, right middle lobe and right lower lobe alveolar opacity decreased. Bilateral pleural effusions are unchanged, still small, more marked on the right. Right hemodialysis catheter still ends in the right atrium. Clips in the upper abdomen are unchanged. There is no other change. Brief Hospital Course: 63 F with cirrhosis, ESRD s/p thoracentesis who presents with hypoxia and hypotension in setting likely re-expansion pulmonary edema . #. Hypoxia- patient currently 99% on 2L and comfortable. Suspect she had some desaturation in setting of re- expansion edema which has stabilized. No evidence of pneumothorax on multiple CXR, there is re-accumulation of fluid in the right lung. She was monitored for 48 hours in the ICU and had stable blood pressure and oxygen saturation on 2 liters of oxygen. She was discharged to rehab facility. She should have future thoracentesis by interventional pulmonary in order to follow trans pulmonary pressures to avoid re-expansion pulmonary edema. . # Hypotension- patient back to baseline, suspect transient hypotension in setting volume shifts after thoracentesis. Baseline systolic pressure 90s. . # ESRD- [**3-12**] diabetes, continue phos binder, was dialyzed on [**5-15**] with 3 liters removed. - call renal in AM, due for HD - continued midodrine with HD . # Cirrhosis- on transplant list - Encephalopathy- continued lactulose and rifaximin - SBP- h/o prior SBP, continued Bactrim DS ppx - ascites- off diuretics, intermittent PC as indicated, none this hospitalization - varices- nadolol - anemia- cont PPI . # Diabetes- continued lantus and humalog SS . # Seizures- continued lamictal . # Depression- continued celexa CODE STATUS: confimred FULL CODE Medications on Admission: Acetaminophen prn Lactulose 30cc qid Lamotrigine 100 mg qhs Pantoprazole 40 mg daily Allopurinol 100 mg qod Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q8H prn Lorazepam 0.5 mg q8h prn Gabapentin 300 mg daily Sevelamer HCl 800mg po tid Cholecalciferol 800 units daily Rifaximin 200 mg po tid Albuterol prn Ipratropium prn B-Complex with Vitamin C po daily Insulin Glargine 20 units QHS Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY Keppra 1,000 mg Tablet Sig: One (1) Tablet PO once a day Docusate Sodium 100 mg PO BID Bactrim DS 1 tab daily Midodrine 5 mg Tablet Sig: One (1) Tablet PO QTUTHSA Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS Insulin Lispro Subcutaneous [**Month/Day (4) **] Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 2. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). 10. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed. 12. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 17. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20) Subcutaneous at bedtime. 19. Insulin Lispro 100 unit/mL Cartridge Sig: as directed Subcutaneous four times a day: per sliding scale. 20. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 22. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Midodrine 5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 24. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. [**Month/Day (4) **] Disposition: Extended Care Facility: [**Last Name (LF) 2670**] , [**First Name3 (LF) 5871**] [**First Name3 (LF) **] Diagnosis: Re-expansion pulmonary edema [**First Name3 (LF) **] Condition: Stable [**First Name3 (LF) **] Instructions: You were in the ICU for monitoring after fluid removal of your lung. Your vitals were stable. Follow up with the liver doctors [**First Name (Titles) **] [**Last Name (Titles) **]. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2153-6-22**] 11:30

[ "530.81", "518.4", "518.81", "250.60", "456.21", "571.8", "362.01", "250.40", "572.3", "285.21", "E878.8", "511.9", "571.5", "357.2", "250.50", "585.6", "458.29", "327.23" ]

icd9cm

[ [ [] ] ]

[ "34.91", "39.95" ]

icd9pcs

[ [ [] ] ]

4206, 5611

367, 374

3316, 4183

8999, 9147

2357, 2388

5637, 8976

1787, 2142

2403, 3297

286, 329

402, 1152

1174, 1764

2174, 2325

6,183

112,510

20531+57170

Discharge summary

report+addendum

Admission Date: [**2151-4-14**] Discharge Date: [**2151-4-18**] Service: SICU CHIEF COMPLAINT: Transferred from outside hospital for a bronchoscopy by family wishes. HISTORY OF THE PRESENT ILLNESS: The patient is an 81-year-old man with a past medical history significant for hypertension, COPD, status post multiple hospitalizations for this in the recent few months, new onset atrial fibrillation, alcohol abuse, moderate aortic stenosis, who presented to [**Hospital3 **] on [**2151-3-23**] with a COPD flare after being discharged two weeks prior with a COPD flare. At that time, the patient's symptoms were cough, productive yellow sputum, fever, chills, and difficulty breathing. In the Emergency Room, at the outside hospital, chest x-ray showed acute infiltrate superimposed on chronic right middle lobe infiltrate. One month prior to admission, a right pleural based mass was seen. He had a repeat CAT scan on admission at [**Hospital3 **] with an increase in size of mass. The patient was initially treated with Levaquin for community-acquired pneumonia as well as steroids for a COPD exacerbation; however, he grew MRSA in his sputum culture on [**2151-4-12**]. He was started on vancomycin at that time. In addition, he had new onset atrial fibrillation with rapid ventricular response that was treated with Diltiazem and then loaded with Amiodarone. This led to a likely rate-induced ischemia with peak troponin I to 0.54. The patient was given Lovenox to a Coumadin bridge. Of note, he had Guaiac positive diarrhea two days after admission prior to starting anticoagulation. He was treated with 2 units of packed red blood cells on [**2151-4-10**] for a hematocrit of 26.6 down from 36 on [**2151-4-6**]. There were no further Guaiac stools at that time. On [**2151-4-12**], he had an episode of hypoxia with P02 66.8, PC02 58, saturating 92% on a nonrebreather mask. He was then transferred to the [**Hospital1 18**] for further evaluation of his hypoxia and questionable lung mass. PAST MEDICAL HISTORY: 1. Hypertension. 2. COPD, status post multiple hospitalizations and flares. 3. Alcohol abuse. 4. Moderate aortic stenosis with a reported valve area of 0.9. 5. New onset atrial fibrillation. 6. MRSA pneumonia, as described in HPI. 7. Questionable right lower lobe mass versus round atelectasis. 8. Questionable IBD. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON TRANSFER: 1. Coumadin 5 mg q.h.s. 2. Amiodarone 200 mg p.o. b.i.d. 3. Zantac 150 mg p.o. b.i.d. 4. Multivitamin. 5. Rifampin 600 mg q.d. 6. Vancomycin 1 gram IV q.d., day number one is approximately [**2151-4-12**]. 7. Zovirax 400 mg p.o. t.i.d. 8. Lovenox 60 mg subcutaneously b.i.d. SOCIAL HISTORY: The patient smoked for 45 years, two packs per day. He also has a history of asbestos exposure. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 100.3, pulse 73, blood pressure 180/60, respirations 21, 93% on a 50% face mask. General: The patient was in no acute distress, speaking in full sentences. HEENT: Significant for a lesion in the middle of his upper lip that had irregular borders, nontender. Cardiovascular: Regular rate and rhythm with a III/VI holosystolic murmur at the left sternal border heard throughout the precordium. Pulmonary: Poor inspiratory effort, wheezes bilaterally, crackles one-third of the way up bilaterally. Abdomen: Soft, nontender with active bowel sounds, right lower quadrant scar from appendectomy. Extremities: No cyanosis or clubbing, [**2-23**]+ edema to the mid thigh bilaterally, small weeping ulcer on left lower extremity. Neurologic: Intact. LABORATORY/RADIOLOGIC DATA: On admission, white blood cell count 8.1, hematocrit 33.8, platelets 224,000, MCV 87. Chemistries within normal limits. INR 1.6. Chest x-ray showed a right middle lobe and right lower lobe opacity. HOSPITAL COURSE: 1. HYPOXIA: The patient's hypoxia was felt to be multifactorial given the patient's history of congestive heart failure, COPD, recent rapid atrial fibrillation, and multilobar MRSA pneumonia. For the patient's COPD, he was continued on nebulizer treatments. He had completed a full course of steroids at [**Hospital3 **] prior to transfer and thus the patient was not started on IV steroid therapy. It was felt that he was not in acute flare during his ICU course. For the patient's congestive heart failure, he was gently diuresed in the setting of his aortic stenosis. An echocardiogram was obtained which showed an ejection fraction of greater than 55%, pulmonary artery pressure of 20 mmHg, mild symmetric left ventricular hypertrophy, mild 1+ aortic regurgitation, and moderate aortic stenosis with mild dilation of the ascending aorta. The patient's oxygen requirement decreased with continued diuresis. The patient was very responsive to small doses of IV Lasix and was negative daily. The patient was also continued on treatment of his multilobar pneumonia with IV vancomycin at 1 gram q. 12. The patient also had a CAT scan to follow-up on history of lung mass and asbestos exposure. CAT scan showed no pleural mass but loculated fluid in the minor fissure that is somewhat mass-like in appearance. There were emphysematous changes. There was also bilateral air space opacities in the mid lower lungs, right greater than left with some nodular appearance. There were multiple sites of mediastinal lymphadenopathy and bilateral calcified plaques consistent with asbestos exposure. A follow-up CAT scan in three months is recommended. An abdominal aortic aneurysm was also noted infrarenally at 3.7 cm. The patient's hypoxia continued to improve and on the day of transfer to the floor, he was on [**4-27**] liters of nasal cannula with saturations greater than 93%. 2. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS PNEUMONIA: The patient began vancomycin therapy at approximately [**2151-4-12**], however, it is difficult to decipher in the transfer summary from [**Hospital3 **]. It was decided that the patient would have a 14 day course of IV antibiotics and thus a request for a PICC line was placed prior to transfer to the floor. The patient remained afebrile during this admission and his white count was within normal limits as well. His sputum cultures were repeatedly contaminated and his blood cultures are no growth to date. 3. QUESTIONABLE RIGHT LOWER LOBE MASS: There was no mass seen on chest CT here, however, there was lymphadenopathy that could be consistent with infectious reaction. However, it was felt that lymphadenopathy should be followed-up in three months with a CAT scan. 4. PAROXYSMAL ATRIAL FIBRILLATION: The patient's weight was well controlled during his admission until [**2151-4-17**] when he went into atrial fibrillation with rapid ventricular response to the 120s. His hypoxia slightly worsened at this time and thus a Diltiazem drip was started. The patient had a good response to this and was transitioned quickly to p.o. Diltiazem with slow titration upwards. At the time of floor transfer, he is currently on Diltiazem 60 mg p.o. q.i.d. It was thought that a calcium channel blocker would be a better choice in this patient with COPD as opposed to metoprolol. The patient was Coumadin loaded at [**Hospital3 **]. However, this was stopped upon admission to the [**Hospital1 18**] in case procedures were necessary. The patient was started on a heparin drip and Coumadin was held during his ICU course with exception of one dose on the evening prior to transfer. The patient was loaded with Amiodarone at the outside hospital and his dose was decreased in the Intensive Care Unit to 200 mg q.d. The patient's rhythm oscillated between normal sinus as well as rate-controlled atrial fibrillation on day prior to floor transfer. It is uncertain at this time whether Amiodarone will still be indicated in this patient. These issues will be addressed in the patient's floor course. The patient's echocardiogram showed an ejection fraction of greater than 55% with no marked left atrial dilation. Please see above for more details on echocardiogram report. 5. QUESTIONABLE HYPOTHYROIDISM: The patient's TSH was elevated during his Intensive Care Unit course; however, his free T4 was normal. It was thought that this would be hard to interpret in the acutely ill ICU setting and should be followed up as an outpatient. No therapy was started. 6. SKIN LESION: The patient's skin lesion superior to his lip looked worrisome for malignancy and thus a dermatology consult was obtained. Dermatology felt quite certain that the patient's lesion was a squamous cell carcinoma. However, they were unable to biopsy this lesion in-house as microsurgery is indicated and cannot be done in the inpatient setting. They recommended biopsy within ten days at the [**Hospital 2652**] Clinic and the Dermatology Service should be contact[**Name (NI) **] for close follow-up upon discharge. 7. METABOLIC ALKALOSIS: The patient suffered a metabolic alkalosis during his ICU course. It was felt that this was likely due to diuresis. He received three days of acetazolamide and [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] repletion. His respiratory status continued to improve. However, he did have a mild respiratory acidosis as well. This is likely chronic given the patient's history of COPD. His bicarbonate upon admission was also 37. 8. HYPERTENSION: The patient's blood pressure was well controlled during this admission. He was titrated up on Captopril. Diltiazem was also started in the setting of his rapid atrial fibrillation. There were no acute issues. 9. ANEMIA: During the inpatient hospital course at [**Hospital1 **] it was noted that he had Guaiac positive stools with the need of 2 units of packed red blood cells. The patient's hematocrit was stable during his ICU course requiring no transfusions. He was Guaiac positive here. Iron studies showed an anemia of chronic disease picture, however, it is hard to interpret in the setting of recent transfusions. The patient will likely need outpatient follow-up with colonoscopy as he has never been evaluated for this. 10. PROPHYLAXIS: The patient was continued on pantoprazole as well as heparin drip, as above. Communication was with the patient's daughter. Of note, the patient is a DNR/DNI according to multiple discussions with the patient and his daughter. The patient will be transferred to the floor on [**2151-4-18**] to continue his evaluation and treatment. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-986 Dictated By:[**Last Name (NamePattern1) 9244**] MEDQUIST36 D: [**2151-4-18**] 06:44 T: [**2151-4-18**] 18:55 JOB#: [**Job Number 54934**] Name: [**Known lastname **], [**Known firstname **] E Unit No: [**Numeric Identifier 10270**] Admission Date: [**2151-4-14**] Discharge Date: [**2151-4-21**] Date of Birth: [**2069-11-14**] Sex: M Service: ACOVE For the patient's history of present illness, past medical history, social history, family history, allergies, and medications on admission, please see the prior discharge summary, additionally the first part of his hospital course when he was in the ICU has been dictated in the prior discharge summary. HOSPITAL COURSE: The patient was transferred out of the ICU to the Medical floor on [**2151-4-18**]. 1. Hypoxemia and shortness of breath: This has continued to improve while the patient has been on the Medicine floor. Diuresis with the addition of Lasix as needed for his CHF has continued and his O2 requirements on discharge are now down to 3 liters by nasal cannula for O2 saturations in 90-95%. Once he is stabilized and is back to his baseline of no oxygen requirement, he should get pulmonary function tests. He was continued on his nebulizers. They were actually increased back to q.4h. due to some wheezing. 2. MRSA pneumonia: A midline catheter was placed for antibiotics to continue after discharge. He is to continue vancomycin 1 gram q.12h. for a total of 14 days, which will end on [**4-26**]. 3. Questionable right lower lobe mass: He is to followup in three months. 4. Paroxysmal atrial fibrillation: Given the patient's history of CHF, it was felt that he would have long-term benefit from a beta-blocker over diltiazem. Therefore, he was switched to Toprol XL for rate control of his paroxysmal atrial fibrillation in addition to the amiodarone. He will be discharged on a total dose of 75 mg of Toprol XL q.d. Additionally, Coumadin was started for anticoagulation. He will be discharged on Lovenox to bridge him until his INR is therapeutic at a goal of 2 to 3. 5. Diastolic heart failure: The patient continues to have significant lower extremity edema. He continues to diurese mostly on his own with the addition of small doses of Lasix as needed to maintain a goal diuresis of approximately 500 cc negative per day. He continues on an ACE inhibitor and has also been started on a beta-blocker additionally since rapid ventricular response from his atrial fibrillation worsens his heart failure. He is being rate controlled with amiodarone and beta-blocker. He is to continue to follow a low-sodium diet and fluid restriction. 6. Upper lip lesion: Outpatient Dermatology followup has been arranged for him to have the lesion removed as Dermatology consult feels that this lesion has a high likelihood representing skin cancer. DISCHARGE STATUS: To rehab. DISCHARGE CONDITION: Improved. Patient is currently off mask ventilation, although he is still on supplemental O2 by nasal cannula. DISCHARGE DIAGNOSES: 1. Hypoxemic respiratory failure. 2. Chronic obstructive pulmonary disease exacerbation. 3. Diastolic congestive heart failure exacerbation. 4. Methicillin-resistant Staphylococcus aureus pneumonia. 5. Paroxysmal atrial fibrillation. 6. Aortic stenosis. 7. Asbestosis. 8. Upper lip lesion. 9. Anemia. 10. Metabolic alkalosis, resolved. 11. Questionable hypothyroidism. 12. Hypertension. 13. Questionable right lower lobe lung mass. DISCHARGE MEDICATIONS: 1. Flovent 110 mcg two puffs b.i.d. 2. Salmeterol 5 mg one puff b.i.d. 3. Amiodarone 200 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. 5. Atrovent nebulizer q.4h. 6. Albuterol nebulizer q.4h. 7. Coumadin 5 mg p.o. q.h.s. 8. Lisinopril 10 mg p.o. q.d. 9. Toprol XL 75 mg p.o. q.d. 10. Lovenox 60 mg subq q.12h. until INR is therapeutic. 11. Vancomycin 1 gram q.12h. through [**2151-4-26**]. 12. Furosemide 40 mg p.o. as needed to maintain negative output of approximately 500 cc/day. 13. Tylenol prn. 14. Colace 100 b.i.d. prn. FOLLOWUP: At rehab the patient needs to have his weight and ins and outs tracked daily and Lasix given as needed to maintain net gentle diuresis to improve his lower extremity edema, although this needs to be done cautiously given his aortic stenosis. His INR also needs to be followed as he has just been started on 5 mg of Coumadin on [**2151-4-19**]. His goal INR is [**2-23**] and once reached that goal, he may stop the enoxaparin. Additionally, the patient is to followup with his primary care doctor in [**1-22**] weeks after he is discharged from rehab. He is to call her office for an appointment. She will follow up on his pneumonia, COPD, and shortness of breath. She will also followup on his heart failure, lower extremity edema, and atrial fibrillation and may need to adjust the doses of his medications accordingly. While in-house, the patient had some blood-tinge sputum likely secondary to his MRSA pneumonia. However, if he continues to cough up bloody sputum after his pneumonia has resolved, he may need outpatient bronchoscopy and his PCP will determine that. Finally while in-house, he had an elevated TSH with a normal T4, and he will need to have his TSH rechecked as an outpatient. He also needs a repeat CT scan of his chest in approximately three months to make sure that the enlarged lymph nodes have resolved, his pneumonia has resolved, and there is in fact no right lower lobe mass. His PCP will arrange this. He needs to followup with Dermatology for the lesion on his lip concerning for cancer. He has an appointment scheduled with Dr. [**Last Name (STitle) 10271**] on [**5-5**] at 10:40 a.m. They will remove the lesion and send it for pathology. Patient is instructed to phone [**Telephone/Fax (1) 459**] and change the appointment time if he is still in rehab on [**5-5**]. Finally, given that the patient has diastolic heart failure and new onset atrial fibrillation, he would likely benefit from outpatient follow up with a cardiologist. His PCP will recommend someone. [**First Name4 (NamePattern1) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1977**] Dictated By:[**Last Name (NamePattern1) 827**] MEDQUIST36 D: [**2151-4-21**] 11:21 T: [**2151-4-21**] 11:50 JOB#: [**Job Number 10272**]

[ "482.41", "276.4", "428.30", "424.1", "518.81", "427.31", "428.0", "491.21", "305.01" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

13629, 13742

2868, 2907

13763, 14196

14219, 17043

11423, 13607

106, 2026

2922, 3933

2452, 2736

2048, 2427

2753, 2851

54,681

181,842

5083

Discharge summary

report

Admission Date: [**2108-9-24**] Discharge Date: [**2108-10-6**] Date of Birth: [**2024-3-20**] Sex: F Service: MEDICINE Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 99**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Endotracheal intubation Triple lumen central venous catheter EGD Thoracocentesis History of Present Illness: 84F pmhx cad, chf, copd, recent pna, [**Last Name (un) **], afib on coumadin, htn, hld, presents from [**Location (un) **] health center with dark hemoccult positive stool and 3 pt crit drop. From [**Location (un) **] health care center, admitted from hospital following an admission for pneumonia and, reported dark hem positive stool, hct 23.3 baseline hct since admit 26.0, bun 137. full code PMH: renal injury, htn, afib, lipids on coumadin last INR was 5.4 on [**9-20**] med was held INR 1.5 today. . In the ED inital vitals were, 98.5 76 102/40 26 96% 2L Nasal Cannula. Her initial EKG showed EKG atrial fibrillation at 77, and a Qwave in 1 and AVL. She has frank melena on guiaic, and [**First Name8 (NamePattern2) **] [**Location (un) 745**] records has a HCT drop from 26-->23. A RIJ was placed, and her CXR was read as her continuing to have a PNA present. Her NG lavage showed coffee grounds which cleared after ~500cc. GI was consulted, and agreed with a PPI, reversal of her INR, and transfer to the ICU in case of further deterioration. . 84 y/o has been at a nursing home or rehab faciilty, was transferred there with a recent discharge of PNA and COPD, and HCT was 26 -->23, retching and with melanotic stool, and was 3 points lower, and she was very dehydrated looking on her chemistry. Is having a decent amount of melena, cleared 500. No history GI bleed. GI said bolus and gtt, and since cleared quickly, and relatively close hct to baseline, they wouldn't do anything acutely. HR in the 80s (beta blocked) low 90s/40s for BP, similar to sick baseline from prior,a nd still has PNA from CXR. Started Vitamin K 5 mg, INR 1.7. No blood yet, not FFP. NPO overnight. . She was recently admitted to the [**Hospital1 1516**] service, and subsequently transferred to the CCU during an admissionf rom [**Date range (1) 20927**]. During this admission, she had presented with Acute on chronic diastolic CHF exacerbation; she required transfer to the CCU for hypoTN where CVL was placed and she was started on lasix drip and required dopamine drip [**2-8**] hypotension. She was intubed, and subseuqnetly was found on a BAL PCP (pneumocystis jirovecii/carinii). She was ultimately transitioned to Bactrim DS for a total 21 day course after which she will need PCP [**Name Initial (PRE) 1102**]. . Per her son, she has not had any coughing, has not been vomiting any blood, and has not had any abdominal pain . Review of systems: (+) Per HPI Past Medical History: 1. Coronary artery disease; nuclear stress test in [**1-/2100**] showed fixed inferolateral wall defect. 2. Chronic diastolic congestive heart faliure (EF 50% on [**8-/2108**] echo, apical akinesis, also 4+ TR at that time but grossly overloaded) -> admitted to CCU [**8-/2108**] with cardiogenic shock 3. HTN 4. AFib- on beta-blocker, coumadin 5. Hyperlipidemia 6. Migraine 7. Breast Cancer, status post Left mastectomy, radiation, chemo; residual left upper extremity lymphedema. 8. Right hip fx s/p replacement, [**9-14**] and Left hip fx s/p surgery x2, [**12-15**] and [**3-16**] 9. Kidney stones 10. Mild depression 11. Hip fracture s/p replacement 12. Shoulder Fx [**2104**] Social History: Lives at [**Hospital3 **] at [**Hospital 745**] Health Care Center, denies any alcohol or cigarettes. Son [**Name (NI) 20922**] is health-care proxy and is very involved, [**Telephone/Fax (1) 20923**] cell and [**Telephone/Fax (1) 20924**] home Family History: lung cancer (father), GI cancer (mother) Physical Exam: Admission Physical Exam: Vitals: T: BP: 102/44 P: 75 R: 19 O2: 100% 3L General: NAD HEENT: Sclera anicteric, dry MM Neck: supple, JVP not elevated, no LAD Lungs: crackles at the bases bilaterally CV: irregularly irregular, without m/r/g Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, well perfused, 1+ pitting edema bilaterally, L>R upper extremity edema Discharge Physical Exam: Was called in by RN to exam the patient. Listened for breath sounds and felt for breaths and chest wall movement for 1 minute. Listened for heart sounds for 1 minute, unable to auscultate. Felt for pulse (radial and carotid) for 1 min, unable to palpate. Pt did not withdrawal to painful stimuli. No corneal reflex was present. Pupils were fixed and nonreactive. Time and date of death: [**2099**] on [**2108-10-6**] Pertinent Results: [**2108-9-24**] 06:20PM BLOOD WBC-9.9 RBC-2.67* Hgb-7.6* Hct-24.2* MCV-91 MCH-28.5 MCHC-31.5 RDW-19.6* Plt Ct-201# [**2108-9-24**] 06:20PM BLOOD Neuts-93.1* Lymphs-3.8* Monos-2.0 Eos-1.0 Baso-0.1 [**2108-9-24**] 06:20PM BLOOD PT-19.0* PTT-27.0 INR(PT)-1.7* [**2108-9-24**] 06:20PM BLOOD Glucose-108* UreaN-131* Creat-2.6* Na-136 K-6.3* Cl-93* HCO3-33* AnGap-16 [**2108-9-24**] 10:42PM BLOOD Calcium-8.6 Phos-3.2 Mg-2.9* [**2108-9-24**] 06:37PM BLOOD Lactate-2.4* [**2108-10-6**] 03:40AM BLOOD WBC-8.4 RBC-2.61* Hgb-8.0* Hct-25.2* MCV-97 MCH-30.7 MCHC-31.8 RDW-19.3* Plt Ct-105* [**2108-10-6**] 03:40AM BLOOD Neuts-89.5* Lymphs-5.6* Monos-4.2 Eos-0.7 Baso-0 [**2108-10-6**] 03:40AM BLOOD PT-15.9* PTT-28.6 INR(PT)-1.4* [**2108-10-6**] 03:40AM BLOOD Glucose-93 UreaN-142* Creat-4.6* Na-134 K-3.9 Cl-93* HCO3-26 AnGap-19 [**2108-10-6**] 03:40AM BLOOD Calcium-8.6 Phos-6.6* Mg-2.4 CT Head ([**2108-9-26**]) No acute intracranial process. Note that either MRI with diffusion-weighted sequence (if feasible) or CT-perfusion study would be more sensitive for acute ischemia. Ultrasound of UE ([**2108-10-1**]) No evidence of DVT in the bilateral upper extremities. Ultrasound of LE ([**2108-10-1**]) 1. No evidence of deep venous thrombosis. 2. Mixed echogenicity mass in the medial aspect of the right thigh, most in keeping with a hematoma, necrotic nodal mass or other complex fluid collection; clinical correlation is advised. EGD ([**2108-9-25**]) -Abnormal mucosa in the esophagus. While the lesions were not initially bleeding there was a moderate amount of bleeding adter the procedure. -These lesions are likely intermitently bleeding and was made acutely worse by NG tube placement. (cytology) -Medium hiatal hernia -Bile without any blood was present in the stomach and doedenum, with the exception of a few flecks of blood in the mid duodenum. No fresh blood or bleeding source was seen in the duodenum. -Abnormal mucosa in the duodenum -Otherwise normal EGD to third part of the duodenum Esophageal Brushings ([**2108-9-25**]) NEGATIVE FOR MALIGNANT CELLS. Pleural Fluid Cytology ([**2108-10-3**]) NEGATIVE FOR MALIGNANT CELLS. TTE ([**2108-10-1**]) Very porr image quality.The left atrium is markedly dilated. The right atrium is markedly dilated. There is symmetric left ventricular hypertrophy (distal LV/apex not well seen). The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. There is abnormal septal motion/position. 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. An eccentric jet of moderate (2+) mitral regurgitation is seen. Tricuspid regurgitation is present but cannot be quantified. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 84F with PMH significant for CAD, CHF, COPD, recent PNA, afib on coumadin, htn, hld, presents from [**Location (un) **] health center with GI Bleed. She was found to have herpetic esophagitis on IV acyclovir and L lung whiteout on admission. She underwent an EGD on [**2108-9-25**] which revealed significant distal esophagitis, confirmed as HSV. She was treated with acyclovir and given blood transfusions as necessary. Her anticoagulation was held and she was placed on a PPI. Her hematocrit stabilized, but she continued to have brown guaiac positive stools. She suffered a cardiorespiratory arrest requiring intubation on [**2108-9-26**], which was though to be [**2-8**] a mucus plug. She was treated for possible underlying HCAP and prior course for PCP. [**Name10 (NameIs) **] underwent a bronchoscopy and thoracentesis for evaluation of her airway and drainage of a pleural effusion. The patient was later extubated and the family decided against reintubation. She tolerated the extubation well and initially was able to maintain her oxygen saturation with supplementation, however her oxygen requirement gradually increased. Following extubation, the patient no longer had enteral access for feeding. Attempts were made at Dobhoff placement, however the tube could not be advanced. Given her poor functional status, the family came to the decision not to persue more agreesive measures for feeding. It was noted that the patient was leukopenic. The etiology of this remained unclear. The patient was noticed to have decreasing platlets. A HIT antibody screen was positive, however the serotonin release assay was negative. Noninvasive ultrasounds were done of the upper and lower extremeites and were negative for DVTs, however an echogenic mass was seen on the right proximal thigh which was thought to likely be a hematoma. The patient mental status had significantly declined from her baseline. She was non-responsive, her eye movements would not track and she did not withdraw to pain. It was felt that this was most likely multifactorial due to her cardiac arrest and increasing renal failure leading to uremia. The patient was a very poor dialysis candidate and it was decided not to proceed with hemodialysis given medical futility. The patient began to require pressors for blood pressure support and her oxygen requirement gradually increased. During a family meeting, it was decided to withdraw her pressor support and focus her care primarily on comfort. The patient passed away the evening of [**2108-10-6**]. Medications on Admission: 1. warfarin 2 mg Tablet Sig: 0.5 Tablet PO Once Daily at 4 PM. 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) tab PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for constipation. 4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 8. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 16 days: Last day [**10-4**]. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Patient deceased. Discharge Condition: Patient deceased.

[ "286.9", "287.5", "V58.61", "V10.3", "E849.7", "348.30", "272.4", "V49.86", "427.31", "E912", "414.01", "403.90", "428.0", "428.33", "276.3", "038.9", "511.9", "427.5", "584.9", "995.91", "518.81", "518.0", "934.9", "280.0", "578.1", "276.52", "054.79", "486", "V43.64", "585.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "38.93", "33.23", "45.16", "34.91", "96.72" ]

icd9pcs

[ [ [] ] ]

11199, 11208

7772, 10329

296, 379

11269, 11289

4755, 7749

3844, 3886

11170, 11176

11229, 11248

10355, 11147

3926, 4284

2846, 2860

248, 258

407, 2827

2882, 3565

3581, 3828

4309, 4736

32,084

178,430

33797

Discharge summary

report

Admission Date: [**2196-4-11**] Discharge Date: [**2196-4-19**] Date of Birth: [**2152-9-20**] Sex: M Service: CARDIOTHORACIC Allergies: Bactrim Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2196-4-15**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, AVG to PDA) History of Present Illness: 43 y/o male who had new onset chest pain while fishing. Transported to OSH and found to have elevated Troponin without EKG changes. Underwent cath which revealed severe three vessel disease. Transferred to [**Hospital1 18**] for surgical intervention. Past Medical History: Coronary Artery Disease/Myocardial Infarction s/p PCI 4 yrs ago, Hyperlipidemia, Hypertension, Chronic Kidney Disease (Cr 2.9) secondary to Glomerulonephritis Social History: Quit smoking as teenager ([**2-7**] pk yr hx). Occ. ETOH use. Family History: Mother died from MI at 50. Father died from MI at 59. Physical Exam: VS: 57 13 148/54 Gen: NAD Skin: Unremarkable HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM, -JVD, -Carotid Bruit Chest: CTAB Heart: RRR -murmurs Abd: Soft, NT/ND +BS Ext: Warm, well-perfused -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**2196-4-11**] CNIS: 1. There is less than 40% stenosis in the right internal carotid artery. 2. There is no stenosis within the left internal carotid artery. [**2196-4-15**] Echo: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the inferolateral wall. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. MR increased to mild to moderate (1+-2+) with raising of the SBP to 170mm Hg (phenylephrine and Trendelenburg position). POSTBYPASS: LV systolic function appears hyperdynamic (LVEF>55%). RV systolic function is preserved. MR remains mild. The study is otherwise unchanged from prebypass. [**4-17**] CXR: The patient is status post sternotomy. There is prominence of the cardiomediastinal silhouette and increased retrocardiac density. There are small bilateral effusions. No CHF. These findings are all unchanged compared with [**2196-4-16**]. There is a small left apical pneumothorax that is more apparent on today's examination than on [**2196-4-16**] and that appears similar to [**2196-4-15**]. [**2196-4-11**] 05:11PM BLOOD WBC-6.5 RBC-3.72* Hgb-10.9* Hct-31.3* MCV-84 MCH-29.2 MCHC-34.7 RDW-12.9 Plt Ct-101* [**2196-4-19**] 10:45AM BLOOD WBC-9.5 RBC-3.86* Hgb-11.4* Hct-33.0* MCV-86 MCH-29.5 MCHC-34.5 RDW-12.7 Plt Ct-297 [**2196-4-11**] 05:11PM BLOOD PT-12.7 PTT-29.2 INR(PT)-1.1 [**2196-4-15**] 01:29PM BLOOD PT-14.3* PTT-46.4* INR(PT)-1.2* [**2196-4-11**] 05:11PM BLOOD Glucose-101 UreaN-42* Creat-2.8* Na-142 K-4.6 Cl-109* HCO3-24 AnGap-14 [**2196-4-18**] 05:26PM BLOOD Glucose-94 UreaN-58* Creat-3.4* Na-137 K-4.3 Cl-99 HCO3-24 AnGap-18 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] was transferred from OSH to [**Hospital1 18**] following his cardiac cath. He was continued on his medications at time of transfer (including Heparin and Nitro) and underwent usual pre-operative work-up. Plavix was stopped and he received medical management pre-operatively until Plavix washout. He required nephrology consult secondary to his chronic kidney disease. On [**4-15**] he was brought to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Beta blockers and diuretics were initiated on post-op day one and he was gently diuresed towards his pre-op weight. Chest tubes were removed on post-op day one. On post-op day two he had episodes of atrial fibrillation which were treated with beta blockers and amiodarone. He required blood transfusion on post-op day three d/t low HCT (20.5). Later on this day he was transferred to the telemetry floor for further care. Epicardial pacing wires were removed. Over the next couple of days he worked with physical therapy for strength and mobility. On post-op day four he was discharged home with VNA services. Medications on Admission: [**Last Name (un) 1724**]: Plavix 75mg qd, Atenolol 50mg qd, Zocor, Avalide, Corgard 20mg qd MAT: Plavix 75mg qd, NTG gtt, Aspirin 325mg qd, Lopressor 50mg TID, Heparin gtt, Mucomyst 600mg q12, Intergrillin gtt Discharge Disposition: Home With Service Facility: [**Hospital3 6011**] Care Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Post-operative Atrial Fibrillation PMH: Myocardial Infarction s/p PCI 4 yrs ago, Hyperlipidemia, Hypertension, Chronic Kidney Disease (Cr 2.9), Chronic Glomerulonephritis 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**] in 4 weeks Dr. [**Last Name (STitle) 78145**] in [**2-7**] weeks Dr. [**Last Name (STitle) 78146**] in [**1-6**] weeks Completed by:[**2196-4-19**]

[ "997.1", "403.90", "427.31", "410.71", "276.7", "585.9", "285.1", "272.4", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4958, 5014

3328, 4697

284, 384

5289, 5295

1275, 3305

5806, 5988

943, 998

5035, 5268

4723, 4935

5319, 5783

1013, 1256

234, 246

412, 665

687, 848

864, 927

71,129

157,074

34825

Discharge summary

report

Admission Date: [**2161-2-3**] Discharge Date: [**2161-2-10**] Date of Birth: [**2089-9-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 358**] Chief Complaint: Persistent headache and confusion Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 71 year old left handed man with a history of recent ruptured appendix and PE on Coumadin, ? atrial fibrillation, HTN, HLD, and DM who presents with a 3 week history of left frontal/orbital headaches, a 1 day history of vomiting, and then was transferred after an unwitnessed fall at the OSH with subsequent dysarthria. The patient reported a history of right frontal/bilateral orbital headaches over the past 3 weeks. He reports that he usually doesn't get headaches, so this is unusual. He denies photophobia/phonophobia, nausea, weakness/numbness, diplopia. The headaches can be worse when he is laying down flat, and improve when he sits up. He has not noticed if the headache changes in character with Valsalva maneuver. He was recently started on HCTZ for blood pressure control, which was discontinued; however he continues to have headaches. He had a head CT on [**2161-1-2**] given his headaches, which showed "nothing acute." On the morning of admission, he had vomiting at home, therefore he was taken to [**Hospital3 **] for further evalution. At the OSH, bp was 131/81 and labs showed glucose 189, Na 138, WBC 8.5, Hct 33.8, INR 2.0. While in the ED, he had an unwitnessed fall with "syncope in the bathroom", and subsequent slurred speech after the event. He was given Versed 9 mg vs. 20 mg, Ativan 2 mg, and Dilaudid 1 mg. He was transferred to the [**Hospital1 18**] ED. Past Medical History: s/p ruptured appendix in [**State 108**] Pulmonary embolism [**12-1**] on Coumadin ? Atrial fibrillation Hypertension Hyperlipidemia Chronic back pain (lumbar stenosis) with L3 compression fracture Status post aortic aneurysm repair Diabetes mellitus Type II COPD Colonic polyps, last colonoscopy [**2159**] in [**State 108**] GERD withBarrett's esophagus and high grade dysplasia, in CryoSpray Protocol Rotator cuff BPH ? CHF, started on Digoxin in [**State 108**] Social History: reviewed in OMR. Of note, he usually lives in [**State 108**], but was recently hospitalized there with a ruptured appendix, so has been living with his daughter in [**State 350**] recently. Physical Exam: VS: temp 96.7, bp 120/62 (SBP range 120-190), HR 68, RR 18, SaO2 96% on RA, FSBG 181 Genl: Awake, alert, NAD Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Speech is fluent, no dysarthria. Cranial Nerves: Pupils equally round and reactive to light, 2 to 1 mm bilaterally. Extraocular movements intact bilaterally without nystagmus. Sensation intact V1-V3. Facial movement symmetric. Palate elevation symmetric. Tongue midline, movements intact. Motor: No observed myoclonus, asterixis, or tremor. No pronator drift. [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE R 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch in bilateral upper and lower extremities. Reflexes: No ankle clonus bilaterally. Pertinent Results: [**2161-2-2**] 10:07PM BLOOD WBC-11.6*# RBC-4.06* Hgb-11.7* Hct-33.8* MCV-83 MCH-28.8 MCHC-34.6 RDW-15.1 Plt Ct-227 [**2161-2-2**] 10:07PM BLOOD Neuts-85.5* Lymphs-10.7* Monos-3.2 Eos-0.2 Baso-0.4 [**2161-2-2**] 10:07PM BLOOD PT-21.7* PTT-26.7 INR(PT)-2.1* [**2161-2-2**] 10:07PM BLOOD ESR-13 [**2161-2-2**] 10:07PM BLOOD Glucose-179* UreaN-9 Creat-0.9 Na-138 K-4.0 Cl-99 HCO3-26 AnGap-17 [**2161-2-2**] 10:07PM BLOOD CK(CPK)-115 [**2161-2-5**] 05:15AM BLOOD CK(CPK)-2099* [**2161-2-8**] 05:10AM BLOOD CK(CPK)-365* [**2161-2-3**] 06:50AM BLOOD ALT-23 AST-18 LD(LDH)-236 CK(CPK)-192* AlkPhos-66 TotBili-0.7 [**2161-2-2**] 10:07PM BLOOD CK-MB-3 cTropnT-<0.01 [**2161-2-3**] 06:50AM BLOOD CK-MB-4 cTropnT-<0.01 [**2161-2-3**] 02:29PM BLOOD CK-MB-3 cTropnT-<0.01 [**2161-2-3**] 06:50AM BLOOD Albumin-3.8 Calcium-8.0* Phos-1.5* Mg-1.3* Iron-35* [**2161-2-3**] 06:50AM BLOOD calTIBC-228* VitB12-231* Folate-8.8 Ferritn-503* TRF-175* [**2161-2-3**] 06:50AM BLOOD TSH-0.84 [**2161-2-3**] 06:50AM BLOOD CRP-3.3 [**2161-2-3**] 10:33AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 [**2161-2-7**] 05:25AM BLOOD PSA-14.2* [**2161-2-7**] 01:20PM BLOOD CRP-5.2* [**2161-2-3**] 02:29PM BLOOD Digoxin-1.0 [**2161-2-2**] 10:07PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2161-2-2**] 10:15PM BLOOD Type-ART pO2-239* pCO2-53* pH-7.34* calTCO2-30 Base XS-1 [**2161-2-3**] 05:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2161-2-3**] 05:50AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM [**2161-2-3**] 05:50AM URINE RBC-21-50* WBC-[**6-3**]* Bacteri-FEW Yeast-NONE Epi-0 [**2161-2-2**] 10:07PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2161-2-6**] 10:29AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2161-2-6**] 10:29AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2161-2-6**] 10:29AM URINE RBC->1000* WBC-5 Bacteri-NONE Yeast-NONE Epi-<1 [**2161-2-4**] 02:18PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-26* Polys-2 Lymphs-92 Monos-6 [**2161-2-4**] 02:18PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-12* Polys-1 Lymphs-81 Monos-18 [**2161-2-4**] 02:18PM CEREBROSPINAL FLUID (CSF) TotProt-54* Glucose-57 LD(LDH)-38 [**2161-2-3**] 5:50 am URINE Site: CATHETER Source: Catheter URINE SPECIMEN IN LAB NOW @ 10:31 AM.. **FINAL REPORT [**2161-2-6**]** URINE CULTURE (Final [**2161-2-6**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 16 I CEFTRIAXONE----------- 8 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2161-2-3**] 6:50 am SEROLOGY/BLOOD Source: Venipuncture. **FINAL REPORT [**2161-2-4**]** RAPID PLASMA REAGIN TEST (Final [**2161-2-4**]): NONREACTIVE. Reference Range: Non-Reactive. Brief Hospital Course: At [**Hospital1 18**], his blood pressure on admission was 211/114 and he received Ativan 2 mg IV and Midazolam 2.5 mg IVP. CXR showed mild-to-moderate CHF. Head CT showed no acute intracranial process. CT C-spine showed no fracture. Neurology was consulted in the ED, and thought this may have been vasovagal syncope in the setting of vomiting. He was admitted to the MICU for further work up, given his somnolence after heavy sedation. In the MICU, he had an MRI/MRA/MRV performed which was normal. Ophthalmology was consulted, and determined he had no papilledema or disc swelling. His INR was reversed for an LP with Vitamin K, which showed [**1-28**] WBC, [**12-19**] RBC, 54 protein, 57 glucose. Gram stain, cytology and fluid culture were negative. HSV PCR and viral culture were negative. A routine EEG was normal. The patient does not remember what happened at [**Hospital3 **]. On the floor, blood pressure medications were titrated up with resolution of his headaches. He was continued on a heparin drip and restarted on coumadin. He was noted to have persistent gross blood in his urine in the setting of a foley catheter placement and heparing drip. A CT abdomen and pelvis with contrast showed a small non-obstructing left renal calculus, an ulcerated plaque in the distal descending thoracic aorta and an enhancing prostatic lesion. PSA level was noted to be elevated at 14. The heparin drip was discontinued when his INR reached >2.0. Of note, his hematocrit remained stable. Creatinine was normal on admission, but increased to 1.6 during the hospital stay. Etiology of the acute renal failure is likely mutlifactorial including contrast nephropathy from CT scan, prerenal from poor po intake, and a false elevation in creatinine from use of bactrim. . Patient was transferred to the medicine service for further management of these new findings in the setting of anticoagulation for a recent pulmonary embolus and acute renal failure. ACEI were discontinued. Patient was started on IVF and monitored overnight without events. Creatinine had decreased to 1.3 on day discharge. Patient is to follow up with his primary care provider within days of discharge to monitor his INR, creatinine and blood pressure. Medications on Admission: Outpatient Medications (confirmed with PCP [**Name Initial (PRE) 3726**]): Coumadin 5 mg daily (recently changed from 7.5 mg) Fluoxetine 20 mg daily Glyburide 5 mg daily Quinapril 10 mg [**Hospital1 **] Omeprazole 40 mg daily Lipitor 40 mg daily Flomax 0.4 mg qhs Ambien 10 mg qhs Detrol LA 4 mg qAM Metoprolol 20 mg [**Hospital1 **] Digoxin 0.25 mg daily Inpatient Medications: Warfarin 7 mg daily Heparin gtt Quinapril 10 mg PO bid HCTZ 25 mg daily Metoprolol 25 mg tid Glyburide 5 mg daily Bactrim DS [**Hospital1 **] Omeprazole 40 mg daily Tolterodine 4 mg qAM Tamsulosin 0.4 mg qhs Fluoxetine 20 mg daily ISS Ferrous sulfate 325 mg daily Tylenol prn Morphine IV prn Albuterol neb prn Zofran prn Senna prn Docusate 100 mg [**Hospital1 **] Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for UTI for 7 days. Disp:*14 Tablet(s)* Refills:*0* 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 8. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain, fever. 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 14. 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* 15. Soft neck collar Please supply patient with a soft neck collar to be worn at night or when at rest to reduce muscle tension. 16. Outpatient Lab Work Please have patient's INR and BMP (Na, K, Cl, HCO3, BUN, Cr) monitored on [**2161-2-13**]. Lab results should be faxed to Dr. [**Last Name (STitle) 61740**] at [**Telephone/Fax (1) 39191**]. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Headaches secondary to uncontrolled hypertension Hematuria HTN Secondary diagnosis: History of ruptured appendix Pulmonary embolism [**12-1**] on Coumadin ? Atrial fibrillation Hyperlipidemia Chronic back pain (lumbar stenosis) with L3 compression fracture Status post aortic aneurysm repair Diabetes mellitus Type II Chronic obstructive pulmonary disease Colonic polyps, last colonoscopy [**2159**] in [**State 108**] GERD with Barrett's esophagus and high grade dysplasia Rotator cuff Benign prostatic hypertrophy Chronic heart failure, started on digoxin Discharge Condition: Stable Discharge Instructions: You presented to an outside hospital to be evaluated for persistent headache. While there, you had an unwitnessed event after which you were combative and required medical sedation. You were transferred to [**Hospital1 18**] for further evaluation of your headaches and confusion which was likely due to uncontrolled blood pressure. Your blood pressure medications were adjusted until you had adequate blood pressure control. . You were also diagnosed with a urinary tract infection which was treated with a course of antibiotics. During this time you were noted to have frank blood in your urine which was evaluated by CT scan and showed a questionable lesion in your prostate and a small nonobstructing kidney stone. You were resumed on coumadin after the lumbar puncture and placed in an IV heparin drip until your INR reached goal [**1-27**]. . The following changes have been made to your medications: 1) STOP Hydrochlorothiazide 2) STOP Digoxin (lanoxin) 3) STOP Quinapril (accupril) 4) STOP Vicodin 5) INCREASE Metoprolol (lopressor) to 50 mg by mouth twice a day 6) DECREASE Warfarin (coumadin) to 5 mg by mouth once a day 7) START Fluoxetine 20 mg by mouth daily 8) START Ferrous sulfate 325mg by mouth daily 9) START Trimethoprim-sulfamethoxazole (Bactrim) 160-800 mg one tablet by mouth twice a day for 7 days 10) START Docusate 100 mg by mouth twice a day as needed for constipation 11) START Senna 8.6 mg by mouth twice a day as needed for constipation 12) START Acetaminophen (tylenol) 1-2 tablets by mouth every 6 hours as needed for pain . Please take all other home medications as previously directed. . Please make your follow-up appointments as listed below. . If you have any worsening or worrying symptoms, please contact your primary care provider or return to the emergency room. Followup Instructions: Please have your labs drawn on [**2161-2-13**] to monitor your INR and your kidney function. The results will be faxed to your primary care physician. . PCP: [**First Name4 (NamePattern1) 12562**] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62076**] Please call to [**Telephone/Fax (1) **] an appointment within 1-2 weeks of discharge to have your kidney function monitored. . Neurology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 540**], MD Phone: [**Telephone/Fax (1) 541**] Please call and [**Telephone/Fax (1) **] an appointment within 1 month of discharge. . Urology: Please call your Urologist (prostate doctor) to [**Telephone/Fax (1) **] a follow up appointment within one month of discharge to reevaluate your elevated PSA. . Ophthalmology: Please call your eye doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment to have your eyes examined within the next 2 weeks as changes in eye sight may be contributing to headaches.

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icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

11776, 11782

6934, 9173

347, 353

12405, 12414

3401, 6911

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12438, 14246

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11822, 11886

2650, 2776

2635, 2635

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2293, 2486

27,102

169,114

19147

Discharge summary

report

Admission Date: [**2199-7-14**] Discharge Date: [**2199-7-18**] Date of Birth: [**2123-12-6**] Sex: M Service: MEDICINE Allergies: Lisinopril / Macrobid Attending:[**First Name3 (LF) 348**] Chief Complaint: Lightheadedness Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 75 yo Spanish speaking M w/ DM, CAD, diastolic CHF, prostate CA, ESBL ecoli UTI presents with ARF and hypotension. He was recently admitted for the same. Most recently, he c/o generalized weakness and light headedness x 2days. He also notes decreased urine output today. In the ED: initial vitals were: 97.5, 100/50, 64, 20, 97 on 3L. He initially complained of a headache and neck pain. There was some concern for meningitis and he as given meningeal doses of ceftrioxone and vancomycin. However, on further hx. it was discovered that his head and neck pain (due to laying in the bed uncomfortably) are chronic. Additionally, in the ED, he was transiently hypotensive to the 60's which has now improved to the sbp of 90's with 3L of IVF. His labs are notable for a CRT of 4.3 from a recent baseline of 1.5. He has known obstructive renal failure for which he has required a foley in the past and has been evaluated by urology. Per ED report and recent pcp note, he is supposed to straight cath at home [**Hospital1 **] and has not been compliant. After placement of the foley in the ED, approx. 1500cc of urine was recorded in the foley bag. ROS: + fevers 2 days ago (not recorded), denies chills, chest pain, SOB. He has some mild epigastric abd pain, no dysuria, +constipation, slight LE swelling. On transfer to the floor, patient is resting comfortably without complaint. Our initial communication was limited due to a language barrier, but he only complains of pain in his feet at this time. He denies pain in his chest, abdomen, difficulty breathing or with urination. He has had a BM today. Past Medical History: Adenocarcinoma of the prostate- biopsy [**2199-6-24**] ([**Doctor Last Name **] 9+10 prostate cancer recently started on casodex will be transitioned to lupron) Benign Prostatic Hypertrophy s/p TURP with GreenLight [**10-8**] COPD Low back pain Type II Diabetes - not on insulin Diastolic Congestive Heart Failure - echo [**2197**] with EF 55%, resting regional wall motion abnormalities include basal inferior akinesis. Coronary Artery Disease: Mild, reversible inferior wall defect on stress MIBI [**6-5**] Hypertension GERD Obstructive Sleep Apnea on CPAP (intermittently) Migraine Headaches Hypercholesterolemia Social History: The patient has never smoked. He previously used alcohol but quit many years ago. He is married and lives with his wife. [**Name (NI) **] previously worked in aggriculture but is now retired. Family History: His mother is deceased and had heart disease. His father is also deceased but had no health problems to the patient's knowledge. Physical Exam: PE: T 96.5 BP 94/51 HR 69 RR 17 O2Sat 95 Gen: elderly male sitting comfortably in bed HEENT: MMM, poor dentition Neck: no jvd CV: rrr, no murmurs Resp: CTA bilaterally, poor effort Abd: obese, soft, nt/nd, bs normoactive Ext: WWP, L>R 12+ edema in LE. Pertinent Results: [**2199-7-14**] 07:00PM URINE RBC-21-50* WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-[**3-6**] [**2199-7-14**] 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-SM [**2199-7-14**] 06:30PM GLUCOSE-116* UREA N-50* CREAT-4.3*# SODIUM-135 POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-25 ANION GAP-18 [**2199-7-14**] 06:30PM WBC-8.5 RBC-3.70* HGB-10.0* HCT-30.0* MCV-81* MCH-27.0 MCHC-33.3 RDW-13.4 Discharge Labs: [**2199-7-18**] 05:25AM BLOOD WBC-8.2 RBC-3.84* Hgb-10.2* Hct-31.2* MCV-81* MCH-26.7* MCHC-32.8 RDW-13.0 Plt Ct-378 [**2199-7-16**] 05:52AM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR Brief Hospital Course: 75 yo M w/ pmh of urinary obstruction due to Prostate Cancer and ESBL ecoli uti being treated with Meropenem. 1. Hypotension: The patient was initially hypotensive to SBP ~ 60s in the ED. He was given fluid and transfered to the MICU where he was started on Meropenem for an ESBL E. Coli UTI. Once transferred to the floor he was without issue. 2. Acute on chronic renal failure: The patient presented with a Cr of 4.3. With hydration and diuretic administration it returned to his baseline of 1.2. His antibiotics were renally dosed. The foley was removed once transferred to the floor and the patient resumed voiding with supplemental straight catheterizations. His technique was witnessed and improved upon with nursing assistance such that he was allowed to return home on discharge. 3. UTI: The patient was treated on Meropenem for 4 days for an ESBL E. Coli UTI. He was discharged on Ertapenem once daily dosing with Visiting Nurses to administer the drug. He was asymptomatic at discharge. 4. Prostate Cancer: No active issues during this stay. Discussions with Dr. [**Last Name (STitle) **] (Urology) and Dr. [**Last Name (STitle) **] (PCP) yielded the following plan: The patient is to follow up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] the end of the month. He did not need to be seen in house. Dr. [**Last Name (STitle) **] will follow the patient as well and coordinate outpatient imaging to evaluate the progression of his disease. In addition, appointments were initiated on the patient's behalf at the [**Hospital 9197**] Cancer Center and with Dr. [**Last Name (STitle) **] of hematology/oncology. 5. CAD: The patient's home regimen of ASA & Anti-Htn were continued after stabilization without incidence. 6. Hyperlipidemia: The patient was maintained on home Lipitor. 7. CHF: The patient's Lasix & Metalozone were held until his Creatinine normalized at which time he was restarted without incident. 8. Asthma: The patient was maintained on his home inhaler treatments without incident. 9. Peripheral Neuropathy: The patient was maintaned on his Neurontin without incident. 10. Diabetes Mellitus Type 2: The patient was maintained on an Insulin Sliding Scale. He was restarted on Metformin prior to discharge. Medications on Admission: Albuterol [**1-2**] puff q4hrs prn Fluoxetine 20 mg PO DAILY Fluticasone 50 mcg 1 spray qdaily advair 500-50 mcg/Dose 1 inh [**Hospital1 **] doxazosin 2mg [**Hospital1 **] lipitor 40mg PO DAILY Spireva 18 mcg qDAILY Aspirin 81 mg DAILY Acetaminophen 325 mg po q6hrs prn Furosemide 40mg [**Hospital1 **] lisinopril 10mg qdaily (although pt has a recorded allergy) toprol 50mg qdaily Metolazone 10mg qdaily Montelukast 10mg qdaily Metformin 500 mg [**Hospital1 **] neurontin 100 [**Hospital1 **] casodex (recently stopped [**2-2**] to side effects) Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation 1puff [**Hospital1 **] (). 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day. 12. Metolazone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 15. Ertapenem 1 gram Recon Soln Sig: One (1) G Injection Qday () for 10 doses. Disp:*QS * Refills:*0* 16. Line Care PICC Line Care: per NEHT Protocol, Saline & Heparin Flushes 17. Outpatient Lab Work Please draw Cr through PICC line on Monday & Thursday. All results should be sent to Dr. [**Last Name (STitle) **] @ Fax: ([**Telephone/Fax (1) 9190**] 18. Pull PICC Line Please pull PICC line after last dose 19. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnoses: 1. Acute Renal Failure 2. Urinary Tract Infection 3. Hypotension Secondary Diagnoses: 1. Asthma 2. Prostate Cancer 3. Hypertension Discharge Condition: Stable. Discharge Instructions: You have been admitted with acute renal failure and a urinary tract infection. While here you were in the intensive care unit because your blood pressure was low. Your condition improved with antibiotics. You will be discharged on antibiotics for 10 days by IV. Please continue to Catheterize yourself nightly regardless of daily urine output. Please return to the ED for chest pain, shortness of breath or any other medical concern. Followup Instructions: I have called the [**Hospital 9197**] Care Center on your behalf. They can reached at [**Telephone/Fax (1) 52244**]. They should call you to make an appointment. I have called Dr. [**Last Name (STitle) **] on your behalf. They will call you to make an appointment. They can be reached at ([**Telephone/Fax (1) 31457**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2199-7-30**] 2:20 Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2199-7-31**] 3:30

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8529, 8587

3956, 6241

297, 304

8782, 8792

3231, 3673

9277, 9920

2811, 2942

6838, 8506

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332, 1942

1964, 2582

2598, 2795

45,199

111,867

41379

Discharge summary

report

Admission Date: [**2152-2-22**] Discharge Date: [**2152-3-2**] Service: CARDIOTHORACIC Allergies: doxycycline Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2152-2-25**] - 1. Mitral valve replacement 27-mm Biocor tissue heart valve. 2. Coronary artery bypass grafting x3 with reverse saphenous vein graft to the marginal branch, diagonal branch, left anterior descending. History of Present Illness: This 88 year old male with known mitral regurgitation recently developed new onset of exertional chest discomfort. He underwent elective catheterization at [**Hospital1 **] which revealed severe coronary disease. He is transferred for surgical evaluation. He is without pain on transfer. Past Medical History: Mitral Regurgitation Hypertension Peripheral Vascular Disease Pancytopenia Blepharitis Left rib resection Social History: Occupation: retired fire-fighter Cigarettes: Smoked no [] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: < 1 drink/week [] [**1-4**] drinks/week [] >8 drinks/week [] Illicit drug use Family History: No premature heart disease Physical Exam: Pulse:79 Resp:18 O2 sat: 98% B/P Right: Left: Height: 5ft 3" Weight: 150lb Five Meter Walk Test #1_______ #2 _________ #3_________ General: Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade _3/6_____ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: +2 Left:+2 DP Right: +1 Left:+1 PT [**Name (NI) 167**]: +1 Left:+1 Radial Right: +2 Left:+2 Carotid Bruit Right: +2 Left:+2 Pertinent Results: [**2152-2-23**] Carotid U/S: Right ICA <40% stenosis. Left ICA 60-69% stenosis. . [**2152-2-25**] Echo: PRE BYPASS The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the distal anterior, anterolateral, and apical walls. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is partial mitral leaflet flail involving the P1 and P2 scallop interface. There is also a very small area of A! that prolapses. There is also centrally directed mitral regurgitation. There is moderate to severe mitral annular calcification. An eccentric, anteriorly directed jet of severe (4+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is AV paced. There is normal right ventricular systolic function. There is some suggestion of left ventricular septal dyskinesis/dyssynchrony that may be reated to ventricular pacing. The apical and distal anterior, anterolateral hypokinesis noted in the prebypass study remains. Overall ejection fraction is about 45 to 50%. There is a bioprosthesis located in the mitral position. It appears well seated and the leaflets appear to be moving normally. There is a trace perivalvular jet of mitral regurgitation on the anterior side of the prosthesis and a trace jet of valvular regurgitation. The maximum gradient across the valve was 16 mmHg with a mean of 7 mmHg at a cardiac output of about 4.5 liters/minute. This may indicate some element of functional mitral stenosis. The rest of valvualr function is unchanged from the prebypass period. The thoracic aorta is intact after decannulation. . [**2152-3-2**] 05:34AM BLOOD WBC-7.5 RBC-3.46* Hgb-10.5* Hct-33.8* MCV-98 MCH-30.5 MCHC-31.2 RDW-15.2 Plt Ct-164 [**2152-3-2**] 05:34AM BLOOD PT-15.3* INR(PT)-1.4* [**2152-3-1**] 02:00AM BLOOD PT-13.4* PTT-25.0 INR(PT)-1.2* [**2152-2-25**] 06:53PM BLOOD PT-13.6* PTT-35.5 INR(PT)-1.3* [**2152-3-2**] 05:34AM BLOOD Glucose-114* UreaN-42* Creat-1.5* Na-143 K-3.8 Cl-102 HCO3-33* AnGap-12 [**2152-3-1**] 02:00AM BLOOD Glucose-136* UreaN-44* Creat-1.6* Na-138 K-3.8 Cl-100 HCO3-32 AnGap-10 [**2152-2-29**] 02:02AM BLOOD Glucose-156* UreaN-41* Creat-1.8* Na-137 K-4.1 Cl-99 HCO3-33* AnGap-9 [**2152-2-28**] 03:13AM BLOOD Glucose-135* UreaN-32* Creat-1.9* Na-136 K-4.0 Cl-98 HCO3-28 AnGap-14 [**2152-2-26**] 03:03AM BLOOD Glucose-92 UreaN-20 Creat-1.2 Na-139 K-4.7 Cl-108 HCO3-26 AnGap-10 Brief Hospital Course: Mr. [**Known lastname 90075**] was transferred from an outside hospital after catheterization and echo showed severe coronary artery disease and mitral regurgitation. Upon admission he underwent the usual surgical work-up and was medically managed. He remained stable and on [**2-25**] was brought to the Operating Room where he underwent mitral valve replacement and coronary artery bypass graft x 3. He suffered a ventricular fibrillatory arrest in the holding area preoperatively. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition on Milrinone and NeoSynephrine.. He awoke intact, weaned from all vasoactive medications and was weaned from the ventilator and extubated. He developed an ileus that resolved over a couple of days and he was then able to eat, although a modified soft solids and nectar thick liquids. He had urinary retention and the Foley was replaced on two occassions and was therefor, left in at discharge. Coumadin was started for persisitent atrial dysrhythmia and Amiodarone was given with rate control. On POD 6 he was intact and ready for discharge. Rehab was recommended and he consented. He was transferred to [**Hospital1 **] reahb in [**Location (un) 1110**]. Medications on Admission: Lisinopril 40mg daily Toprol xl 25mg daily Amlodipine 2.5mg daily Aspirin 81mg daily Avodart 0.5mg daily Tamsulosin 0.4mg daily Sertraline 50mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 4. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day: as ordered for goal INR 2-2.5 for atrial fibrillation. 9. Outpatient Lab Work INR on ***** 10. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day): 400mg (two tablets) twicew daily for two weeks, then 200mg (one tablet) twice daily for two weeks, then 200mg (one tablet) daily until instructed to stop. 11. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing for 2 weeks. 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO once a day for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Mitral Regurgitation and coronary artery disease s/p mitral valve replacement and coronary artery bypass graft x 3 Hypertension Peripheral Vascular Disease Pancytopenia h/o Blepharitis Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema trace Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema trace Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema trace Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] *Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2152-4-5**] at 3:15 PM Cardiologist: Dr. [**First Name (STitle) 437**] on [**2152-3-8**] at 11:20am in [**Hospital Ward Name 23**] 7 Wound check in [**Last Name (un) 6752**] 2A on [**2152-3-14**] at 10:15 am Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]([**Telephone/Fax (1) 3658**]) in [**3-2**] 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 for Coumadin ?????? indication atrial fibrillation Goal INR 2-2.5 First draw [**3-3**] Will need Coumadin follow up arranged after rehab discharge Completed by:[**2152-3-2**]

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icd9cm

[ [ [] ] ]

[ "39.61", "36.13", "35.23", "99.60" ]

icd9pcs

[ [ [] ] ]

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30566

Discharge summary

report

Admission Date: [**2170-5-8**] Discharge Date: [**2170-5-14**] Date of Birth: [**2110-11-23**] Sex: M Service: MEDICINE Allergies: Sustiva Attending:[**First Name3 (LF) 1990**] Chief Complaint: abdominal discomfort Major Surgical or Invasive Procedure: IVC filter History of Present Illness: 60 yo male with hx DVT, HIV, Hep C, HCC,RCC with mets to lung s/p cyberknife (last one 2 days ago) presents with epigastric pain and chest pain, worse with swallowing. Started after cyberknife, worse with swallowing leading to decreased POs; no pleuritic component or SOB. In the ED, hemodynamically stable. CTA chest with saddle PE. Echo with mild RV dilatation. Bolused with heparin and admitted to unit for close monitoring. Past Medical History: HIV- Dx [**2154**]. Nadir CD4 141; last CD4 [**6-6**] 610 Exposure risk: IDU Med Exposures: indinavir-- complicated by hematuria efavirenz-- CNS side effects nevirapine-- hepatotoxicity Combivir??????anemia ITP- s/p splenectomy [**2158**] HCV- Dx [**2154**], Genotype 1 Bx [**3-/2167**] [**7-6**] fibrosis; [**9-11**] HAI no therapy; EGD [**3-/2167**]- no varicies AFP increasing flex sig [**2165**]- Hyperplastic polyp removed from colon DVT LLE [**9-5**] Likely HCC ( characteristic lesions on CT at dome of liver and elevated AFP) RCC, metastatic to lung, dx [**2169**] during liver tx workup, s/p RFA ablation to kidney mass, s/p [**4-2**] cyberknife tx to lung met on left, last on [**5-3**] Adult onset DM, onset [**2160**] HTN BPH with normal PSAs HBV Post-infection s/p R inguinal hearnia repair [**2161**] Hx of IVDU, ETOH abuse Social History: Occupation: automobile detailer and substance abuse counselor Drugs: Hx IVDU, drug/substance free x 9 years. Tobacco: 1ppd Alcohol: Hx ETOH abuse Other: Lives alone, no pets. Has a very supportive girlfriend who is HCV positive. Has a 22 yr old daughter and reports good relationship with her. Family History: Father died from ETOH related complications; mother died from liver cancer. ? skin cancer Physical Exam: 98.2, 99, 119/76, 100% General Appearance: Well nourished, No acute distress, Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), RRR, no heave or JVD 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: Bowel sounds present, Distended, Acites Extremities: Right: trace, Left: 1+ Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): , Movement: Purposeful, Tone: Normal Pertinent Results: [**2170-5-8**] CTA CHEST: IMPRESSION: 1. Large non-occlusive thrombus involving the right and left main pulmonary arteries extending into the segmental and subsegmental branches bilaterally. 2. Stable appearance of the left upper lobe mass with interval improvement in post-obstructive pnuemonia/pneumonitis. 3. Scattered sub-4-mm noncalcified lung nodules as described above. Attention to these lesions should be paid in followup scans. 4. Cirrhotic liver with lesion at the dome, best seen on [**2170-3-7**], CT of the abdomen study. [**2170-5-8**] CXR: IMPRESSION: No acute pulmonary process. Stable fiducial markers as previously noted. [**2170-5-8**] ECHO: The left atrium and right atrium are normal in cavity size. The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. The pulmonary artery is not well visualized. There is no pericardial effusion. IMPRESSION: Mildly dilated and hypokinetic right ventricle. At least mild pulmonary artery systolic hypertension. [**2170-5-9**] BLE ULTRASOUND: IMPRESSION: DVT involving the superficial femoral and popliteal vein on the left. Clot is also identified in the lesser saphenous vein on the left. Findings were discussed with Dr. [**Last Name (STitle) **] upon completion of the study. [**2170-5-9**] CT HEAD: IMPRESSION: No hemorrhage and no mass effect. Brief Hospital Course: 60M with HIV, HCV with cirrhosis/ascites, hx DVT, RCC and HCC presenting with chest/epigastric pain, found to have large saddle pulmonary embolus. 1. Submassive pulmonary embolus: The patient's CTA was consistent with a submassive PE. He was hemodynamically stable. BLE ultrasounds showed large clot burden. CT head checked given malignancy and need for anti coagulation--no masses. It was felt that the patient would need lifelong anticoagulation, but given the large clot burden and the submassive PE, it was felt that he would benefit from an IVC filter. This was done by IR. The patient remained hemodynamically stable. He was started on a heparin drip in the ICU and was then transferred to the general medical floor. Maintained on heparin until therapeutic on coumadin. Patient's anticoagulation to be managed by Dr. [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) 1226**] office who was contact[**Name (NI) **] and is aware of need for close monitoring, esp in setting of concurrent fluconazole therapy. Given extent of VTE, multiple malignancies and that this is second episode of VTE, patient needs lifelong anticoagulation. 2. Odynophagia/Dysphagia/Candidal esophagitis: Unclear etiology, though likely candidal esophagitis given HIV/HCV/malignancy. Other possibilities include radiation espophagitis vs CMV esophagitis or contigious spread of malignancy in setting of thickened appearance on CTA. GI was consulted and they will evaluate for cause of dysphagia and agreed likely candidal esophagitis. Empiric three week course of fluconazole initiated on [**5-8**] and to finish [**5-28**]. Too high risk for endoscopy given PE and heparin therapy. Patient should have endoscopy within one month, once stabilized on coumadin regimen, especially given cirrhosis (? varices) and possibility of spread of malignancy to esophagus. Symptoms much improved on fluconazole. 3. HIV. The patient gets his care at [**Hospital1 2177**], currently well controlled on HAART regimen. CD4 of 100 here. Maintained HAART. Contact[**Name (NI) **] Dr. [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) 1226**] office (PCP and ID doctor for Mr. [**Known lastname **]). Bactrim prophylaxis given. 4. Hepatitis C/Cirrhosis/Ascites: Maintained on home diuretics (spirinolactone 200 adn lasix 80 with control of ascites - however, dose reduced given hyponatremia, slight, and slight increase in Creatinine and dry overall appearence. Patient should follow up for endoscopy within one month to evaluate for varices especially given concurrent coumadin therapy (arranged follow up at [**Hospital1 **] with his GI MD, [**Last Name (un) 14429**]) 5.Oncology: RCC/mets to lung/probable HCC: S/p cyberknife radiation (less likely to cause radiation esophagitis than traditional XRT). He is not candidate for IL-2 given liver disease. 6. Diabetes. Continued ISS and standing long-acting per home regimen 7. BPH: maintained on terasozin. Medications on Admission: Spironolactone 200mg daily lasix 80mg daily terazosin 5mg daily Truvada 1 tabl Po QHS fosamprenavir 700mg [**Hospital1 **] Discharge Medications: 1. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Fosamprenavir 700 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16): Dose to be managed by coumadin clinic and Dr. [**First Name (STitle) **] as arranged. Disp:*30 Tablet(s)* Refills:*0* 7. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for muscle cramping. Disp:*10 Tablet(s)* Refills:*0* 8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 10. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 11. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 12. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Thirty Three (33) Units, insulin Subcutaneous QAM insulin. 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty Eight (38) Units, insulin Subcutaneous at bedtime. Discharge Disposition: Home Discharge Diagnosis: 1. Massive pulmonary embolus 2. Dysphagia 3. Probable [**Female First Name (un) **] esophagitis 4. Hepatitis C 5. HIV/AIDS 6. Hepatocellular Carcinoma 7. Renal Cell Carcinoma 8. BPH 9. Cirrhosis 10. Ascites Discharge Condition: Stable, tolerating PO, therapeutic inr on coumadin Discharge Instructions: Follow up as below. All medications as prescribed. As discussed, you will need to have lab work monitoring to guide the dose of your coumadin. You will be on coumadin for the rest of your life given that this is your second episode of blood clots. We have contact[**Name (NI) **] your primary care doctor, Dr. [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) **], and her office will be managing your coumadin dosing. You will need to get frequent labs (up to a few times per week initally and then eventually once or twice a month) to monitor your "INR" level which shows how effective the coumadin is. Your goal INR is [**3-4**]. Based on your INR level, your doctor will continue to adjust your dose of coumadin. You will continue to take the fluconazole for a total of three weeks. You were started on [**5-8**] and therefore will continue this through [**5-28**]. This medication can effect the INR and the effect of the coumadin and thus you need very close monitoring in the next few weeks. Coumadin helps prevent new clots and helps prevent the old clots from becoming bigger. It thins your blood and makes you more likely to have bleeding. If you have any signs of bleeding including blood in your stool you must notify your doctor immediately. Other medications can effect the level and make you more likely to bleed and therefore before any starting new medication, let your doctors know [**Name5 (PTitle) **] are on coumadin. We have given you patient information hand-outs about this topic. Otherwise, take all medications as you were previously before coming into the hospital; your lasix and spirinolactone were adjusted down (see med list below). If you develop chest pain, shortness of breath, fevers, chills, signs of bleeding, including blood in the stool, contact your doctor or go to the emergency room immediately. Followup Instructions: Follow up with Dr. [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) **]. As above, you must follow up with her office for anti coagulation. Follow up with your liver doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14429**]. You should be seen within a month and he should perform an upper endoscopy on you within one month. You are risk of 'esophageal varices' (enlarged blood vessels in your food pipe) because of your cirrhosis which can lead to bleeding and the only way to diagnose/treat these is with endoscopy. Follow up with your cancer doctors including Dr. [**Last Name (STitle) **]. The following are the appointments we have arranged for you: [**Hospital 197**] Clinic appointment Appt will be tomorrow a@2:30 pm in [**Location (un) 47**]. Heart Center of [**Hospital1 **] Phone: [**Telephone/Fax (1) 6256**] [**Last Name (NamePattern1) 26916**]., [**Location (un) 47**], [**Numeric Identifier 59599**] PCP [**Name Initial (PRE) **] ([**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) **]) Wednesday [**5-16**] @10:40am at [**Hospital6 **]. [**Last Name (LF) **],[**First Name3 (LF) **] M [**Telephone/Fax (1) 42773**] Dr. [**Last Name (STitle) 14429**], [**Hospital6 **] - keep your scheduled appointment for [**6-14**].

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icd9cm

[ [ [] ] ]

[ "38.7" ]

icd9pcs

[ [ [] ] ]

9412, 9418

4699, 7678

289, 301

9669, 9722

2840, 4619

11639, 12945

2070, 2162

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9439, 9648

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329, 761

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1757, 2054

27,463

102,027

33963

Discharge summary

report

Admission Date: [**2119-9-16**] Discharge Date: [**2119-9-19**] Date of Birth: [**2051-4-21**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: elevated INR Major Surgical or Invasive Procedure: None History of Present Illness: 68 F with ESRD on HD, CHF with EF 15%, CAD s/p CABG, Afib on coumadin, admit from ED with significantly elevated INR now s/p 4 units FFP. Patient reports being in her usual state of health with exception of mild diarrhea starting yesterday. Patient reports daughter gave her a medication for this. On [**9-14**], INR checked and noted to be 8.6. During HD today, INR rechecked and greater than assay. Initial BP 81/36, post BP 93/50 (range 73-93). Hgb 9.2. Other than diarrhea, patient has been feeling well. No abdominal pain, fever, chest pain, bloody stools, epistaxis, hematemesis or other e/o bleeding; no dyspnea, though feels "wheezy" following FFP, feels like she got too much fluid. No dysuria though has had "dark urine". . In ED, vitals 98.4, HR 72, BP initially 76/40, R20, 100% on 4L. Started on 4 units FFP, received 5 vit D SQ and 5 IV. Hct 32 (at baseline). 3pm labs pending. Likely to dialysis tomorrow. Ace and B-blocker have been held. . Hospital course: s/p 4 U FFP. Hct stable w/o source of bleed. BP now in 90s. Past Medical History: 1. CHF with EF of 15% s/p BiV pacer on coumadin, recently admitted for CHF exacerbation in [**7-23**] 2. ESRD - on HD since [**2119-8-1**], *EDW 64.4 kg* 3. CAD s/p MI & CABG x 2 ([**2108**] and revised in [**2118**]) 4. DMII x 4yrs on insulin 5. s/p L AKA 6. Hypothyroidism 7. a-fib on coumadin 8. home oxygen (needed at night when sleeping) Social History: Lives at home with daughter. Remote smoking history less than 2-3yrs total, pt has not smoked in over 30yrs. There is no history of alcohol abuse or IVDU. Family History: non-contributory Physical Exam: Vitals: T 97 (afeb), BP 105/55 (80-100/40-50), HR 78 (paced), R 16, 100% 2L. wt 69 kg; I/O 170/anuric General: Pleasant female, NAD HEENT: NC/AT, PERRL, sclera anicteric, MM slightly dry Neck: Supple, no adenopathy. L EJ in place Chest: +bilateral rhonchi with few wheezes, no crackles appreciated Heart: RRR S1 S2, [**3-22**] SM at LUSB Abdomen: soft, NTND, no HSM, +BS Extrem: s/p L AKA, RLE without edema. Neuro: alert, appropriate, MAE. Pertinent Results: Labs: [**2119-9-16**] 03:00PM BLOOD WBC-4.4# RBC-3.49* Hgb-10.0* Hct-32.5* MCV-93 MCH-28.7 MCHC-30.9* RDW-20.8* Plt Ct-158 [**2119-9-19**] 07:15AM BLOOD WBC-5.0 RBC-3.21* Hgb-9.1* Hct-31.7* MCV-99* MCH-28.4 MCHC-28.8* RDW-21.4* Plt Ct-189 [**2119-9-16**] 03:00PM BLOOD Glucose-104 UreaN-14 Creat-1.4* Na-139 K-7.4* Cl-100 HCO3-34* AnGap-12 [**2119-9-19**] 07:15AM BLOOD Glucose-148* UreaN-37* Creat-1.9* Na-141 K-4.2 Cl-101 HCO3-34* AnGap-10 [**2119-9-17**] 04:42AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.5 Mg-1.6 [**2119-9-19**] 07:15AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.1 [**2119-9-17**] 04:42AM BLOOD ALT-16 AST-32 LD(LDH)-242 AlkPhos-234* TotBili-0.3 [**2119-9-17**] 04:42AM BLOOD TSH-5.2* [**2119-9-18**] 01:10PM BLOOD Free T4-1.3 [**2119-9-16**] 03:00PM BLOOD Vanco-13.2 [**2119-9-16**] 04:23PM BLOOD Lactate-1.2 . INR [**2119-9-16**] 04:15PM BLOOD PT-150* PTT-150* INR(PT)->22.8* [**2119-9-19**] 04:00PM BLOOD PT-17.7* INR(PT)-1.6* . [**2119-9-16**] Blood cx- no growth . CXR [**2119-9-16**]: IMPRESSION: Persistent small bilateral pleural effusions. Marked interval improvement in right-sided pleural effusion. Support lines as described. No pneumothorax. Increased airspace opacity involving both lungs may simply reflect low lung volumes, but mild pulmonary edema is not excluded. Brief Hospital Course: ASSESSMENT AND PLAN: 68 F with ESRD on HD, CHF, Afib on coumadin; admit to MICU with supratherapeutic INR now s/p 4 units FFP and IV vit K. . # Elevated INR. The patient had an elevated INR which was greater than assay at one point early on in her admission. Of note, the patient took a bowel regimen for constipation and reports significant diarrhea prior to admission. The patient was not taking excess coumadin doses. In addition the patient was on vancomycin for a previous HD catheter infection which could have contributed to the increased INR. The patient had no signs of bleeding at the time of admission or during her hospitalization. Her INR normalized with giving IV vit K and 4 units of FFP. The patient was restarted on coumadin prior to discharge. She was discharged on 4mg of coumadin daily with a follow up INR check at hemodialysis. . # Hypotension. The patient became hypotensive with SBPs in the 70s in ED and at HD. She was admitted to the MICU for monitoring and her home BP medications were stopped. She had a negative blood cx and a negative CXR. She was receiving vancomycin with HD for a previous line infection. Her SBP on the day of discharge ranged from 100-110s and she was not restarted on her BP meds prior to discharge. . #Hypothyroidism: She had and elevated TSH at 5.2 and a normal free T4. Her dose of levothyroxine was increased from 125 to 150mcg daily. . # Systolic CHF: The patient has systolic CHF with an EF of 15%. She received 4 units FFP plus additional IVF while in the MICU. She did not require early HD as she was not volume overloaded. Her carvedilol and ACEI were held due to her hypotension and not restarted prior to discharge. . # Diabetes type II: The patient was continued on her home Lantus and ISS. . # ESRD on HD: The patient received HD while at the hospital as per her normal schedule. She finished her doses of vancomycin for her previous line infection. . # CAD. The patient has a history of CAD and CABG x2 with CHF. She was continued on ASA while in the hospital. The patient was not able to tell me the name of her new PCP so [**Name Initial (PRE) **] could not find out why she was no longer on a statin. I did confirm her medications with her pharmacy and she was not receiving a statin. Her ACE and beta-blocker were held due to her hypotension. These medications should be restarted as an out-patient after follow up with her PCP. . #Lesions on back of calf and bleeding of R big toe secondary to nail clipping. The lesion of the back of her calf is surrounded by erythematous tissue suggesting adequate blood flow to heal the lesion. . Left phantom limb pain. The patient felt her ultram was not helping her. She uses a lidocaine patch on her left leg which provides some relief. I started gabapentin which the patient requested to be discharged on. . # Full code: discussed with patient [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 3315**] PGY-1, [**MD Number(1) 78445**] Medications on Admission: Carvedilol 3.125 mg daily Lantus 12 units at HS Senna 1 tab [**Hospital1 **] Humalog sliding scale ASA 325 mg daily lorazepam 0.5 mg HS prn albuterol neb QID prn wheeze lisinopril 5 mg daily Percocet 5-325, 1-2 tabs QID prn pain tramadol 50 mg Q6H prn colace 100 [**Hospital1 **] levothyroxine 125 daily warfarin 5 mg daily Flovent MDI [**Hospital1 **] vanco with HD zolpidem 5mg qHS Bisocodyl 5mg 1-2 tabs daily enulose 90ml, 15ml q4hrs vicadin 5 tabs 5/500 q4hrs lidoderm patch 5% 1 daily PRN limb pain Discharge Medications: 1. Sevelamer HCl 400 PO TID W/MEALS 2. Levothyroxine 150 mcg PO once a day. 3. Aspirin 325 mg PO DAILY 4. Docusate Sodium 100 mg PO BID: PRN as needed for constipation. 5. Senna 8.6 mg PO BID:PRN as needed for constipation. 6. Acetaminophen 500 mg Two Tablet PO q6hrs: PRN pain as needed for pain. 7. Zolpidem 5 mg PO HS (at bedtime) as needed for insomnia. 8. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. 9. Lactulose 10 gram/15 mL Solution Fifteen ml PO every four (4) hours as needed for severe constipation. 10. Lorazepam 0.5 mg PO qHS as needed for anxiety. 11. Lidocaine 5 %(700 mg/patch) One Adhesive Patch DAILY 12. Oxycodone 5 mg PO every four (4) hours as needed for pain. 13. Guaifenesin 600 mg Tablet PO twice a day as needed for cough. 14. insulin glargine continue home dose of 12units subcut qHS 15. humalog continue previous home sliding scale 16. Warfarin 4 mg PO once a day. 17. Fluticasone 110 mcg/Actuation Aerosol Two Puff Inhalation [**Hospital1 **] 18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) One Inhalation every six (6) hours as needed for wheeze. 19. Gabapentin 300 mg One Capsule PO Q24H as needed for limb pain. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary 1. Supratherapeutic INR 2. Hypotension 3. End Stage Renal Disease on hemodialysis . Secondary 1. Chronic Congestive Heart Failure with EF 15% 2. Coronary artery disease s/p myocardial infarction 3. Left above the knee amputation 4. Hypothyroidism 5. Atrial fib Discharge Condition: Blood pressure stable and INR no longer supratherapeutic Discharge Instructions: You were admitted with a supratherapeutic INR and with decreased blood pressure. Your supratherapeutic INR was treated with fresh frozen plasma and vitamin K. Your blood pressures have improved and you have been put back on coumadin with a goal INR of [**3-19**]. . The doses of the following medications were changed: -warfarin -levothyroxine . The following medications were discontinued: -carvedilol -lisinopril -dextromethorphan-guaifenesin . The following meds were started: gabapentin . Adhere to 2 gm sodium diet Fluid Restriction to 2L . Please return to the hospital if you develop dizziness, difficulty breathing, chest pain, blood in stool, vomiting blood, blood in urine, any sign of bleeding, or any new medical condition. . Please check INR with dialysis Followup Instructions: Please follow up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks and discuss restarting your blood pressure medications. Completed by:[**2119-9-29**]

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8503, 8560

3762, 6745

328, 334

8873, 8932

2449, 3739

9751, 9908

1953, 1972

7301, 8480

8581, 8852

6771, 7278

1336, 1398

8956, 9728

1987, 2430

276, 290

362, 1319

1420, 1764

1780, 1937

18,996

164,005

17057

Discharge summary

report

Admission Date: [**2163-9-13**] Discharge Date: [**2163-9-23**] Date of Birth: [**2130-8-4**] Sex: M Service: MEDICINE Allergies: Penicillins / Shellfish Attending:[**First Name3 (LF) 30**] Chief Complaint: back pain Major Surgical or Invasive Procedure: PICC placement/removal History of Present Illness: 33 yo male with ESRD presents to ED for uncontrolled back pain. Pt seen in ED yesterday, x-ray negative, given percocet and valium and discharged home. However, he missed his HD session yesterday given that the dialysis chair exacerbates his back pain, and he returned to the ED today. He was given IV morphine and dilaudid for pain control and is being admitted to medicine for dialysis and further treatment. . In the ED, vitals were 97.6/71/108/68/16/ 100% RA. Labs revealed a creatinine of 17.7, K+ 5.1. . Pt states the pain began Sunday morning somewhat slowly but then progressed over the course of the day. He took his children to Six Flags, but limited his activity, and by the time he arrived home, he was in excruciating pain. After dc from the ED, he took the valium and 2 percocets, and was able to sleep for 2 hours before awakening again for pain. Tried to take another valium and percocet, but did not receive any relief. Pt states he has had similar pain, particularly with his hemorrhoids, in the past, but never to this degree. No new heavy lifting, no new activities. Pain is located midline L4-L5 area and then radiates to the posterior aspect of his thigh/inferior gluteus. He has also started having B/L groin pain which is new today. Describes pain as constant [**4-28**] pain with intermittent "cramps" up to [**2165-8-26**]. No numbness or tingling, is anuric from ESRD but denies any fecal incontinence, no saddle anesthesia. No recent falls or injuries. No preceding F/C/wt loss or night sweats, no rash. No recent URIs or other viral illness, no sick contacts, no myalgias, other arthralgias, or malaise. Does note rectal bleeding in the recent past [**2-19**] hemorrhoids, states that this occurs almost on a daily basis for the past year. All other ROS negative. Past Medical History: # ESRD: Secondary to membranous glomerulonephritis diagnosed on renal biopsy in [**2158**]. Has been on HD x 5 yrs, awaiting renal transplant. AVF placed in LUE in [**2161-10-30**]. # Hypertension # Hyperlipidemia # Chronic fatigue syndrome # Aortic endocarditis/abscess with MSSA, presumed secondary to HD line infection, status post aortic valve replacement in [**9-24**] (23 mm [**Doctor Last Name **] Magna aortic valve bioprosthesis. Model number 3000 TFX, serial number [**Female First Name (un) 47962**]). Post-op course complicated by aortic root abscess requiring re-do AVR/homograft on [**2161-9-29**]. Completed 6 week course of nafcillin on [**2161-11-12**]. # Bilateral subclavian vein thromboses on US in [**9-24**] # PFO, with left to right shunt across interatrial septum at rest, seen on TTE [**2161-9-29**]. # Pyloric stenosis in childhood, surgically repaired Social History: Originally from [**Male First Name (un) 1056**]. Has 3 sons. Drinks 2-3 drinks/month, continues to smoke 1ppd x10 years, no illicits. Works part-time as a teacher. Family History: mother - breast ca at 45, survivor, aunt - died of MI at 50, no other family hx of renal disease, no DM or other CA in the family Physical Exam: 95.2/ 78/ 18/ 97% on RA GEN: awake, lying semi-upright in bed, appears uncomfortable, thin HEENT: atraumatic, anicteric, dry mucosa CV: RRR, 3/6 systolic murmur, no rub NECK: no JVD LUNGS: CTA B/L with good inspiratory effort ABD: soft, nt, nd, nabs. No organomegaly or masses appreciated EXT: LUE fistula with palpable thrill and audible bruit. No [**Location (un) **]. BACK: + point tenderness over vertebral bodies L4-S1, some paraspinal tenderness B/L. No flank tenderness. Straight leg testing positive B/L. SKIN: warm, dry, no rash NEURO: A/OX3. CN II-XII intact, [**5-23**] proximal muscle strength in all 4 extremities, although + pain with active resistance in LE B/L. DTRs present and symmetric. Tactile sensation intact and symmetric B/L on LE. RECTAL: deferred for now as pt needing to go to dialysis Pertinent Results: Admission Labs: [**2163-9-13**] 06:00AM BLOOD WBC-7.2 RBC-4.16* Hgb-13.6* Hct-42.7 MCV-103* MCH-32.6* MCHC-31.8 RDW-14.8 Plt Ct-141* [**2163-9-13**] 06:00AM BLOOD Neuts-59.6 Lymphs-30.9 Monos-5.7 Eos-3.3 Baso-0.5 [**2163-9-13**] 06:00AM BLOOD Plt Ct-141* [**2163-9-13**] 05:48PM BLOOD PT-16.8* PTT-38.5* INR(PT)-1.5* [**2163-9-14**] 03:08PM BLOOD Fibrino-493*# D-Dimer-1382* [**2163-9-13**] 06:00AM BLOOD Glucose-73 UreaN-117* Creat-17.7*# Na-139 K-7.4* Cl-102 HCO3-17* AnGap-27* [**2163-9-13**] 05:48PM BLOOD ALT-20 AST-40 LD(LDH)-348* AlkPhos-116 TotBili-1.3 [**2163-9-13**] 06:00AM BLOOD Calcium-9.2 Phos-6.1* Mg-3.0* [**2163-9-13**] 05:48PM BLOOD Albumin-3.7 Calcium-8.0* Phos-3.2# Mg-1.5* [**2163-9-14**] 08:14PM BLOOD Hapto-127 [**2163-9-13**] 04:05PM BLOOD CRP-55.6* [**2163-9-14**] 03:13AM BLOOD Vanco-8.9* [**2163-9-15**] 03:28AM BLOOD Genta-4.1* Vanco-33.8* [**2163-9-14**] 11:42AM BLOOD Type-[**Last Name (un) **] pH-7.28* calTCO2-23 Dicharge Labs: [**2163-9-23**] 08:00AM BLOOD WBC-4.5# RBC-2.99* Hgb-9.7* Hct-29.1* MCV-97 MCH-32.5* MCHC-33.4 RDW-14.8 Plt Ct-187 [**2163-9-21**] 08:00AM BLOOD Neuts-63.5 Lymphs-26.3 Monos-4.5 Eos-5.5* Baso-0.2 [**2163-9-23**] 08:00AM BLOOD Plt Ct-187 [**2163-9-22**] 06:09AM BLOOD Plt Ct-167 [**2163-9-22**] 06:09AM BLOOD PT-17.5* PTT-46.1* INR(PT)-1.6* [**2163-9-23**] 08:00AM BLOOD Glucose-115* UreaN-47* Creat-11.4*# Na-141 K-3.8 Cl-99 HCO3-29 AnGap-17 [**2163-9-23**] 08:00AM BLOOD ALT-29 AST-31 LD(LDH)-258* AlkPhos-172* TotBili-0.6 [**2163-9-23**] 08:00AM BLOOD Calcium-9.1 Phos-4.8* Mg-2.3 [**2163-9-21**] 09:25PM BLOOD Genta-2.7* [**2163-9-21**] 05:27PM BLOOD Genta-<0.3* Reports: [**2163-9-12**] Cardiac MR: mpression: 1. Normal regional left ventricular systolic function with mildly increased left ventricular cavity size. The LVEF was low normal at 56%. The effective forward LVEF was minimally decreased at 53%. 2. Normal right ventricular cavity size and systolic function. The RVEF was normal at 62%. 3. Moderate aortic valve stenosis. Mild aortic regurgitation. Mild mitral regurgitation. 4. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was mildly increased. 5. Normal coronary artery origins with no evidence of anomalous coronary arteries, and normal signal characteristics of all visualized vessel segments. [**2163-9-12**] [**Month/Day/Year 47963**]: The lower lumbar spine as well as the pelvic bones are obscured by retained contrast in the bowel from a prior contrast examination; within these limitations, there is mild lumbar scoliosis convex to the left. There is no fracture. The sacroiliac joints and the hip joints are unremarkable. The bowel gas patterns appear unremarkable. CONCLUSION: No bony abnormality or fracture. [**2163-9-14**] Echo: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. No masses or vegetations are seen on the aortic valve. Moderate (2+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is mild pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. [**2163-9-14**] MR [**Last Name (Titles) 47963**]: IMPRESSION: 1. No evidence of discitis or osteomyelitis. No epidural collection. 2. At L4/5, there is a disc bulge which contacts and may impinge upon both [**Name (NI) 13032**] nerve roots in the neural foramina. 3. At L5/S1, there is a central disc extrusion which contacts the right S1 nerve root and compresses the left S1 nerve root in the lateral recesses. 4. While the imaged portion of the sacrum appears unremarkable on the current study, a thorough evaluation of the sacrum and other pelvic bones may be performed by a dedicated pelvic MRI, if clinically indicated. [**2163-9-15**] TEE: The left atrium is normal in size. Overall left ventricular systolic function is low normal (LVEF 50-55%). The aortic valve appears to be a homograft. The prosthetic aortic valve leaflets are thickened. The aortic annulus is also thickened. No masses or vegetations are seen on the aortic valve. Moderate (2+) aortic regurgitation is seen. The aortic regurgitation jet is relatively [**Name2 (NI) 15015**] and eccentric, directed against the anterior mitral leaflet. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetations is seen on the mitral valve. The tricuspid valve is normal structurally with trivial regurgitation. There is no pericardial effusion. IMPRESSION: Due to presence of thickening of valve leaflets and annulus, a focal vegetation or abscess cannot be definitively excluded. However, there is no substantial change from prior echo on [**2163-8-18**]. [**2163-9-15**] Bilateral LE US: IMPRESSION: 1. No DVT in bilateral lower extremity. 2. An approximately 2.4-cm fluid collection in the region of the left groin. Correlation with prior interventional procedures in the region of the groin is recommended. [**2163-9-17**] Unilateral UE US: FINDINGS: Grayscale and Doppler evaluation of left internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins demonstrate normal compressibility, flow, response to augmentation in the deep veins. No intraluminal thrombus was identified. Distended perijugular collateral were again noted. Limited interrogation of the left arm AV fistula demonstrates turbulent flow. There is no fluid collection or abscess surrounding the fistula site. IMPRESSION: No DVT in the left upper extremity. Persistent left perijugular collateral. [**2163-9-18**] CT Abd/Pelvis: Lung bases are clear. There is prominent gastric distention, of uncertain etiology. Contrast freely passes, and small bowel loops as well as colon are opacified. Therefore, there is no evidence of obstruction. There is no free fluid. There is no organized fluid collection. There is no free air. The lack of intravenous administration limits the evaluation of solid organs. Allowing for this limitation, there is no gross abnormality associated with the liver, pancreas, adrenals or gallbladder. The spleen is enlarged, measuring 16 cm in length. As on the previous CT, there are small, subcentimeter abdominal lymph nodes. The abdominal aorta is non-aneurysmal. The kidneys appear somewhat effaced by both the liver and the spleen. The right kidney measures approximately 9 cm in length. The left kidney measures approximately 10 cm in length. Renal sizes are stable in length when compared with the previous study of [**2161**]. Correlation with renal function is recommended. PELVIS: Bladder, prostate and seminal vessels are unremarkable. The appendix is well opacified and is normal in caliber. Within the left inguinal canal, again seen is a relatively low attenuation structure, which was also present on the study of [**2161**] and was further evaluated with scrotal ultrasound on [**2163-4-12**]. At that time, a septated cystic lesion was described. Internal features were better evaluated with ultrasound, however, there is no gross change in size. OSSEOUS STRUCTURES: There are no lytic or sclerotic lesions. Vertebral body heights and disc spaces are maintained. IMPRESSION: 1. No intra-abdominal abscess. 2. Finding in the left inguinal canal, which was better evaluated on scrotal ultrasound of [**2163-4-12**]. See above. [**2163-9-21**] US IMPRESSION: Stable examination. Small region of non-occlusive thrombus within the right internal jugular vein. No new thrombus seen. Brief Hospital Course: 33 yo male with ESRD admitted for uncontrolled acute low back pain, now w/ gram-positive cocci sepsis. # Sepsis: Micro from [**9-13**] grew out MSSA. The pt was started on Vanc/ Gent, then changed to Nafcillin, Gent, and Rifampin. Surveillance blood cultures were negative [**Date range (1) 47964**], and a repeat TEE did not show any change. An MRI of the Lumbar spine without contrast was obtained and did not show any evidence of fluid collection or abscess. It was discussed whether an MRI with contrast would be a better study, however after extensive discussion with the radiologist it was felt that this was not necessary. A CT of abdomen and pelvis was negative for abscess. The decision of the team in conjunction with ID was to treat empirically for endocarditis. There would be no imaging which would reassure enough to treat for shorter duration. The pt was found to have a RIJ clot on US. He was also noted to have a slowly decreasing WBC count which was attributed to Nafcillin. Nafcillin was changed to Cefazolin. WBC count did improve with this change. Therefore his discharge regimen will be: Cefazolin 2g at HD on M, W and Cefazolin 3g on Friday with HD. He was continue to get Gentamicin with HD - only two doses remaining at the time of discharge. He is also taking oral Rifampin for a 6 week course. He will be followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] of ID and has a prescription for surveillance CBC and LFTs while on antibiotics. At the time of discharge he remained afebrile and feeling well. . # Hypotension: The pt reports having a low blood pressure at baseline, but then became hypotensive to the 60's systolically on the day of admission following dialysis. He was transferred briefly to the ICU, and his BP stabilized with fluids and antibiotics. His ACE inhibitor and Beta-Blocker were initially discontinued, but then the ACE was resumed once his BP remained stable. Labetolol was also restarted after the patient was noted to have several measurements in the systolic 140-160s. At the time of discharge he was on Labetolol 200mg TID and will follow up with his primary care doctor next week for repeat BP check. . # Back pain- The pt presented with low back pain of acute duration. An MRI without contrast showed disc derangements at L4/L5 and disc extrusion at S1 likely causing nerve root compression. The pt did not have any signs to suggest cord compression, and his neuro exam remained normal. He was initially given IV narcotics and then transitioned to a Fentanyl patch with standing Tylenol to control his pain. The pt was able to ambulate without difficulty at discharge. . # Thrombocytopenia: The patient experienced a drop in his platelets, with a nadir of about 50. Heparin products were stopped and a HIT antibody was sent, which was negative. The platelets increased up to the 180s and remained stable, he did not show any evidence of active bleeding requiring transfusion. . # Cardiac 1. vessels- He had a cath in [**2161**] w/diffuse atherosclerosis, no flow limiting disease. He was continued on an aspirin, statin, but hi beta-blocker was held in the setting of hypotension/ sepsis. This was restarted prior to discharge. 2. pump- echo in [**7-26**] with global hypokinesis, EF 45% and cath in [**2161**] with evidence of diastolic dysfunction. His fluid balance was monitored carefully and corrected with dialysis. His ACE and beta-blocker were initially held in the setting of sepsis, but both were resumed once his blood pressure stabilized. 3. Valves- mod AR, pt recently underwent cardiac MR last week to further evaluate at the recommendations of his cardiologists. Although his repeat TEE was unchanged, it was thought that endocarditis was the most likely cause of his bacteremia and he will be treated with a 6 week course of antibiotics. He will follow-up with his cardiologist as planned at discharge. . # ESRD: He was continued on his normal dialysis schedule of MWF. He was continued on all of his renal medications, with the dialysis team following. . # Heme: he had a slow trend down in his hematocrit, although his baseline hematocrit ranges from 30-38. Given his elevated Ferritin, it was thought to be anemia of chronic disease, although difficult to acertain in acute infection. Pt also reported history of BRBPR secondary to hemorrhoids. He was placed on a bowel regimen with cortisone cream to try and prevent exacerbation of hemorrhoids. He also had evidence of a RIJ clot on US and was on a heparin drip. A repeat US showed persistent nonocclusive clot in the right IJ. After extensive discussions with the patient regarding the risk/benefits of anticoagulation in the setting of IJ clot, he decided against outpatient anticoagulation. The case was briefly discussed with Interventional Radiology regarding whether thrombectomy would be an option. They felt that this would be too high risk of a procedure given the chronicity of the clot, MSSA infection and need for multiple interventions to fully remove the clot. Therefore he did agree to full dose aspirin. He will also follow up with GI regarding his bloody bowel movements while on heparin gtt. . The patient was discharged home to complete a prolonged course of antibiotics both orally and to be given at HD. He will follow-up with the [**Hospital **] clinic, his cardiologist, and his primary care physician as planned. Medications on Admission: labetalol 200 mg TID lisinopril 20 mg 3X/WEEK on HD days, 30 mg daily all other days asa atorvastatin renagel fosrenal vitamin B complex Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer HCl 800 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). Disp:*15 Capsule(s)* Refills:*0* 11. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*5 Patch 72 hr(s)* Refills:*0* 12. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q 8H (Every 8 Hours) for 40 days: Start date [**9-20**], to complete 6 weeks. Last dose 10/7. Disp:*120 Capsule(s)* Refills:*0* 13. Cefazolin 10 gram Recon Soln Sig: [**2-20**] grams Injection HD PROTOCOL (HD Protochol): Please give 2g on M, W and 3g on F. First day [**9-17**] to complete 6 week course. Last day [**10-28**]. 14. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 16. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day) as needed for hemorrhoids. 18. Outpatient Lab Work CBC with differential to be done on Monday [**9-26**] and Friday [**9-30**] then weekly until antibiotic course is completed, LFTs done weekly beginning Monday [**9-26**], and Gentamicin peak done on Wednesday [**9-28**]. Please fax results to Dr. [**Last Name (STitle) 7443**] at [**Telephone/Fax (1) 432**] 19. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 20. Gentamicin Sulfate (PF) 80 mg/8 mL Solution Sig: Eighty (80) mg Intravenous qHD for 2 doses: Needs doses 9/8 and [**9-28**] after HD. Last dose 9/10 for total 2 weeks. Discharge Disposition: Home Discharge Diagnosis: Primary: - MSSA septicemia and prosthetic valve endocarditis - Non-occlusive right internal jugular thrombus. - Hematochezia - Leukopenia - Inguinal mass NOS - L4/L5/S1 disk herniation Secondary: - Focal segmental glomerulosclerosis c/b ESRD on hemodialysis. - Native valve MSSA aortic endocarditis and perivalvular abscess. - AVR with closure of the aortic abscess, c/b recurrent abscess and valve dehiscence requiring redo AVR with homograft aortic root replacement. - Aortic regurgitation 2+ - Bleeding diathesis NOS - Systolic heart failure - resolved - Bilateral subclavian vein thromboses on US in [**9-24**] - Hypertension - Hyperlipidemia - Pyloric stenosis in childhood, surgically repaired Discharge Condition: [**Name (NI) 14658**] pt afebrile, tolerating a regular diet. Discharge Instructions: You were admitted for low back pain and found to have a blood infection. An MRI of your back showed disc disease. You will need to complete a 6 week course of Cefazolin (first dose 8/30) with dialysis and you will need to stay on the Gentamicin (first dose 08/27) with dialysis sessions for the next 6 days. You will also be taking Rifampin for a total of six weeks (first dose [**9-20**]). You will need to have certain lab tests to monitor your blood counts and liver function while you are on the antibiotics. . Your blood pressure medication was initially discontinued when you arrived in the hospital however this was slowly restarted. You should follow up with your primary care doctor for a blood pressure check to see if this is stable. You were also noted to have a decreased white blood cell count which is being attributed to the antibiotics you were taking. The white blood cell count improved on a new antibiotic. The antibiotics were changed, however you should have a complete blood count on Monday to ensure it continues to be normal. You will also need surveillence blood tests while you are on antibiotics to check your blood counts and liver function tests. A prescription for this blood work has been provided for you. You had bright red blood in your stools while on anticoagulation. You should follow up with gastroenterology as an outpatient for this issue. Please return to the emergency room or call your doctor if you experience worsening back pain, difficulty walking, fevers or chills. Followup Instructions: You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**], of Infectious Disease, on [**2163-9-28**] at 9AM. Phone:[**Telephone/Fax (1) 457**] . You have an appointment with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Monday [**2163-9-26**] at 440PM. If you have any questions please call [**Telephone/Fax (1) 250**]. You may benefit from physical therapy for your back pain. You should also have your blood drawn the day of your appointment with Dr. [**Last Name (STitle) **]. This is to check your white blood cell count.

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Discharge summary

report

Admission Date: [**2134-3-21**] Discharge Date: [**2134-4-15**] Date of Birth: [**2087-11-5**] Sex: M Service: MEDICINE Allergies: Cephalosporins / Morphine / Fentanyl Attending:[**First Name3 (LF) 2297**] Chief Complaint: somnolence, hypoxic resp failure Major Surgical or Invasive Procedure: R femoral line, now d/c'd right Midline [**3-27**] by IR History of Present Illness: 46 y/o M w/ h/o morbid obesity, COPD, chronic trach dependence, DMII, PVD, s/p L BKA, h/o Klebsiella/Proteus UTI, PNA, MRSA, VRE, who presents with increasing somnolence and hypoxic respiratory failure . Presented to [**Location (un) 620**] ER in respiratory distress, hypoxic to 40's at home. T to 101.Trach noted to have copius secretions, which were aggressively suctioned, given o2, nebs, antibiotics (zosyn/vanco). Improved respiratory status, but still somnolent and also noted to be hyperkalemic at 6.4. No EKG changes. Given Insulin/D50, calcium IV. Kayexalate ordered (but not given PTA). Also had positive troponin of 0.05 (nL <0.01). Acidotic at 7.16 w/ CO2 of 65. Therefore placed on VENT for transport to [**Hospital1 18**]. U/A at OSH pos for WBC >100, Bacteria, neg nitr, Lge leuk's. Hct 31.7, WBC 15.6, Plt 358, 84.5%N. Creat 2.6. . Also as patient was leaving, patient care technician who cares for patient at home says he may have fallen the night PTA. . In ED here. Vitals on arrival T99.8, BP 119/51, RR 16, 99% on Vent. Vanco infusing. BP's subsequently dropped to 80's syst-> then 69/34. Recieved 2L NS IVF PTA and given 1 more L NS in ED. Started on dopa gtt at 5mcg/kg/min, titrated up to 10 mcg/kg/min. BP initially up to 100's systolic, then back down to 80's. Changed to levophed gtt. ASA 325mg given. Trach tube changed to Portex 6.0, cuffed to Vent 600/100/16/5. BP subsequently up to 150's systolic. . Vanco given at 1700. Zosyn 4.5 gm prior to arrival at 1415. Also given 10 U Insulin, 1 amp D50, 1 gm Ca Gluconate. R Femoral line placed under U/S guidance. EKG w/ NSR. Nl axis. TWI V1, 1mm ST elev 2. . Recent admission [**1-8**] for presumed urosepsis. . Past Medical History: 1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low as 0.8 in the last couple of years, however widely fluctuant, as high as 2 in the recent past. 0.9 in [**1-7**]. 2) COPD, on home O2. Multiple episodes of respiratory failure requiring intubation in recent years. Most recently, was admitted in [**12-6**] with a perforated transverse colon requiring partial colectomy and transverse colostomy. This course c/b anticipated respiratory failure and anticipatory tracheostomy, pseudomonal and MRSA PNA. Also with acalculous cholecystitis requiring cholecystostomy tube. Had G-tube placed. 3) OSA on CPAP 3) VRE 4) s/p tracheostomy, as above in [**1-7**] 5) HTN 6) CHF: During hospitalization in [**10-20**] it was thought that failure contributed to his respiratory failure. Last echo was in [**12-6**] at which time LVEF thought to be roughly normal, however very poor study and RV not visualized. Not on lasix. 7) Anemia of chronic disease, multiple transfusions in the past 8) s/p BKA for chronic LE ulcer 9) TIA in [**2125**]. 10) Difficult intubation; fiberoptic guidance in [**Month (only) 359**] of [**2131**]. 11) Urinary retention. 12) Osteoarthritis. 13) Depression. 14) C. Difficile in [**2129**]. 15) Hypogonadism. 16) Morbid obesity . PAST SURGICAL HISTORY: 1. Bilateral carpal tunnel release in [**2123**]. 2. Hydrocele repair in [**2126-4-3**]. 3. Quadriceps tendon repair in [**2127**]. 4. Status post partial resection of transverse colon, end transverse colostomy, mucus fistula, jejunostomy tube and percutaneous tracheostomy on [**2132-12-16**]. Social History: Lives home alone with VNA. Denies etoh. Remote cigar smoking, no cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **]. Family History: Non-contributory Physical Exam: Physical Exam- T 99.8, BP 107/38, HR 75, RR 24, 100% AC 24 x 600. 100FiO2. 10 PEEP Gen- sleepy but arousable to voice HEENT- Pupils equal and reactive 3->2 b/l. OP Clear Neck- trach in place, no purulent secretions PUlm- Ant w/ coars b/s b/l. no focal ronchi or rales CV- distant heart sounds, RRR. no m/r/g ABD- b/l osteomies intact w/o erythema. midline erythematous scar tissue w/o ulceration. Ext- 2+ pedal edema on R. R dist LE cellulitis w/o ulceration. L BKA w/o cellulitic change. stump clean BAck- no sacral decub. small area of erythema on R upper buttocks dressed w/ guaze Neuro-able to grip hands b/l= equal strength. wiggles R toes. sticks out tongue. opens eyes to voice. Pertinent Results: Radiology: ======== CXR [**4-12**]: Tracheostomy tube, nasogastric tube, and right PICC line remain in place, with a right PICC line continues to terminate in the right subclavian vein. Cardiac silhouette remains enlarged, and there is persistent increased pulmonary vascularity as well as perihilar haziness and bilateral moderate pleural effusions. Overall, there has not been a significant change in degree of CHF. . LENI RLE [**4-12**]- IMPRESSION: Technically difficult exam, but no evidence for DVT . TTE [**4-5**]: Suboptimal technical quality. 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 chamber size is normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. PICC [**2134-3-25**]- IMPRESSION: 1. The tip of the right-sided PICC line in the distal portion of the right subclavian vein. 2. Moderate congestive heart failure with cardiomegaly and small bilateral pleural effusion. Bibasilar patchy atelectasis . LENI B/L LE's- IMPRESSION: No evidence for DVT. . Micro Data: ========== [**2134-3-26**] 7:04 am SPUTUM Source: Expectorated. **FINAL REPORT [**2134-3-30**]** GRAM STAIN (Final [**2134-3-26**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2134-3-30**]): SPARSE GROWTH OROPHARYNGEAL FLORA. CITROBACTER KOSERI. SPARSE GROWTH. WORK-UP REQUEST PER DR . This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER KOSERI | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- <=1 S 8 S CEFTAZIDIME----------- 4 S 32 R CEFTRIAXONE----------- 16 I CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S 2 S IMIPENEM-------------- <=1 S =>16 R LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S 8 I PIPERACILLIN---------- =>128 R 64 S PIPERACILLIN/TAZO----- 64 I 64 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R . [**2134-3-22**] 1:52 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2134-3-26**]** GRAM STAIN (Final [**2134-3-22**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2134-3-26**]): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. PSEUDOMONAS AERUGINOSA. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- 16 I CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S 2 S IMIPENEM-------------- 8 I LEVOFLOXACIN---------- =>8 R MEROPENEM------------- 8 I OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- 64 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TOBRAMYCIN------------ <=1 S VANCOMYCIN------------ <=1 S . [**2134-3-22**] 1:52 am URINE **FINAL REPORT [**2134-3-24**]** URINE CULTURE (Final [**2134-3-24**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. 2ND ISOLATE. <10,000 organisms/ml. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . . Sputum [**4-5**]: GRAM STAIN (Final [**2134-4-11**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2134-4-14**]): OROPHARYNGEAL FLORA ABSENT. ACINETOBACTER BAUMANNII. HEAVY GROWTH. PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- 16 I 16 I CEFTAZIDIME----------- =>64 R =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 2 S 2 S IMIPENEM-------------- 8 I 8 I LEVOFLOXACIN---------- 4 I MEROPENEM------------- 8 I PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 46 y/o M w/ h/o morbid obesity, chronic trach dependence secondary to OSA, DMII, PVD, s/p L BKA, h/o Klebsiella/Proteus UTI, MRSA/VRE pneumonias, who initially presented with increasing somnolence and hypoxic respiratory failure. This was felt to be secondary to MRSA pneumonia which was treated with a course of vancomycin and Klebsiella UTI which was treated with Zosyn. He responded well to antibiotic therapy and was weaned off ventilatory support. However, he subsequently re-developed hypoxic respiratory failure. The cause of this second episode was felt to be multi-factorial from aspiration pneumonia, pulmonary edema, de-recruitment of alveoli given body habitus and developement of a new right pleural effusion. He was treated with an 8 day course of meropenem for ventilator associated pneumonia and he was diuresed to improve his pulmonary edema. Recruitment maneuvers, including intermittent APRV ventilation, were used to bridge him through hypoxic episodes. In addition, intervential pulmonary re-positioned his trach on [**4-2**] after it was found to be obstructed against the posterior wall of his trachea. . A brief hospital course by problem is also outlined below: . 1. Hypoxic Respiratory Failure: Initially admitted for hypoxic respiratory failure with evidence of pneumonia on CXR with associated fever and leukocytosis. Sputum culture revealed evidence of MRSA in addition to Pseudomonas (S to Zosyn), and he was treated with a 10 day course of Vanco/Zosyn with good resolution of hypoxia. He was weaned off ventilatory support and was doing well on trach collar whe he developed a subsequent episode of hypoxia, with oxygen saturation transiently in the 60's, improved with bag-mask ventilation and placement back on the ventilator. This second episode was thought to be multifactorial. He had evidence of aspiration pneumonitis/pneumonia clinically and radiographically and he was initially continued on vancomycin and zosyn as above. After completion of this course of antibiotics he continued to demonstrate hypoxia. Therefore repeat sputum culture was performed which also demonstrated citrobacter organism that was resistant to zosyn, but sensitive to meropenem. Given his worsening clinical condition he was additionall treated with a course of meropenem antibiotics. Secondly, he had evidence of pulmonary edema on CXR which was felt to be contributing to his respiratory distress. Therefore he was diuresed initially with a lasix drip and then daily boluses IV. He diuresed well, over 1L negative per day. Over this hospital course he had also inadvertantly pulled out his trach and it was replaced emergently with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] #6. He did well with this new trach, however did have one episode of acute obstruction on [**4-2**] where it was found to be lodged against the posterior wall of the trachea, causing near 80% obstruction of air flow. This was re-positioned by interventional pulmonary with subsequent resolution of flow. Lastly, he also developed an increasing R pleural effusion, suspected secondary to CHF. A right sided thorocentesis was performed with drainage of 1500cc. The fluid was c/w a parapneumonic effusion. Of importance, he also had lower extremity non-invasive ultrasounds to r/o DVT, which were negative, helping to argue against pulmonary embolism. However due to size he was not able to undergo CT angiogram and V/Q scan was felt to be sub-optimal as well, especially while on the ventilator. It was felt that the other on-going issues, as described above, were more likely the cause of his acute hypoxic episodes and therefore he was not anti-coagulated with heparin. His most recent CXRs have been c/w pulmonary edema and bilateral pleural effusions. He has diuresed well with Lasix 80mg IV QD making him negative >1L per day. His oxygenation has improved with weaning of his vent settings. On discharge he was on PS [**12-10**], FiO2 of 50%. This should continue to be weaned as he becomes more euvolemic with diuresis. . It is also important to note that his hypoxic episodes were often concurrent with a large component of anxiety. In fact his anxiety was difficult to treat throughout his hospital course. While it was not likely completely causative of his hypoxia, it certainly exacerbated this acute episodes. He was placed on standing clonazepam, which he took as outpatient. In addition, he was given prn doses of zyprexa and evening trazadone. . 2. Somnolence: He initially presented very somnolent, minimally responsive to sternal rub and not able to follow commands. This was felt to be a mixed picture from hypercarbia, infection (pneumonia, UTI) and hypoxia. ABG w/ CO2 at 65. He had improvement of his mental status after correcting his hypercarbia/hypoxia and treating underlying infectious processes. Upon improvement of his mental status he was found to have no focal neurologic deficits. Although he had intermittent episodes of lethargy in the setting of oversedation (particularly after morphine), he was largely awake and alert for the remainder of his hospital course. . 3. Hyperkalemia: Initially hyperkalemic, with potassium of 7. Likely exacerbated by acidemia and acute renal failure. This was treated aggressively with D50, Insulin, Calcium, Kayexalate, and bicarbonate. In addition, the hypercarbic component was corrected through controlled ventilation. EKG demonstrated no peaked T's or interval widening throughout and he had no dysrythmia on telemetry monitoring. Potassium subsequently normalized and was not an issue the remainder of his hospital course . 4. ARF: 2.6 on admission, which was up from 0.9 1 year prior. BUN also elevated, with pre-renal physiology (FeNa =0.3%, BUN:Cr ratio >20). No evidence of ATN by urine sediment. He was initially treated aggressively with IV fluid repletion. Nephrotoxic agents were held and medications were renally dosed. Creatinine subsequently improved to 1.0-1.1. He had a second episode of ARF to 2.0 during his hospital course which subsequently improved to 1.4 on discharge with diuresis . 5. Troponin Leak: Max troponin 0.09 (upper limit <0.10) with flat CK/MB. He also had non-specific ST changes by EKG without any acute ischemic changes. He was continued on ASA, STATIN, B-Blocker. Heparin was held as he never had evidence of acute coronary syndrome. . 6. Hypotension/SIRS: Early sepsis (distributive) vs hypovolemic hypotension on admission. SIRS criteria including tachypnea, leukocytosis of 16,000. Lactate was 2.4 on admission and systolic blood pressure improved after 3 liter NS IVF. He was transiently placed on low dose pressors with levophed to maintain MAP >65, with lactate rising to a peak of 4.8. Pressors were weaned off after adequate IVF repletion and lacate normalized. Suspected sourse of infection included pneumonia and UTI. Importantly, blood cultures remained negative throughout. His blood pressure remained wnl during the rest of his hospital stay. His labetolol and captopril were added back to his antihypertensive regimen. . 7. Anemia of Chronic Disease: Baseline hematocirt appears to be around 29, which is where he was at on admission. There was a spurious level of 12 on admission, however repeat checks did not corroborate this level. He had no signs of active bleeding and hematocrit remained stable, although fluctuated from 22-26, seeming to correlate with volume status. Iron studies were checked and were felt to be consistent with anemia of chronic disease. He was started on iron on this hospital stay. He was placed on EPO for 1 week until his creatinine improved and then it was d/c'd. He was guiac negative. . 8. DM2: Initially placed on insulin drip for tight glycemic control. He was subsequently re-started on glargine with sliding scale insulin for breakthrough control. On admission he was on 44 units [**Hospital1 **]. This was adjusted based on blood glucose levels as needed [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. Hi insulin was titrated up to Glargine 60 u [**Hospital1 **] with SSI QID . 9. Hypertension: Systolic blood pressures were noted as high as 200's-220's. Often in the setting of anxiety, however it was also suspected that he also had a component of difficult to control essential hypertension. His blood pressure medications were titrated up, with BP's subsequently controlled in 100's-110's. Initially he was on metoprolol, but his was changed to standing labetolol with good effect. His BP was controlled on Labetolol and Captopril . 10. Emesis: Transient nausea, vomiting for 1 day, thought to be secondary to gastroparesis, exacerbated from recent hyperglycemia. He was placed on IV reglan w/ improved nausea. Erythromycin also used transiently, then stopped because of new rash. Reglan was then titrated off as pt was not having any residuals from his TF. . 11. Nutrtion: During most of his hospital course, pt received TF from an NGT. His prior PEG had been d/c'd before admission as pt was tolerating pos. Nutrition was consulted and he had a video swallow test on PS [**12-10**], 50% with no signs of aspiration on direct visualization. He can tolerate a full diet. . 12. ID: Pt has grown multiple resistant organisms from his sputum including MRSA, Pseudomonas, Citrobacter and Acinetobacter. He was treated with a course of Vanco/Zosyn and then Meropenem for a VAP. On discharge, he had scant sputum, was afebrile and showed no signs of focal infiltrates on CXR. He also has grown resistant Klebsiella from his urine which was treated. He recently had a negative UA with a Ucx growing G-rods thought to be a colonizer as he was afebrile without an elevated WBC. His foley was changed on [**4-14**]. On [**4-13**], vancomycin was started for a 7 day course for a RLE cellulitis. A vancomycin trough should be checked [**4-14**] before his evening dose and dose adjusted accordingly. His cellulitis looked improved on d/c. . 13. Code status: Full code . 14. Contact and HCP: brother [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 28633**] . 15. PPX: heparin sc TID, PPI, bowel regimen, HOB elevated > 30, peridex oral care . 16. Access: Midline placed by IR on [**3-27**] Medications on Admission: Paxil 40mg 9am, 5pm Trazadone 100mg qhs prn MOM 30cc prn Vicodin q 4 prn APAP 650mg q4 prn Klonopin 0.5mg [**Hospital1 **] prn FS QID: SS humalog Lopressor 75mg 9 am , 9pm Flonase 2 spray [**Hospital1 **] prn senna 2 tabs [**Hospital1 **] prn neurontin 600mg 6am, 2pm, 10pm pulmocort 1 puff by mouth 9am,9pm Heparin SQ TID Reglan 10mg QID Albuterol/Atrovent by mouth QID Lantus 44 units SC qam, qhs Humalog SS Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg PO Q12H (every 12 hours). 5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day). 8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**1-4**] Tablet, Sublinguals Sublingual PRN (as needed) as needed for chest pain. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fluticasone 110 mcg/Actuation Aerosol Sig: Eight (8) Puff Inhalation [**Hospital1 **] (2 times a day). 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 8-10 Puffs Inhalation QID (4 times a day). 14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) ml PO DAILY (Daily). 15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 16. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold if sbp<100, pulse<55. 17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 18. Clonazepam 1 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 20. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 21. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): hold if sbp<90. 22. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Ten (10) ML Intravenous DAILY (Daily) as needed. 23. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg Injection Q6H (every 6 hours) as needed. 24. Lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4 hours) as needed. 25. Furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection DAILY (Daily). 26. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 7 days. 27. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty (60) units Subcutaneous twice a day: see additional sliding scale order. 28. Humalog 100 unit/mL Cartridge Sig: as dir units Subcutaneous four times a day: Sliding Scale FS<60 give oj, [**Name8 (MD) 138**] md FS61-120 mg/dL: 0 units 121-160 mg/dL: 2 units 161-200 mg/dL 4 201-240 mg/dL 6 241-280 mg/dL 8 281-320 mg/dL 10 321-360 mg/dL 12 361-400 mg/dL 14 >400 [**Name8 (MD) 138**] md. 29. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Pneumonia Obstructive Sleep Apnea Diabetes type 2 COPD Urinary tract infection Anemia Acute renal failure Peripheral vascular disease diastolic chf Discharge Condition: stable Discharge Instructions: Please check vanco level before next dose ([**4-14**]) Please check electrolytes qod and replete lytes as needed check hematocrit two times a week and more often if falling from in hospital value to HCT 22.8. Transfuse if <21 Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 22882**] within 2 weeks [**Telephone/Fax (1) 28634**] Completed by:[**2134-4-14**]

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icd9cm

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icd9pcs

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36014

Discharge summary

report

Admission Date: [**2109-11-3**] Discharge Date: [**2109-11-27**] Service: MEDICINE Allergies: Hydrochlorothiazide Attending:[**First Name3 (LF) 4365**] Chief Complaint: hepatobiliary sepsis and liver abscess Major Surgical or Invasive Procedure: Percutaneous drain placed in liver History of Present Illness: Mr. [**Known lastname 10940**] is an 84 year old male with a history of coronary artery disease, ischemic cardiomyopathy, PVD, and type 2 DM who was initially transferred to [**Hospital1 18**] from [**Hospital **] Hospital on [**11-3**] with hepatobiliary sepsis and possible liver abscess after presenting with 1 week of fevers and chills, abdominal cramping, and anorexia. He was initially admitted to [**Hospital **] Hospital on [**2109-11-3**]. His initial labs were concerning for obstructive hepatitis and biliary sepsis with elevated WBC, LFTs including alk phos and Tbili with elevated direct fraction. He also had elevated Trop to 0.78 and acute renal failure with Cr 2.7. He had a 5.4 cm liver lesion concerning for abscess. He was admitted and covered with broad spectrum antibiotics including zosyn and flagyl. He also received NS hydration. He was then transferred to [**Hospital1 18**] for further management. Upon arrival to [**Hospital1 18**], labs again confirmed picture of obstructive hepatopathy with leukocytosis to 16,000 and ARF with Cr 2.7. Troponin was elevated here on arrival as well but CKs were negative. Other labs revealed anemia to 32 and no evidence of DIC. RUQ u/s here showed multiple liver lesions, largest in L lobe concerning for abscess. Surgery was consulted and recommended a triple phase CT scan to prep for possible percutaneous drain placement. He was continued on zosyn and flagyl here and also had vancomycin added. On the evening of transfer, after returning from CT scan, patient began rigoring, became tachycardic to the 150s, hypothermic to 96 and then spiked a temp to 101.2. He maintained his SBPs in 130s-140s. O2 requirement increased to 5L NC and his skin was diffusely mottled. At the time of evaluation on the floor, rigoring had stopped and he felt improved. However, tachycardia persisted despite fluid bolus. He was transferred to the ICU and upon arrival to ICU, required intubation and was briefly on pressors. During his time in the ICU a percutaneous drain was placed in his liver by general surgery. Eventually the patient was extubated and hemodynamically stable enough to be transferred to the floor. Past Medical History: # CAD # Ischemic cardiomyopathy, EF 40% # DM II # Hypertension # Hypercholesterolemia # prior liver cyst in L lobe # PVD s/p bilateral aortoiliac stenting # Cataract s/p prior surgery. # Gout Social History: >60 pack-year smoking history, quit 4 years ago. Denies EtOH or drug use. Married. Retired microwave engineer. Family History: No history of stomach or hepatobiliary cancer. Physical Exam: Physical Exam on Transfer to the Floor: PE 97.5, 156/66, 68, 95% on 5L, wt 70.4, BG 143 Gen: Asian male, week, polite HEENT: nasal feeding tube in place, moist MM CV: Regular. Tachy. Normal S1 and S2. pulses 2+. Chest: wheezes at bases, no egophany, no rhonchi or crackles ABD: +BS, NT, Soft, small dry dressing on upper abdomen EXT: no c/c/e. NEURO: strength 3/5 in lower extremities, CN intact, A and O x 3 Pertinent Results: ADMISSION LABS: [**2109-11-3**] 10:11PM WBC-16.0* RBC-3.93* HGB-12.3* HCT-35.3* MCV-90 MCH-31.2 MCHC-34.7 RDW-13.9 [**2109-11-3**] 10:11PM NEUTS-87.4* LYMPHS-9.2* MONOS-1.7* EOS-1.1 BASOS-0.7 [**2109-11-3**] 10:11PM PLT COUNT-441* [**2109-11-3**] 10:11PM PT-14.2* PTT-31.9 INR(PT)-1.2* [**2109-11-3**] 10:11PM GLUCOSE-240* UREA N-56* CREAT-2.4* SODIUM-134 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-17* ANION GAP-17 [**2109-11-3**] 10:45PM LACTATE-5.6* [**2109-11-3**] 11:50PM LACTATE-9.0* [**2109-11-3**] 06:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2109-11-3**] 06:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-TR [**2109-11-3**] 06:35PM URINE RBC-21-50* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2109-11-3**] 03:34PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE IgM HAV-NEGATIVE [**2109-11-3**] 03:34PM HCV Ab-NEGATIVE ------------------ MICRO: [**2109-11-3**] 10:00 pm BLOOD CULTURE Source: Line-central 2 OF 2. **FINAL REPORT [**2109-11-7**]** Blood Culture, Routine (Final [**2109-11-7**]): KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [**2109-11-4**]): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Doctor Last Name 17975**] AT 307 [**2109-11-4**]. Aerobic Bottle Gram Stain (Final [**2109-11-6**]): GRAM NEGATIVE ROD(S). [**2109-11-4**] 4:06 pm ABSCESS Source: liver abcess. GRAM STAIN (Final [**2109-11-4**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2109-11-7**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2109-11-10**]): NO GROWTH. FUNGAL CULTURE (Final [**2109-11-17**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2109-11-5**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): -------------------- [**2109-11-5**] 1:57 pm ABSCESS Source: abd abscess drainage FROM WOUND DRAIN. **FINAL REPORT [**2109-11-18**]** GRAM STAIN (Final [**2109-11-5**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2109-11-8**]): GRAM POSITIVE RODS. RARE GROWTH. UNABLE TO IDENTIFY FURTHER. ANAEROBIC CULTURE (Final [**2109-11-11**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Final [**2109-11-18**]): NO FUNGUS ISOLATED. --------------- PATHOLOGY: [**11-4**] FNA, Liver abscess: NEGATIVE FOR MALIGNANT CELLS. Abundant neutrophils and debris with rare group of epithelioid cells, probably reactive mesothelial cells --------------- IMAGING STUDIES: CT Abdomen/Pelvis [**2109-11-5**]: 1. 5-cm cystic lesion within the left lobe of the liver, with suggestion of internal heterogeneity. Concurrent ultrasound demonstrates marked internal debris and multi-septations. While this lesion is incompletely characterized without IV contrast, this is concerning for a hepatic abscess. Additional vague hypodensities in the caudate lobe may also reflect additional abscesses. Differential diagnosis for these lesion inludes necrotic metastases, although this seems less likely. The large lesion in the left lobe is amenable to aspiration/catheter drainage. (The latter was discussed with Dr. [**First Name (STitle) **] on monday [**11-4**] at 11:46AM by Dr. [**Last Name (STitle) **] 2. Foci of air within the bladder, with a Foley catheter in place. Several locules of air appear somewhat peripheral in location. This may be located within the lumen of the bladder related to instrumentation; however, correlation with a UA is recommended to exclude associated cystitis. 3. Diverticulosis without diverticulitis. 4. Hypodensities in bilateral kidneys, too small to characterize. -------------------- Abdominal Ultrasound [**2109-11-4**]: Multiple, predominantly hypoechoic liver lesions with largest lesion located within the left lobe. Given son[**Name (NI) 493**] features, this dominant lesion most likely represents an abscess. In the right clinical circumstances, this could represent a echinoccochal cyst with associated daughter cysts. Recurrent pyogenic cholangitis is another possibility given the history of elevated bilirubin although in the abscence of biliary dilatation, this diagnosis is much less likely. MRCP and/or ERCP are recommended for further evaluation. 2. Cholelithiasis without evidence of acute cholecystitis. -------------------- [**2109-11-6**] CT Abdomen and Pelvis - 1. The left lobe of liver catheter is well positioned, with near complete resolution of the left hepatic lobe abscess. 2. Multiple small additional hepatic collections are not amenable to percutaneous drainage at this time. There are several tiny adjacent collections within the caudate lobe, which are not amenable to percutaneous drainage. 3. Interval development of small bilateral pleural effusions, ascites, and left basilar consolidation. -------------------- Liver Ultrasound [**2109-11-22**] IMPRESSION: Stable appearing liver. There is a small residual cavity which is not hypervascular and the appearance is not suggestive of an expanding abscess. Chest XRAY [**2109-11-23**]: IMPRESSION: Increase in interstitial [**Doctor Last Name 5926**] suggesting failure. Brief Hospital Course: 84 year old male with a history of coronary artery disease, ischemic cardiomyopathy, PVD and DM [**Hospital **] transferred from [**Hospital **] Hospital with hepatobiliary sepsis and liver abscess. #. Klebsiella Bacteremia/Severe Sepsis: The patient initally presented to OSH where he was found to have fever, leukocytosis. RUQ US showed a cystic hepatic mass concerning for infection. He was started on zosyn and flagyl and transferred to [**Hospital1 18**]. On arrival to [**Hospital1 18**] vancomycin was added and CT A/P was obtained demonstrating a 5-cm cystic lesion. Shortly after transfer he became febrile and hemodynamically unstable and was transferred to MICU where he was intubated and started on pressors. Blood cultures from [**11-3**] grew Klebsiella. ID was consulted and cipro was added as well as a one time dose of gentamicin. Source control for liver abscess as below. The patient was extbuated after 12 days with eventual wean of pressors. Vancomycin was discontinued on [**11-13**]. Zosyn was discontinued on day 19 of treatment due to eosinophilia and new onset low grade fever and meropenem was begun. Following this antibiotic change the patient remained afebrile. The plan for the patient's antibiotic regimen at time of discharge is to discontinue meropenem and begin ertapenem. He is scheduled to complete ertapenem on [**2109-12-19**] (this will complete a total of a 6 week course of antibiotics). Patient scheduled to follow up in infectious disease clinic on [**2110-1-2**]. #. Liver abscess: The patient was started on Zosyn as above and switched to meropenem. He underwent CT guided drainage of left lobe liver abscess on [**2109-11-4**]. Cultures from drainage yielded no growth. He underwent repeat CT A/P on [**11-6**] demonstrating near complete resolution of the left hepatic lobe abscess and multiple small additional hepatic collections which were not amenable to percutaneous drainage. The drain was removed prior to the [**Hospital 228**] transfer from the MICU to the floor. As noted above, he will be transitioned to ertapenem for daily dosing upon discharge and complete a total of 6 weeks of antibiotics on [**2109-12-19**]. He is scheduled to have a repeat liver ultrasound on [**2109-12-16**] at 10:15 am (should be NPO for 6 hrs prior to study). #. Hypoxemic Respiratory Failure: Pt was intubated in the setting of sepsis as above. He developed significant volume overload from fluid resuscitation and ARF. Following the resolution of his sepsis he was diuresed with lasix and weaned from ventilator. His oxygen requirements continued to improve with lasix 40mg IV daily and he was transitioned to oral lasix at time of discharge- lasix 80 mg daily up from home dose of 20 mg daily. Patient continued to require 3L of oxygen via nasal cannula- O2 sat at rest 94-96% on 3L. Patient's oxygen should continue to be weaned as tolerated and lasix may need to be adjusted to ensure proper level of diuresis. Can also continue nebulizer treatments as needed. #. Acute renal failure: Patient developed acute renal failure in the setting of sepsis likely related to overwhelming infection and hypovolemia. Creatinine peaked at 2.7 and has since stabilized at 1.3. Renal function should continue to be monitored closely and medications should be renally dosed. #. Hypertension: Following resolution of sepsis patient was started on Carvedilol to 25mg [**Hospital1 **]. He was also started on hydralazine 50mg po TID with the expectation that he would be transitioned to an ACE inhibitor when his kidney function improved. Patient's home regimen of metoprolol, amlodipine and clonidine were discontinued. At time of discharge patient's blood pressure remained in a normotensive range. Hydralazine was discontinued and he was started on lisinopril 10 mg daily. The lisinopril will likely need to be titrated up. In summary, anti-hypertensive regimen now consists of carvedilol and lisinopril which should also benefit his heart failure. #. Anemia of Chronic Disease: Patient requried two packed red blood cell transfusions during this admission. Following transfusions Hct remained stable. Iron studies indicated anemia of chronic disease given Fe:64, Ferritin:507*, TIBC:229*. Hct stable 27-29 at time of discharge. #. Systolic CHF: ECHO on [**2109-11-4**] demonstrated EF 30-35%. As noted above, while intubated the patient developed significant volume overload secondary to fluid resucitation while he was septic. The patient was successfully extubated. Patient continued on 40 mg IV lasix daily in order to continue diuresis. CXR on [**2109-11-23**] continued to show persistent failure. Patient transitioned to 80 mg oral lasix daily. He was also continued on carvedilol and started on lisinopril. #. Type II Diabetes Mellitus: Patient's outpatient glipizide held during this admission. Pt initiated on glargine 20 units qhs in addition to a humalog sliding scale which was likely necesitated [**12-23**] being on TF. The morning of discharge patient's blood sugar dropped to 29 from 140 in the pm (though he did get 2 of humalog) which likely reflects that glargine dose too high. We recommend reduced glargine from 20 units qHS to 10 units qHS. This may need to be titrated up if am blood sugar continue to run high. Patient will likely need outpatient medication changes given he was only on glipizide coming in. #. Gout: During this admission patient's allopurinol held given acute renal failure and significantly reduced GFR. On day prior to discharge patient developed discomfort on the plantar surface of his left great toe but no joint pain, swelling or erythema. Seems unlikely that this pain represents a gout flare. Given improved renal function patient restarted on allopurinol 100mg daily. Giving percocet for pain control. Would suggest monitoring for any evidence of acute flare developing. #. Speech and Swallow Evaluation: Upon initial evaluation speech and swallow team felt patient had severe oral-pharyngeal dysphagia and recommended that an NG tube be placed and he remain NPO. Patient was advanced to purees and nectar thickened liquids with supervision and with chin tuck manuever with 1:1 supervision. A calorie count was instituted. NG was removed when patient able to take enough calories PO to maintain good nutrition. A repeat video swallow on [**2109-11-26**] indicated that diet could be advanced to Soft (dysphagia); Thin liquids A. 1:1 supervision for all POs. , B. CHIN TUCK for ALL swallows, liquids and solids., C. Alternate bites and sips., D. Provide cues and reminders as needed to use Chin Tuck. # Hematuria: Pt had hematuria following foley removal likely [**12-23**] trauma. This resolved. #. Vitamin D Deficiency: On admission patient reportedly taking ergocalciferol 5000 units daily. Unclear how long he has been on this regimen. Would suggest changing to vitamin D 800 mg daily and rechecking a hydroxyvitamin D. #Gastroesophageal reflux disease: Stable during this admission. Omperazole changed to pantoprazole while patient unable to take NPO. Changed back to omeprazole at time of discharge. # BPH: Pt continued on his outpatient regimen of tamsulosin Patient was a FULL code during this admission. Medications on Admission: Aspirin 325mg Daily Allopurinol 100mg Daily Glipizide 2.5mg Daily Ergocalciferol 5000 units daily Furosemide 20mg Daily Metoprolol 25mg Daily Omeprazole 20mg Daily Amlodipine 10mg Daily Atorvastatin 80mg Daily at night Tamsulosin 0.04mg Daily at night Clonidine dose unknown Fish Oil Discharge Medications: 1. Ertapenem 1 gram Recon Soln Sig: One (1) Intravenous once a day for 22 days: Last dose on [**2109-12-19**]. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for 7 days: apply to groin . 5. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed. 6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Insulin Glargine 100 unit/mL Solution Sig: 10 units Subcutaneous at bedtime: may need to be titrated up. 13. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous QACHS: per sliding scale. 14. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 16. Liver U/S scheduled for [**12-16**] at [**Hospital1 18**] Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Primary: Klebsiella bacteremia, Liver Abscess, Acute Renal Failure, Respiratory Failure Secondary: Hypertension, Type II Diabetes Mellitus, Gout, Anemia of chronic disease Discharge Condition: stable, afebrile Discharge Instructions: You were transferred to this hospital because you were found to have an infection involving your liver. You were intitially in the ICU and required intubation. You received intravenous fluids and intravenous antibiotics. Your condition stabilized, you were extubated and transferred to the medical floor. We continued your antibiotics for the infection in your blood and liver. We also monitored your kidney function which was initially impaired, but has now improved. You will need to continue taking this antibiotic until [**2109-12-19**]. You will also need to have a repeat ultrasound of your liver which we have scheduled for [**2109-12-16**]. You were started on the following new medications: -Ertapenem: this is an antibiotic that you will need to continue until [**2109-12-19**] -Lantus: this is a type of insulin that you need for blood sugar control. your doctors at rehab [**Name5 (PTitle) **] decide whether you will continue this medication when you go home. -Humalog: this is a short acting insulin that also acts to control your blood sugar again, your rehab doctor will determine if you need to go home on this medication. -Lisinopril: this is a blood pressure medication -Carvedilol: this is a blood pressure medication -Vitamin D 800 mg daily The following changes have been made to your medications: -Your lasix dose was increased to 80 mg. This may be altered when you leave rehab. The following medications have been stopped: -metoprolol -amlodipine -clonidine -ergocalciferol If you experience fevers, chills, sweats, chest pain, or difficulty breathing please contact your primary care condition or go to the emergency department for evaluation. Followup Instructions: Provider: [**Name Initial (NameIs) 706**] (Liver Ultrasound )Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2109-12-16**] 10:30. [**Hospital1 18**] [**Hospital Ward Name 517**] [**Location (un) **]. Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD (Infectious Disease) Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2110-1-2**] 10:30 You will need to schedule a PCP follow up when patient is ready to leave rehab Completed by:[**2109-11-27**]

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icd9cm

[ [ [] ] ]

[ "50.91", "99.04", "96.72", "96.04" ]

icd9pcs

[ [ [] ] ]

18556, 18636

9495, 16704

267, 303

18852, 18871

3358, 3358

20593, 21078

2864, 2912

17040, 18533

18657, 18831

16730, 17017

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2927, 3339

6060, 6838

189, 229

331, 2504

3374, 6027

2526, 2720

2736, 2848

6856, 9472

58,653

133,485

18872

Discharge summary

report

Admission Date: [**2117-12-6**] Discharge Date: [**2117-12-10**] Date of Birth: [**2054-7-21**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2117-12-6**] Coronary artery bypass grafting x 3, left internal mammary artery graft, left anterior descending, reverse saphenous vein graft to the marginal branch of the posterior descending artery. History of Present Illness: This is a 63 year old male who presents with exertional dyspnea and chest tightness. Recent stress test was positive for ischemia. Subsequent cardiac catheterization revealed severe three vessel coronary artery disease. He was referred for surgical revascularization. [**2117-11-18**] Cardiac Catheterization @ [**Hospital1 **]: Right dominant. Mid LAD 60%, ramus 80%, circumflex 70%, RCA 90% @ origins of the PDA and PLV. LVEF 59%. Mean wedge pressure of 15mmHg. [**2117-11-17**] Cardiac Echocardiogram: LVEF 60-65%. Trivial MR. [**First Name (Titles) **] [**Last Name (Titles) 6878**] aortic root and ascending aorta, measuring about 3.9cm. Past Medical History: Hypertension Dyslipidemia Chronic Renal Insufficiency(preop creatinine 1.3) Hypothyroidism Past Surgical History: Lumbar surgery [**2113**] Left hand surgery Social History: Race: Caucasian Last Dental Exam: N/A Lives: Alone Occupation: Retired Tobacco: Denies ETOH: Social Family History: Mother with MI in late 60's Physical Exam: Pulse: 80 Resp: 18 O2 sat: 98% B/P Right: 125/94 Left: 122/85 Height: 5'[**17**]" Weight: 226 General: Well-developed male in no acute distress Skin: Warm[X] Dry [X] intact [X] HEENT: NCAT[X] PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema - Varicosities: Superficial Neuro: Grossly intact [X] 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: - Left: - Pertinent Results: [**2117-12-10**] 04:55AM BLOOD WBC-9.5 RBC-3.00* Hgb-9.3* Hct-27.7* MCV-92 MCH-31.1 MCHC-33.6 RDW-13.9 Plt Ct-222# [**2117-12-6**] 11:10AM BLOOD Fibrino-231 [**2117-12-10**] 04:55AM BLOOD Glucose-118* UreaN-34* Creat-1.1 Na-137 K-4.1 Cl-97 HCO3-33* AnGap-11 [**2117-12-9**] 12:11PM BLOOD ALT-15 AST-23 LD(LDH)-207 AlkPhos-56 Amylase-29 TotBili-0.4 [**2117-12-9**] 12:11PM BLOOD Albumin-3.7 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2117-12-6**] where the patient underwent coronary artery bypass grafting x 3, left internal mammary artery graft, left anterior descending, reverse saphenous vein graft to the marginal branch of the posterior descending 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 breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. 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 home with visiting nurse services in good condition with appropriate follow up instructions. Medications on Admission: Diltiazem 240 daily, Lisinopril 10 daily, Simvastatin 40 daily, Gemfibrozil 600 twice daily, Aspirin 81 daily, Levothyroxine 100 mcg daily, Omeprazole 20mg daily, Bupropion 100mg TID, Glucosamine, Vitamin E Allergies: NKDA Discharge Disposition: Home with Service Discharge Diagnosis: Coronary Artery Disease s/p cabg Hypertension Dyslipidemia Chronic Renal Insufficiency(preop creatinine 1.3) Hypothyroidism Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema ................ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call 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) **] [**12-30**] @ 1:45pm Cardiologist: Dr [**Last Name (STitle) 14522**] on [**1-4**] at 9:45am Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**4-26**] weeks [**Telephone/Fax (1) 30837**] **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:[**2117-12-10**]

[ "403.90", "414.01", "585.9", "244.9", "272.4", "458.29", "413.9" ]

icd9cm

[ [ [] ] ]

[ "36.12", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

4265, 4284

2698, 3990

343, 548

4452, 4697

2284, 2675

5621, 6137

1536, 1566

4305, 4431

4016, 4242

4721, 5598

1356, 1402

1581, 2265

283, 305

576, 1220

1242, 1333

1418, 1520

14,995

102,432

9880+9898

Discharge summary

report+report

Admission Date: [**2102-9-18**] Discharge Date: [**2102-9-30**] Service: CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old man with history of dilated cardiomyopathy since [**2094**] which was diagnosed in [**Hospital6 1129**], at which time his catheterization revealed an ejection fraction of 38% with no coronary artery disease. Over the last several years he has been followed with echocardiogram which has revealed worsening of his congestive heart failure. He also has 3+ aortic regurgitation, 3+ mitral regurgitation and had pacemaker placement in [**2101-12-7**] for marked AV conduction delay. He has had several admissions for congestive heart failure between [**12/2101**] and [**6-6**] and did reasonably well for approximately 6-8 weeks in regimen of Hydralazine and diuretics. Over the last 5 months had deterioration with several visits to the Emergency Room at CCH. Major reason for the Emergency Room visits was shortness of breath. He had a sleep study which revealed obstructive sleep apnea and therefore was started on C-PAP approximately two weeks prior to admission but did not tolerate it well. On [**9-16**] he was transferred from CCH to [**Hospital3 4527**] and had pacemaker interrogation which showed conversion from normal sinus rhythm to atrial fibrillation. The patient was started on Heparin and received one dose of Coumadin. Now he has been transferred to [**Hospital1 69**] for transesophageal echo and plan for cardioversion biventricular pacing. PAST MEDICAL HISTORY: Significant for atrial fibrillation with recent onset, cardiomyopathy diagnosed in [**2094**] with an EF of 38%. Echocardiogram in [**2097**], [**Month (only) 404**], revealed an EF of 45% with mild aortic regurgitation and mitral regurgitation with diffuse hypokinesis. In [**2100-10-6**] he had an EF of 45% with severe mitral regurgitation. In [**2102-5-7**] ejection fraction of less than 20% with severe aortic regurgitation and mitral regurgitation as well as left ventricular dilatation. In [**2101-10-7**] he had a DDD pacemaker placed for AV synchrony. He had an abdominal aortic aneurysm repair in [**2093**], history of anemia, combined iron deficiency and chronic disease and he is status post cholecystectomy. Also has a history of severe pulmonary hypertension, obstructive central mixed sleep apnea, gout. MEDICATIONS: On admission, Reglan 10 mg q d, Heparin 1,000 units per hour, Iron Sulfate 325 mg q d, Ambien 5 mg q d, Probenecid 250 mg [**Hospital1 **], Vitamin E 400 IV q d, K-Dur 40 mEq q d, Spironolactone 25 mg [**Hospital1 **], Lasix 80 mg [**Hospital1 **], Zaroxolyn 5 mg [**Hospital1 **], Hydralazine 50 mg tid, Imdur 60 mg q h.s., Digoxin 0.125 mg q d, Carvedilol 25 mg [**Hospital1 **], Colchicine 0.6 mg [**Hospital1 **], Lescol 30 mg q d, Protonix 20 mg q d and Mag Oxide 400 mg [**Hospital1 **]. REVIEW OF SYSTEMS: Positive for shortness of breath, anorexia over the past two days prior to admission. He denied chest pain, headache, nausea, vomiting, diarrhea, fever, chills, numbness. PHYSICAL EXAMINATION: On admission he was afebrile with blood pressure of 102/48, pulse 64, respirations 18 to 20. He appeared comfortable, with no distress. HEENT: Pupils are equal, round, and reactive to light, bilateral ptosis which is noted to be longstanding. Neck, positive JVD but no carotid bruits. Cardiac, S1 and S2, normal with a [**3-14**] holosystolic murmur at the apex and a 1-2/6 diastolic murmur at the left lower sternal border. No gallops. Lungs were clear to auscultation. Abdomen soft, nontender, non distended with active bowel sounds. Extremities, positive for edema, positive pedal pulses. Neuro exam, normal motor exam, 1+ DTRs bilaterally and [**Name2 (NI) 14451**] toes. LABORATORY DATA: On admission were notable for hematocrit approximately 32.4, potassium approximately 3.2 and T3 of 35 with TSH of 1.3. Dig level 1.8. Echocardiogram done on [**9-19**] revealed an EF of 15% with marked left atrial enlargement and right atrial enlargement with patent foramen ovale, left ventricular dilatation and 2+ aortic regurgitation, moderate to severe mitral regurgitation, no major changes since the echocardiogram done in [**2102-5-7**]. HOSPITAL COURSE: The patient was admitted to the C-Med service and then transferred from the C-Med service to the CCU on [**9-20**] for invasive hemodynamic monitoring and optimization of his cardiovascular status. He had a transesophageal echocardiogram and subsequent unsuccessful cardioversion, was started on Amiodarone with plan to reattempt cardioversion in [**5-12**] weeks. The decision was made to delay biventricular pacing at that time given his atrial fibrillation and suboptimal hemodynamics. Instead he was brought to the CCU for invasive hemodynamic monitoring with Milrinone therapy. Throughout his hospital course, as far as his pump function was concerned, he was put on a Milrinone drip which was increased to 5 mcg/minute and successfully increased his cardiac output and cardiac index in the [**6-11**] and 2-3 range. He was able to then be given Lasix intravenously and often Diuril followed by Lasix with successful diuresis and lost approximately 2 liters per day while he was on the Milrinone drip. He was then switched to Captopril and his Coreg was started as well as low dose Digoxin. His Captopril was increased to a max dose of 100 mg tid and then it was changed to Mavik 4 mg po for once a day dosing. His cardiac function remained stable, however, he became dry last few days of admission with decreased po intake and continued po diuresis with Lasix and his Lasix dose was held on [**2102-9-19**] and po intake was encouraged to keep him euvolemic. As far as his coronaries were concerned, he remained AV paced for most of his stay in CCU with his DDD pacemaker. He was switched to Amiodarone po 400 mg q d and was given Heparin until the date of discharge at which point his Coumadin became therapeutic and that was stopped. Pulmonary wise he had severe pulmonary edema on admission and had an oxygen requirement, however, this improved markedly with his diuresis and over the last few days of his hospital course he had no oxygen requirement whatsoever, was satting well on room air. Renal, his BUN and creatinine decreased to 1.9 creatinine and this later increased after being transferred from the unit up to 2.7, most likely secondary to dehydration and intravascular depletion. However, remained stable on discharge with move towards euvolemic status. GI, he had occasional bouts of loose bowel movements. Because of this his Reglan was held at times. He continued to have poor po intake and for this reason a swallowing study was done which revealed no abnormalities in swallowing except for some poor chewing and suggestion was made for soft diet with lots of fluid supplement. As far as his gout was concerned he was treated initially with Probenecid and Colchicine. The Probenecid was stopped because of his renal function. Colchicine was continued for treatment of his gout. Other issues: Insomnia, he was given Trazodone because Ambien was ineffective in inducing sleep in this patient. The patient was started on Effexor because of depression and was seen by physical therapy and case management because of decreased strength compared to his baseline. Plan was made for transfer to rehab facility. DISCHARGE STATUS: Stable. DISCHARGE PLAN: Transfer to [**Hospital **] Rehab Facility on [**2102-9-30**] on the following medications: Amiodarone 400 mg po q d, Lipitor 20 mg po q d, Mag Oxide, Vitamin E, K-Dur, Iron Sulfate, Reglan, Coreg 3.125 mg po bid, Digoxin 0.0625 mg po q d, Lasix 80 mg po bid, Colchicine, Zaroxolyn 2.5 mg three times a week, Effexor, Metamucil, Mavik 4 mg po q d, and Coumadin 2.5 mg po q d. His attending will be contact[**Name (NI) **] and he will have follow-up with him and his primary care physician. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 6069**] MEDQUIST36 D: [**2102-9-29**] 16:08 T: [**2102-9-29**] 21:15 JOB#: [**Job Number 31395**] cc:[**Hospital 33158**] Admission Date: [**2102-9-18**] Discharge Date: Service: ADDENDUM: This is a STAT addendum to the Discharge Summary previously done on Mr. [**Known lastname 33205**]. DISCHARGE DIAGNOSES: 1. Dilated cardiomyopathy. 2. Renal insufficiency. 3. Insomnia. 4. Depression. DISCHARGE STATUS: Transfusion to [**Hospital **] Rehabilitation. MEDICATIONS ON DISCHARGE: 1. Effexor 37.5 mg p.o. b.i.d. 2. Metamucil one to two teaspoons p.o. q.d. 3. Mavik 4 mg p.o. q.d. 4. Coumadin 2.5 mg p.o. q.h.s. (hold doses until Monday because INR was 4.9; please check coagulations on Monday morning and dose Monday evening as appropriate; but no dose of Coumadin on Saturday or Sunday). 5. Amiodarone 400 mg p.o. q.d. 6. Lipitor 20 mg p.o. q.h.s. 7. Magnesium oxide 400 mg p.o. q.d. 8. Vitamin E 400 IU p.o. q.d. 9. K-Dur 40 mEq p.o. q.d. 10. Iron sulfate 325 mg p.o. q.d. 11. Reglan 10 mg p.o. q.a.c. 12. Coreg 3.125 mg p.o. b.i.d. 13. Digoxin 0.0625 mg p.o. q.d. (please hold until Monday; first dose on Monday; no doses on Saturday or Sunday as digoxin level was 1.9 when last checked). 14. Lasix 80 mg p.o. b.i.d. (please call covering physician to adjust Lasix dose as the patient's weight increases or decreases). 15. Colchicine 0.6 mg p.o. q.d. 16. Trazodone 50 mg p.o. q.h.s. p.r.n. for insomnia. DISCHARGE PLAN: The plan was to go to rehabilitation, lots of exercise, and increase p.o. intake, and was to follow up with Dr. [**Last Name (STitle) 121**] as Dr. [**Last Name (STitle) 121**] sees fit. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 6069**] MEDQUIST36 D: [**2102-9-30**] 09:41 T: [**2102-9-30**] 10:09 JOB#: [**Job Number 33206**]

[ "780.52", "414.01", "280.9", "585", "416.0", "428.0", "396.3", "427.31", "425.4" ]

icd9cm

[ [ [] ] ]

[ "99.61", "88.72", "38.93", "42.23" ]

icd9pcs

[ [ [] ] ]

8476, 8628

8655, 9614

4300, 7476

3129, 4282

2933, 3106

102, 124

153, 1553

9631, 10083

1576, 2913

71,921

135,295

34378

Discharge summary

report

Admission Date: [**2177-9-28**] Discharge Date: [**2177-10-6**] Date of Birth: [**2105-12-7**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: s/p Motor vehicle crash vs. pole Major Surgical or Invasive Procedure: ORIF right femur & acetabular fractures IVC filter placement History of Present Illness: 71 male driver, s/p motor vehicl crash vs. telephone pole. ?LOC prior to crash. He was transported to an area hospital and becasue of his extensive injuries he was transferred to [**Hospital1 18**] for further care. Past Medical History: Depression CAD s/p coronary stent x2, s/p peripheral arterial stent Social History: Married, lives with wife Family History: Noncontributory Physical Exam: Upon admission: T 97.3, HR 105, BP 100/p, RR 20, SpO2 95% +deformity RLE L hand: 4 cm long and 2 mm deep laceration on volar aspect of MCP joint crease wrapping around base of L thumb. Some bruising on radial aspect of volar and dorsal surface of L hand. Good capillary refill in thumb. Good flexion/extension of thumb at IP joint. Sensation intact in median, ulnar, and radial nerve distributions. Pertinent Results: [**2177-9-28**] 08:25PM CK(CPK)-2672* [**2177-9-28**] 08:25PM CK-MB-16* MB INDX-0.6 cTropnT-0.11* [**2177-9-28**] 10:30AM GLUCOSE-153* UREA N-33* CREAT-2.0* SODIUM-138 POTASSIUM-6.1* CHLORIDE-104 TOTAL CO2-23 ANION GAP-17 [**2177-9-28**] 10:30AM WBC-13.6* RBC-3.64* HGB-11.6* HCT-33.1* MCV-91 MCH-31.8 MCHC-34.9 RDW-14.8 [**2177-9-28**] 10:30AM PLT COUNT-230 [**2177-9-28**] 03:20AM PLT COUNT-270 [**2177-9-28**] 03:20AM PT-13.4 PTT-24.3 INR(PT)-1.2* [**2177-9-27**] 10:18PM UREA N-23* CREAT-1.2 [**2177-9-27**] 10:18PM cTropnT-0.22* [**2177-9-27**] 10:18PM ASA-NEG ETHANOL-11* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CT Pelvis [**2177-9-28**] IMPRESSION: 1. Comminuted impacted fracture dislocation of the right femur. The right femur is dislocated posteriorly. The femoral shaft is dislocated posteriorly and laterally with respect to the proximal fracture fragment. In addition, there is a markedly comminuted fracture involving all three columns of the acetabulum with marked comminution and multiple intra-articular fracture fragments. 2. Additional fractures involved the right and left superior pubic rami, right inferior pubic ramus, and left inferior pubic ramus extending to the ischial tuberosity. 3. Nondisplaced left sacral alar fracture, which does not involve the neural foramen. Cardiology Report ECG Study Date of [**2177-9-27**] 10:25:50 PM Sinus rhythm Leftward axis Inferolateral ST-T changes are nonspecific No previous tracing available for comparison Intervals Axes Rate PR QRS QT/QTc P QRS T 94 160 82 328/387 71 -24 86 CT head [**2177-9-28**] IMPRESSION: No acute intracranial abnormality. Mild thickening of the right maxillary sinus. Please note that there is contrast in the vessels from prior CT abdomen which limits sensitivity for subtle hemorrhage. ECHO [**2177-9-30**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.5 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.13 m/s > 0.08 m/s Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 24 Findings LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Hyperdynamic LVEF >75%. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. No MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is elongated. 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. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with vigorous/hyperdynamic biventricular global systolic function. Carotid Series [**2177-10-1**] IMPRESSION: 1. No right ICA stenosis, there is a mild stenosis involving the right CCA, however. 2. No significant left ICA stenosis. Brief Hospital Course: He was admitted to the Trauma Service. He was transferred to the Trauma ICU for close monitoring. A syncope workup was also initiated (see Pertinent results section). Orthopedics and Plastic Surgery were consulted given his injuries. His left hand laceration was irrigated and sutured in the Emergency department. He was taken to the operating room on [**2177-9-29**] for ORIF of his RLE fractures; there were no intraoperative complications. Postoperatively he was transferred to the regular nursing unit where he remained. Lovenox was started per Orthopedics recommendation. he did have a hematocrit drop as a result of the hip surgery and was transfused with 1 unit packed cells; his post transfusion hematocrit was 34.1, up from 23 pre-transfusion. Given that he will be non weight bearing on the right leg the decision was made to place an IVC filter; this was done on [**2177-10-3**]. He did have some periods of confusion felt most likely related to delirium given his injuries and some of the medications he received for pain and sedation. A sitter was put into place and these were eventually discontinued as his mental status cleared significantly. He was evaluated by Physical therapy and is being recommended for rehab. Medications on Admission: ASA 325', Plavix 75', Depakote Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO HS (at bedtime). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for HR <60; SBP <110. 9. Enoxaparin 40 mg/0.4 mL Syringe Sig: 0.4 ML's Subcutaneous Q 24H (Every 24 Hours) for 3 weeks. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML's PO Q8H (every 8 hours) for 5 days. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: s/p Motor vehicle crash Right inferior pubic ramus fracture Right posterior hip dislocation Right proximal femur and acetabulum fractures Rib fractures on left Left hand laceration Acute blood loss anemia Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: The Lovenox injections will continue for another 3 weeks per Orthopedics recommendation. Followup Instructions: Follow up in 2 weeks, in [**Hospital 5498**] Clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP, call [**Telephone/Fax (1) 1228**] for an appointment. Please request for a Tuesday morning appointment. Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery, call [**Telephone/Fax (1) 6429**] for an appointment. Clinic is held on Tuesday's. Request to coordinate with Orthopedics appointment. Follow up this week in Plastic Surgery Hand clinic, call [**Telephone/Fax (1) 5343**] for an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2177-10-6**]

[ "882.0", "807.00", "414.01", "V45.82", "E815.0", "285.1", "835.00", "808.0", "820.22" ]

icd9cm

[ [ [] ] ]

[ "79.85", "86.59", "38.7", "79.39", "79.35" ]

icd9pcs

[ [ [] ] ]

8739, 8819

5949, 7185

347, 409

9068, 9148

1256, 5926

9285, 9991

804, 821

7268, 8716

8840, 9047

7211, 7245

9172, 9262

836, 838

275, 309

437, 654

852, 1237

676, 746

762, 788

73,040

139,526

28507

Discharge summary

report

Admission Date: [**2194-8-7**] Discharge Date: [**2194-8-26**] Date of Birth: [**2140-8-11**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Transfer from OSH for necrotizing pancreatitis Major Surgical or Invasive Procedure: None History of Present Illness: 53F with a history of pancreas divisum and recurrent pancreatitis transferred from [**Hospital 1474**] hospital with acute pancreatitis. Last night around 6pm, the patient reports she had acute onset of nausea, non-bilious vomiting, diarrhea, and abdominal pain. The emesis and diarrhea were non-bloody. She has had 6 episodes of vomiting and 4 episodes of diarrhea since last night. She has not eaten anything since yesterday evening. She states that these symptoms felt typical of her prior episodes of pancreatitis and that she attempted to take PO dilaudid at home. Her abdominal pain is diffuse and constant; it does not radiate. She rates the pain an [**8-26**]. Her vomiting and pain persisted, and she then presented to the [**Hospital 1474**] Hospital ED last night. . At the OSH this morning, her vital signs were 97.8 110 136/99 18 96% on RA. An EKG showed sinus tachycardia. Her WBC was 21, Hct rose from 41 to 49.8. Lipase was 1400, Amylase 1096, LDH 308, Glc 261, transaminases WNL. She had a contrast abd CT that was read as: diffusely enlarged head and body of pancreas with demonstration of extensive diffuse peripancreatic fat stranding, edema, and free fluid, consistent w/ acute pancreatitis. Portions of the pancreatic head, body, and proximal tail fail to enhance, consistent with necrotizing pancreatitis. Ascites is present. She was treated with IVF, pain control with dilaudid, and Imipenem 500 mg q8h. The decision was made to transfer the patient to [**Hospital1 18**]. . Upon arrival to the floor, vitals were 97.0 113 118/80 17 91% on RA, 96% on 2L. She was dry appearing on exam and in mild distress due to pain. Initial labs were notable for WBC 26.4, Hct 47.7, Glc 233, normal AST ,LD 415, and lipase of [**2092**]; Calcium 8.3. Past Medical History: - Pancreas divisum - HTN - Recurrent pancreatitis x 6; most recent ~1 year ago - Osteoporosis - s/p ERCP with stent on [**2192-5-1**]; removed [**2192-5-11**] - s/p tubal ligation Social History: -lives in [**Hospital1 1474**], MA with her husband - works as a maid with [**Name (NI) 60400**] Maids - Tobacco: no - etOH: no - Illicits: no Family History: - Mother: died at 76 from MI, also HTN, DM - Father: HTN, died at 57 from perforated ulcer - 3 healthy children Physical Exam: VS: 97 113 118/80 17 91% on RA; 96% on 2L GEN: lying in hospital bed with towel over forehead, states she is in pain; alert and oriented x 3 HEENT: dry mucus membranes, PERRL, EOMI, JVP 5 cm, neck is supple, no cervical, supraclavicular, or axillary LAD CV: hyperdynamic precordium, tachycardic, regular; systolic ejection murmur heard best at 2nd left intercostal space PULM: CTAB ABD: normoactive bs, soft, diffusely mildly TTP, no masses or HSM, no stigmata of chronic liver disease LIMBS: No LE edema, no tremors or asterixis, no clubbing SKIN: No rashes or skin breakdown NEURO: CNII-XII nonfocal, strength 5/5 of the upper and lower extremities, reflexes 2+ of the upper and lower extremities, toes down bilaterally On Discharge: VS: 98.3, 88, 116/78, 18, 98% RA Gen: NAD, mildly depressed HEENT: NC/AT, PERRL, EOMI, neck supple, mucus membranes moist CV: RRR, no m/r/g Lungs: Diminished b/l ABD: Soft, ND/NT, normoactive BS x 4 Extr: Warm, +PP, no c/c/e Pertinent Results: [**2194-8-7**] 11:22PM GLUCOSE-233* UREA N-28* CREAT-1.0 SODIUM-136 POTASSIUM-5.4* CHLORIDE-103 TOTAL CO2-20* ANION GAP-18 [**2194-8-7**] 11:22PM estGFR-Using this [**2194-8-7**] 11:22PM ALT(SGPT)-22 AST(SGOT)-31 LD(LDH)-415* ALK PHOS-59 TOT BILI-1.2 [**2194-8-7**] 11:22PM LIPASE-[**2092**]* [**2194-8-7**] 11:22PM ALBUMIN-4.4 CALCIUM-8.3* PHOSPHATE-2.5* MAGNESIUM-1.6 [**2194-8-7**] 11:22PM WBC-26.4*# RBC-5.28 HGB-16.4*# HCT-47.7# MCV-91 MCH-31.1 MCHC-34.4 RDW-13.0 [**2194-8-7**] 11:22PM PLT SMR-NORMAL PLT COUNT-235 [**2194-8-7**] 11:22PM PT-13.4 PTT-24.4 INR(PT)-1.1 [**2194-8-10**] 05:19AM BLOOD WBC-13.1* RBC-3.51* Hgb-10.9* Hct-31.2* MCV-89 MCH-31.2 MCHC-35.0 RDW-13.2 Plt Ct-132* [**2194-8-10**] 05:19AM BLOOD Glucose-229* UreaN-15 Creat-0.4 Na-138 K-4.0 Cl-106 HCO3-27 AnGap-9 [**2194-8-10**] 05:19AM BLOOD ALT-12 AST-20 AlkPhos-58 Amylase-193* TotBili-2.2* [**2194-8-15**] 06:00AM BLOOD calTIBC-207* Ferritn-863* TRF-159* [**2194-8-20**] 05:33AM BLOOD WBC-35.7*# RBC-3.49* Hgb-10.6* Hct-30.4* MCV-87 MCH-30.4 MCHC-34.9 RDW-13.5 Plt Ct-507* [**2194-8-20**] 05:33AM BLOOD Glucose-277* UreaN-19 Creat-0.4 Na-130* K-4.4 Cl-96 HCO3-24 AnGap-14 [**2194-8-20**] 05:33AM BLOOD ALT-17 AST-21 AlkPhos-116* Amylase-444* TotBili-0.6 [**2194-8-26**] 05:41AM BLOOD WBC-15.8* RBC-2.81* Hgb-8.5* Hct-25.4* MCV-90 MCH-30.2 MCHC-33.4 RDW-14.1 Plt Ct-431 [**2194-8-26**] 05:41AM BLOOD Glucose-134* UreaN-18 Creat-0.3* Na-135 K-4.6 Cl-105 HCO3-22 AnGap-13 [**2194-8-26**] 05:41AM BLOOD Amylase-175* [**2194-8-26**] 05:41AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.8 [**2194-8-25**] 06:07AM BLOOD calTIBC-215* Ferritn-681* TRF-165* MICROBIOLOGY: [**2194-8-8**] 3:02 am URINE Source: CVS. **FINAL REPORT [**2194-8-9**]** URINE CULTURE (Final [**2194-8-9**]): NO GROWTH. [**2194-8-8**] 4:24 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2194-8-14**]** Blood Culture, Routine (Final [**2194-8-14**]): NO GROWTH. [**2194-8-16**] 9:28 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2194-8-17**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2194-8-17**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2194-8-22**] 5:57 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2194-8-23**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2194-8-23**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 69073**] @ 0539 ON [**2194-8-23**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). RADIOLOGY: [**2194-8-8**] CHEST PORT: FINDINGS: No previous images. There are low lung volumes. Atelectatic changes are seen at both bases. In the appropriate clinical setting, the possibility of supervening pneumonia could be considered. [**2194-8-18**] CT ABD: IMPRESSION: 1. Extensive peripancreatic fat stranding. Significant pancreatic fluid collections appear more organized when compared to [**2194-8-7**] study, without evidence of a pseudocyst formation. 2. A 9-mm saccular focus of enhancement near splenic artery, most likely represents a pseudoaneurysm. Portal vein, SMV and splenic vein appear patent. 3. Interval resolution of ascites. [**2194-8-25**] CHEST CTA: IMPRESSION: No evidence of pulmonary embolism. New small bibasal pleural effusions and atelectasis. [**2194-8-21**] EKG: Sinus tachycardia. Possible prior septal myocardial infarction, age undetermined. Compared to the previous tracing of [**2194-8-8**] the findings are similar. Brief Hospital Course: 53 y/o female with recurrent pancreatitis [**2-18**] pancreas divisum, transferred from [**Hospital 1474**] Hospital with acute pancreatitis and report from OSH of necrotizing pancreatitis. Patient was admitted on General Surgery Service for evaluation and treatments. Patient's lipase was [**2092**], and amylase - 338 on admission. . Pancreatitis: Thought to be [**2-18**] the patient's known pancreas divisum. On transfer from OSH, the patient showed evidence of intravascular hemoconcentration and met [**3-21**] initial [**Last Name (un) **] criteria. Her CBC, lipase, Chemistry inc. calcium, liver function tests, blood and urine cultures were followed. She received aggressive IV fluid resuscitation. Her nausea was controlled with Zofran and her pain with q3 Dilaudid. On [**2194-8-8**] PICC line was placed and nutrition consult was called for TPN recommendations. Patient was started on TPN on [**2194-8-9**]. On [**2194-8-11**] patient was started on sips of clears, and her diet was advanced to clears on [**2194-8-12**]. Later on [**8-12**], patient complained increase abdominal pain, and she was changed back to sips only, and later she was made NPO. On [**2194-8-14**] patient diet was advanced to sips, and on [**2194-8-15**] - to clear liquids. Patient tolerated clears well and on [**8-16**] her diet was advanced to full liquids. On [**8-17**], patient's diet was advanced to regular. Patient was able to tolerate only small amount of regular food, her abdominal pain increased dramatically, patient was made NPO. On [**8-19**], patient diet advanced to clears, and later changed back to NPO [**2-18**] increased abdominal pain. On [**2194-8-18**] patient underwent abdominal CT scan, which demonstrated significant pancreatic fluid collections without evidence of a pseudocyst formation. Patient's diet was advanced to sips of clears on [**8-24**], and advanced to clears on [**8-26**]. Patient was continued on TPN throughout hospitalization, her TPN was cycled prior discharge. Patient was discharged on continue TPN as outpatient, she will follow up with Dr. [**Last Name (STitle) **]. Patient will have an abdominal CT scan prior her follow up appointment. On discharge patient's lipase was 193, and amylase 175. . Pain control: The patient received IV Dilaudid 2-4 mg Q3H on admission for pain control. When her pain improved, her dose was decreased to 0.5-1.0 mg with good effect. with good effect and adequate pain control. Patient was required breakthrough Dilaudid for spikes of pain. When tolerating oral intake, the patient was transitioned to oral pain medications. . CV/HTN: On admission patient had sinus tachycardia and she was placed on telemetry to monitor her heart rate. After aggressive fluid resuscitation, patient heart rate converted to regular. Patient continue to have episodes of sinus tachycardia, especially with increased pain or anxiety. Patient takes on 15 mg of Lisinopril to control her HTN at home. While in hospital, she was found to have BP 180s-100s, and she was started on IV Metoprolol with minimal effect. Her BP continue to be high, she was started on IV Hydralazine PRN for SBP > 160. Eventually, patient's BP became well controlled with this regiment. When tolerated PO medication, patient was started on PO Metoprolol 50 mg [**Hospital1 **], and her BP remained WNL. Patient recommended to follow up with PCP after discharge to continue monitor her BP. . Pulmonary: Chest xray revealed bilateral atelectasis on admission. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. On [**2194-8-24**] patient developed rapid onset of the pleuritic chest pain and tachypnea, patient underwent chest CTA which showed no evidence of pulmonary embolism. Chest pain resolved spontaneously. Patient remained stable from pulmonary stand point. . GU: Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. . Leukocytosis/C-diff: On admission, patient's WBC was found to be 26.4. Urine and blood cultures were sent for microbiology evaluation, and they were negative. Patient was afebrile during hospitalization. WBC was tranding down until patient tried regular diet and her abdominal pain increased. Patient's WBC spiked up to 25.7 on [**8-15**] and stool was sent for c-diff. Stool result was negative on [**2194-8-16**]. On [**2194-8-20**] patient's WBC went up to 35.7, patient remained afebrile. Stool was sent for c-diff, and at this time was positive. Patient was started on Ciprofloxacin PO x 14 days total. . Hyperglycemia: Patient doesn't have a history of diabetes, reports been hyperglycemic during acute pancreatitis in the past. Patient was started on TPN and since that patient blood sugar increased to 250-300. Insulin was increased in TPN, and patient was started insulin sliding scale. It was noticed that, when patient's abdominal pain is better her blood sugar is better as well. Prior discharge insulin teaching was initiated and patient demonstrated good progress. Patient will be discharge on TPN, she will continue to use insulin sliding scale at home. Patient's lab will be followed weekly by [**Hospital1 18**] team. Patient instructed to contact her PCP or [**Name9 (PRE) **] Surgery team if she will have any questions regarding her insulin/blood sugar level. Patient educated about hypo/hyper glycemia signs and symptoms . Hematology: The patient's complete blood count was examined routinely; no transfusions were required. . Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Lisinopril 15', Fosamax qmonth Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Insulin Regular Human 100 unit/mL Solution Sig: 6-20 units Injection as directed. Disp:*2 vial* Refills:*2* 6. Insulin Syringe-Needle U-100 [**1-18**] mL 29 X5/16 Syringe Sig: One (1) syringe Miscellaneous as directed. Disp:*1 box* Refills:*2* 7. Alcohol Prep Swabs Pads, Medicated Sig: One (1) pad Topical as directed. Disp:*1 box* Refills:*2* 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 12 days. Disp:*36 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Home Solutions Infusion Therapy Discharge Diagnosis: 1. Acute pancreatitis 2. Pancreas divisum 3. Hyperglycemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. 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 [**5-26**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you PICC Line: *Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is significantly soiled for further instructions. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2194-9-5**] 10:45 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**] Date/Time:[**2194-9-5**] 11:30 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **] . Please follow up with Dr. [**Last Name (STitle) **] (PCP) regarding you blood pressure control or if you have any questions about insulin sliding scale Completed by:[**2194-8-26**]

[ "577.1", "577.0", "789.59", "427.89", "401.9", "V58.67", "518.0", "577.8", "276.2", "250.00", "733.00", "008.45" ]

icd9cm

[ [ [] ] ]

[ "99.15", "38.93" ]

icd9pcs

[ [ [] ] ]

14805, 14867

7506, 13580

359, 365

14970, 14970

3658, 7483

17370, 17869

2543, 2657

13661, 14782

14888, 14949

13606, 13638

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2672, 3399

3413, 3639

273, 321

393, 2164

14985, 15097

2186, 2367

2383, 2527

56,390

179,240

50573

Discharge summary

report

Admission Date: [**2200-3-14**] Discharge Date: [**2200-4-2**] Date of Birth: [**2116-6-4**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: Pneumonia Major Surgical or Invasive Procedure: Intubation for mechanical ventilation History of Present Illness: 83M with esophageal CA, recent admission for FTT, pneumonia. The patient was sent from nursing home, reportedly ill-appearing. We do not yet have any history from his facility, [**Hospital3 537**]. I have left a message with the nurse on duty. The patient's sister reports that he had been treated for pneumonia two weeks ago at [**Hospital3 **]. (Our records suggest the patient was discharged on [**2200-3-3**], but not treated for pneumonia at that time.) The patient did have a prescription for levaquin in his records from [**Date range (1) 105283**], so he probably was diagnosed with pneumonia recently. His sister spoke to him the day before this hospitalization and says he sounded fine. He was able to go to lunch and dinner that evening. The patient's sister also reports that his usual nuring support could not reach him due to the inclement weather this week. . In the ED, the patient was tachycardic, hypoxic on RA on arrival. He was brought in looking unwell, hypoxic, and with altered mental status. In addition, the patient was exteremly cachectic. The patient's CXR showed PNA and he received vancomycin, levaquin, zosyn (recently admitted with Pseudomonas). The patient had terrible IV access and so was underresuscitated. A Right IJ triple lumen was placed. The patient was progressively tachypneic to low 40s, and his lactate was 4.9. After failureo f NRB, the ED felt the need to intubate, with sedation via fentanyl and Versed. Though his SBP was 115 before intubation, afterward he had transient periods of SBP around 60-90. Phenylephrine was then started. Though altered, pt wished to be full code. (His sister was unaware of her brother's exact wishes but felt he would probably want to be full code and would agree to all of the items on the ICU consent form.) Past Medical History: Esoph Ca s/p esophagectomy with ? gastric pullup at [**Hospital1 2025**] ~ 10 years ago Prostate Ca Nephrolithiasis Social History: Immigrated from [**Country 4754**] in 62. Worked for Sears-[**Last Name (un) 40191**]. Smoked until his esophagectomy ~ 10 years ago. No recent EtOH. Lives independently at [**Hospital3 537**], takes his own medications, sporadic nursing checks. Family History: Non-contributory Physical Exam: Admission physical exam: VS: Temp: 97.3 BP: 108/65 HR: 63 (RR: 22 O2sat 96%) GEN: intubated, sedated, cachectic HEENT: PERRL, secretion in mouth, oropharynx with some erythema, likely secondary to intubation. RESP: Quiet breath sounds with wheeze CV: S1, S2, no murmurs auscultated ABD: Non-distended, quiet bowel sounds, no guarding, liver felt below costal margin. EXT: Clubbing of nails, dusky fingernails with > 2 seconds capillary refill, no edema. SKIN: Many seborrheic keratoses NEURO: Sedated, small pupils, but responsive to light. 2+ biceps reflexes bilaterally. 2+ patellar reflexes bilaterally. Babinski downgoing in left foot, equivocal in right. Pertinent Results: Admission labs: [**2200-3-14**] 02:00PM WBC-16.4* RBC-3.95* HGB-10.3* HCT-34.9* MCV-88 MCH-26.0* MCHC-29.4* RDW-15.1 [**2200-3-14**] 02:00PM NEUTS-77* BANDS-11* LYMPHS-4* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-0 [**2200-3-14**] 02:00PM GLUCOSE-75 UREA N-25* CREAT-0.8 SODIUM-145 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-23* [**2200-3-14**] 02:00PM CALCIUM-8.9 PHOSPHATE-5.1* MAGNESIUM-2.1 [**2200-3-14**] 02:00PM cTropnT-<0.01 [**2200-3-14**] 03:38PM LACTATE-4.9* . CT torso [**2200-3-18**]: IMPRESSION: 1. Multifocal pneumonia and signs of atypical infection including tree-in-[**Male First Name (un) 239**] opacities (which can be seen with endobronchial PNA or tuberculosis) as well as centrilobular ground-glass nodules (which can be seen with atypical pneumonia such as mycoplasma or viral pneumonia). Secretions within the right main stem bronchus and trachea are likely due to extensive infection as the patient is intubated and aspiration is less likely. 2. Extremely limited evaluation of the abdomen, however, possible right hydronephrosis. If clinically indicated, a renal ultrasound could be performed for further evaluation. 3. Small-to-moderate axial hiatal hernia. . ECHO [**2200-3-19**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is moderate thickening of the mitral valve chordae. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Moderate pulmonary hypertension. Moderate tricuspid regurgitation. Very small pericardial effusion. . [**2200-3-19**] Renal ultrasound: IMPRESSION: 1. Echogenic kidneys compatible with medical renal disease, although without atrophy. Indeed the parenchyma seems mildly swollen. No evidence of hydronephrosis or abscess. 2. Extensive ascites. . [**2200-3-26**] CXR: FINDINGS: As compared to the previous radiograph, there is no relevant change. Minimally increase in opacities at the left lung base, the other opacities in both the left and the right lung are constant. Unchanged high position of the endotracheal tube, the tube could be advanced by 1 to 2 cm. No newly appeared focal parenchymal opacities. Unchanged bilateral symmetrical apical thickening. Brief Hospital Course: The patient had a complicated hospital course including a MICU stay where he was on pressors for quite a while as well as refractory respiratory failure. He was treated with multiple courses of antibiotics for HCAP but failed to improve. Given his failure to improve and the severity of his illness, a goals of care conversation was conducted by the MICU team. The patient's sister did not feel that pursuing a tracheostomy, a PEG tube and prolonged intubation were consistent with his wishes. As such, the patient was made DNR/DNI and was extubated on [**3-30**]. He actually did well initially. As such, a code conversation was had with the sister and he was made [**Name (NI) 3225**]. He was transferred out of the unit on [**3-31**]. He initially did well and was able to communicate with his sister and with myself. However, his respiratory status deteriorated. He was given morphine for pain and for respiratory distress. He ultimately passed away on [**4-2**] at 1:40 PM. His family was at his bedside at the time of his death. Medications on Admission: nexium 40 mg qd florinef 0.1mg qd Zoloft 25 mg qd bethanecol 25 qd Carafate 1g QID Discharge Disposition: Expired Discharge Diagnosis: Sepsis, respiratory failure Discharge Condition: Deceased Discharge Instructions: Expired Followup Instructions: Expired

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icd9cm

[ [ [] ] ]

[ "33.24", "96.72", "00.14", "96.6" ]

icd9pcs

[ [ [] ] ]

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754+55231

Discharge summary

report+addendum

Admission Date: [**2100-7-16**] Discharge Date: [**2100-8-12**] Service: NEUROLOGY Allergies: Bactrim Attending:[**First Name3 (LF) 618**] Chief Complaint: Left sided weakness, neglect, and global aphasia Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: History obtained from speaking with the patient's family and review of OMR. Ms. [**Known lastname 5021**] is a 89 year-old right-handed [**Known lastname 595**] speaking woman with past medical history significant for hypertension, anemia, hypothyroidism, chronic renal insufficiency, renal cell cancer s/p right nephrectomy and left frontal stroke in [**2100-5-11**] with no residual deficits who presents with left sided weakness, neglect and aphasia. She was first found this morning at 1030hrs on [**2100-7-16**] on the floor, by her husband. It was unknown how long she was down for. At that time, she was able to communicate and said she couldn't hear or see well. She did say that she tripped and fell and that was why she was on the floor. She was also confused when she was found; she was asking how to get to the bathroom. EMS came to her house; by that time, she was walking, talking and reportedly oriented, so she remained at home. During the afternoon, there is a question if she had a visual field cut. She was napping on and off all afternoon, but was reportedly talking to her husband at times and it was thought she may have not been completely acting like herself. She was also thought to still be confused; an example given was that she may have had trouble telling time. Her granddaughter went to check on her at 1700hrs and at that time, she was again found on the floor, moaning, not speaking and nor moving her left arm (unclear if moving left leg). Her husband had reportedly went to the bathroom just prior to this and when he left, she was not on the floor, though no one know with certainity if she was moving her left arm and when the last time was that she actually spoke. EMS was called again and brought the patient to [**Hospital1 18**]. EMS notes upon finding the patient, the left arm was plegic, but she began moving it en route. Upon arrival to [**Hospital1 18**], a CODE STROKE was called. Neuro ROS: unable to obtain from patient. Past Medical History: -left frontal stroke ([**2100-5-11**]) -HTN -B12 deficiency -anemia -hypothyroidism -chronic renal insufficiency -renal cell carcinoma s/p right nephrectomy Social History: - She lives with her husband. - No Tobacco, EtOH, or Illicit substance use. Family History: Non-contributory, no known family hx of strokes. Physical Exam: Physical Exam on Admission: Vitals: P: 63 R: 21 BP: 143/72 SaO2: 100% General: Awake, agitated HEENT: NC/AT, no scleral icterus noted, MMM Neck: Supple, no carotid bruits appreciated Pulmonary: lcta b/l Cardiac: RRR, S1S2, III/VI systolic murmur Abdomen: soft, NT/ND, +BS Extremities: warm, pitting edema b/l NIH Stroke Scale score was: 21 1a. Level of Consciousness: 0 1b. LOC Question: 2 1c. LOC Commands: 2 2. Best gaze: 2 3. Visual fields: 2 4. Facial palsy: 2 5a. Motor arm, left: 3 5b. Motor arm, right: 0 6a. Motor leg, left: 3 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 2 10. Dysarthria: 1 11. Extinction and Neglect: 2 Mental Status: Awake, alert. She does not produce any comprehensible speech (per her grandaughter who was speaking with her in [**Year (4 digits) 595**]) and does not follow any commands. She does not mimic. She has a dense left sided neglect. Cranial Nerves: PERRL. Right gaze preference and she does not cross midline to look to the left. She resists attempted Doll's maneuvers to get her to cross midline. She appears to have a left hemianopia as she blinks to threat on the right but not on the left. Left lower facial droop. Motor: Normal tone. She moves the right side more spontanenously compared to the left and more antigravity. She is able to move her left side and is frequently reaching across her body with her left arm though does not maintain it off antigravity. She is also able to hold her left leg antigravity briefly, but it will drift to bed. She would not cooperate with formal strength testing. Sensory: She grimmaces to noxious simulation throughout. DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 3 0 R 2 2 2 3 0 Plantar response was extensor on L>>R. Coordination: she would not cooperate with coordination testing, but no ataxic movements noted on observation. Gait: deferred Physical Exam on Discharge: Pertinent Results: Labs on Admission: [**2100-7-16**] 06:00PM WBC-6.2 RBC-2.90* HGB-8.8* HCT-27.3* MCV-94 MCH-30.5 MCHC-32.4 RDW-14.3 [**2100-7-16**] 06:00PM PT-10.9 PTT-25.7 INR(PT)-1.0 [**2100-7-16**] 06:00PM UREA N-51* CREAT-2.2* SODIUM-141 POTASSIUM-5.0 CHLORIDE-114* TOTAL CO2-17* ANION GAP-15 [**2100-7-16**] 06:00PM ALT(SGPT)-25 AST(SGOT)-17 ALK PHOS-169* TOT BILI-0.2 Relevant Labs: [**2100-7-16**] 06:00PM %HbA1c-5.6 eAG-114 [**2100-7-16**] 06:00PM ALBUMIN-3.9 [**2100-7-16**] 06:00PM cTropnT-0.02* [**2100-7-16**] 06:00PM BLOOD cTropnT-0.02* [**2100-7-17**] 05:45AM BLOOD CK-MB-5 cTropnT-0.08* [**2100-7-17**] 11:20AM BLOOD CK-MB-5 cTropnT-0.16* [**2100-7-17**] 07:10PM BLOOD CK-MB-6 cTropnT-0.17* [**2100-7-18**] 04:17AM BLOOD CK-MB-5 cTropnT-0.14* [**2100-7-22**] 05:18AM BLOOD CK-MB-15* MB Indx-2.6 cTropnT-0.17* [**2100-7-17**] 11:20AM BLOOD VitB12-1256* [**2100-7-17**] 05:45AM BLOOD Triglyc-85 HDL-44 CHOL/HD-3.1 LDLcalc-75 [**2100-7-17**] 11:20AM BLOOD TSH-2.1 [**2100-7-25**] 04:00PM BLOOD Phenyto-12.6 Phenyfr-2.3* %Phenyf-18* [**2100-7-26**] 02:21AM BLOOD Phenyto-13.5 Imaging: NCHCT, Perfusion CT [**2100-7-17**] 1. Markedly motion-limited head CT without evidence of gross acute hemorrhage. 2. CT perfusion study is slightly limited, but demonstrates a large area of ischemia in the right middle cerebral artery territory and in the right occipital lobe. An infarction also appears to be present, at least in the superior right middle cerebral artery territory, likely smaller in size than the area of ischemia. Chest x-ray [**2100-7-17**] Heart size is enlarged, unchanged. Mediastinal contour is stable. Lungs' assessment demonstrates mild volume overload but no overt pulmonary edema. Right upper quadrant surgery is redemonstrated. MR/A head and neck [**2100-7-17**] 1. Extensive right MCA territory infarcts and also a small focus in the right PCA territory, without mass effect, new since the prior study. 2. Occlusion of the right middle cerebral artery in the distal M1 segment and nonvisualization of the rest of the middle cerebral artery branches. TTE [**2100-7-19**] IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. Minimal aortic valve stenosis. Mild-moderate mitral regurgitation. Moderate pulmonary artery systolic hypertension. No definite structural cardiac source of embolism identified. Compared with the prior report (images unavailable for review) of [**2093-1-20**], the severity of mtiral regurgitation and the estimated PA systolic pressure are now higher. Chest x-ray [**2100-7-21**] The ET tube tip is 5 cm above the carina. Heart size and mediastinum are grossly unchanged. There is newly developed left retrocardiac opacity that may reflect atelectasis, but infectious process or aspiration cannot be excluded. No pulmonary edema, pneumothorax or appreciable interval increase in pleural effusion seen. NCHCT [**2100-7-21**] Extensive right MCA territory ischemic infarction without evidence of hemorrhagic conversion. Subtle hemorrhage or extension of the infarction may be better assessed by MRI if indicated. EEG [**2100-7-22**] IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of frequent electrographic seizures arising from the right occipital region and spreading to the right posterior quadrant. There are a total of 15 seizures, lasting 1-2 minutes, most in a cluster between 17:00 and 19:03. In addition, there is continuous focal slowing with intermixed theta and delta range frequencies, attenuation of faster frequencies, and absent alpha rhythm in the right hemisphere. These findings are indicative of an epileptogenic focal structural lesion in the right hemisphere, and are consistent with the clinical history of right MCA stroke. Some of the focal attenuation may be secondary to postictal effects. Background activity is slow with a slow alpha rhythm on the left, indicative of more widespread cerebral dysfunction, which is etiologically nonspecific, but may in part be secondary to sedating medications. EEG [**7-27**] IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of continuous focal slowing and attenuation of faster frequencies in the right posterior region. These findings are indicative of a focal structural lesion in the right hemisphere and are consistent with the clinical history of right MCA stroke. Background activity shows continuous generalized background slowing in mixed theta and delta range frequencies suggestive of moderate encephalopathy which is etiologically non-specific. No epileptiform discharges or electrographic seizures are present. Compared to the prior day's EEG, faster frequency activities have started to appear in the right posterior region indicating improving dysfunction in the right posterior quadrant. PORTABLE HEAD CT W/O CONTRAST - [**2100-7-27**] 8:58 AM IMPRESSION: Normal changes consistent with evolution of a right MCA infarction. No definitive evidence of hemorrhagic transformation. No evidence of new infarction. Chronic changes as indicated above. EEG [**7-28**] IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of continuous focal slowing with absent alpha rhythm and attenuation of faster frequencies in the right hemisphere, maximal in the posterior quadrant. These findings are indicative of a focal structural lesion in the right hemisphere and are consistent with the clinical history of right MCA stroke. Background activity shows continuous generalized background slowing in mixed theta and delta range frequencies along with frequent and prolonged runs of triphasic waves indicative of moderate encephalopathy which is etiologically non- specific. Compared to the prior day's EEG, there is no significant change Brief Hospital Course: 89yo RHF ([**Month/Year (2) 595**] speaking only) h/o L Frontal Stroke, HTN, Hypothyroid, Anemia, Chronic Renal Insufficiency c/b RCC s/p R nephrectomy p/w L weakness, neglect, and global aphasia with imaging suggestive of dual R MCA and R PCA distribution thus likely secondary to embolic event given pt with paroxysmal AFib while inpatient. Course further complicated by status epilepticus. # Neuro: On admission, patient had left neglect, aphasia (both productive and receptive), right gaze preference with seeming inability to cross the midline, left hemianopia and left hemiparesis. tPA not given since recent stroke and [**Last Name (un) 5487**] onset of symptoms time as well as recent frontal stroke. The etiology of her right MCA stroke was likely thromboembolic given the extent of infarct and likely secondary to paroxysmal atrial fibrillation which she was found to be in on the floor. Patient initially had some improvement neurologically and was following commands, answering questions appropriately with short words/phrases and moving her left side to antigravity. For her stroke, she was continued on full dose ASA and started on statin. Initially on high dose statin, but as LDL <100, will discharge on Atorvasatin 40 mg daily. On [**7-21**] in the afternoon, pt had rhythmic shaking of LUE and LLE; however, she was awake, alert, speaking and answering questions appropriately. At ~1700, pt had a generalized tonic-clonic seizure with unresponsiveness, L gaze preference. Was given ativan 1mg IV x2 with no response. Loaded with Keppra 1000mg x1 which resulted in transient arrest of the seizure for 1min, but then seizure activity resumed. Started Dilantin, and placed prophylactic NRB with O2 sats in the high 90s. Remained in status through 1800. BP was 95/48, started NSD5W bolus. At that time after confirming change in codes status with family (pt had been DNR/DNI), called anesthesia for elective intubation, pt was transferred to Neuro ICU. Patient was transferred to ICU for further management after ictal episode requiring intubation for airway protection. Initially, she was maintained on Fentanyl/Versed which limited evaluation of neurologic function. Continuous EEG monitoring revealed electrographic seizures despite any change in mental status of the patient, or evident convulsions. Of note, during AM examination, the patient was noted to have no abnormal movements or change in status from previous exams, but was reported to have rhythmic epileptiform activity on EEG. Versed was held and propofol used due to patient's chronic renal insufficiency. The patient on [**7-22**] was also started on Dilantin (bolused to bring to theraputic levels). Repeat measurements of her Dilantin level, corrected for hypoalbuminemia, fell between 18 and 21 Ms. [**Known lastname 5021**] was weaned from propofol over [**Date range (1) 5488**], and was more active bilaterally in upper and lower extremities. During this period, EEG monitoring continued to reveal no electrographic seizures. She opened eyes spontaneously but remained unresponsive to command (in [**Date range (1) 595**]). Propofol was used for sedation to agitiation between [**Date range (1) 5489**], during which patient was less responsive in examination. Baseline agitation was maintained also with Seroquel / Zyprexa. After evaluation by anesthesia and a successful spontaneous breathing trial, Ms. [**Known lastname 5021**] was extubated on [**7-27**] without event. She remained globally aphasic not responding to commands from relatives who are [**Name (NI) 595**] speaking. On the subsequent morning, the patient was responding with garbled phrases to her granddaughter. However, she remained unresponsive to command in the morning and only opened her eyes to repeat stimulation. Lethargy was attributed partially to sedating effects of antiepileptics (on Keppra and Dilantin [**Hospital1 **]). Also, had fevers attributed to Dilantin as infectious w/u was neg. Discontinued Dilantin, started Vimpat 50mg PO bid instead. Decreased Keppra dose. She was started on Modafinil to help with her level of alertness. She was also started on Fluoxetine as her mood appeared depressed and given that Fluoxetine can improve 3 month outcome after a stroke. # Cardiopulmonary: Overnight on admission, pt's HRs were in the high 30s to low 40s while asleep. On [**7-17**] at ~9am, HR was 140s and she was in new onset atrial fibrillation. She was treated with metoprolol 5mg IV and tachycardia resolved. ECG was obtained and showed 1mm depressions in V3-V6. Cardiac enzymes, trops 0.02-->0.08-->0.06, MB 5, 5. Cardiology was consulted for evaluation for ACS as well as new onset afib. Cardiology felt that troponin leak was secondary to demand ischemia, not ACS. Recommended metoprolol 12.5mg [**Hospital1 **] for rate control and titrate up as needed as well as atorvastatin 80mg qd. While in the ICU, the patient was persistently bradycardic in the 40-50 bpm range, which per her family is baseline for the patient. She was able to autoregulate her pressures within normal physiologic range without medication or intervention. On [**7-26**], the patient per the multidisciplinary ICU team was ready for extubation; however, concern for a swollen tongue and potential obstruction caused a delay for one day to [**7-27**]. Per conversations with the family, the patient will be DNR/DNI upon extubation. She was administered decadron to decrease the glossal swelling on [**7-28**]. After evaluation by anesthesia and a successful spontaneous breathing trial, Ms. [**Known lastname 5021**] was extubated on [**7-27**] without event. On discharge, she was restarted on her home BP meds, except Diltiazem ER (she will be d/c on low dose Metoprolol for rate control, though she is often bradycardic, this should be held for pulse less than 60). # Renal: The patient's known renal insufficiency was factored into decisions regarding her medical management, knowing that excretion of some medications would be compromised. # GI: The patient had a nasogastric tube placed early during her ICU stay for tube feeds. This got dislodged and was replaced by a Dobhoff tube (placed by interventional neuroradiology). She was also maintained on H2 Blockers for reflux. # Endo: She was on Synthroid as an outpatient. She did not receive this for part of time during admission. TSH was checked prior to discharge and was elevated at 8.3. She is restarted on Synthroid at time of discharge. # Goals of care: Had discussions with family about code status. After initial status epilepticus, said they would not want to intubate pt and that she was DNR/DNI. Wanted to wait if she would become less sedated with weaning AEDs prior to making decision about PEG vs. comfort care. Palliative care was consulted. Plan to go to LTACH with Dobhoff for feeding and determining if she will wake up more and tolerate PO intake/rehab. 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL =75) - () No 5. Intensive statin therapy administered? (for LDL > 100) (x) Yes - () No (if LDL >100, Reason Not Given: ) 6. Smoking cessation counseling given? () Yes - (x) No (Reason (x) non-smoker - () unable to participate) 7. Stroke education given? (x) Yes - () No 8. Assessment for rehabilitation? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No (if LDL >100, Reason Not Given: ) 10. Discharged on antithrombotic therapy? (x) Yes (Type: () Antiplatelet - (x) Anticoagulation) - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - (x) No - () N/A. Oral anticoagulation not started given age/fall risk. Will continue ASA 325 mg daily. Medications on Admission: -Mavik 1 mg daily (brand name only) -Vitamin B12 1000 mcg IM or SQ q 2 months -Diltiazem ER 360 mg daily -HCTZ 25 mg daily -Synthroid 50 mcg daily -Ammonium Lactate 12% topical cream -ASA 325 mg daily Discharge Medications: 1. Atorvastatin 40 mg PO DAILY 2. Famotidine 20 mg PO Q24H 3. Fluoxetine 10 mg PO DAILY 4. modafinil *NF* 100 mg Oral Daily Reason for Ordering: Pt lethargic weeks out from stroke; data exists that modafinil can be beneficial in such cases 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Lacosamide 50 mg PO BID 7. LeVETiracetam Oral Solution 750 mg PO BID 8. Lorazepam 1 mg IM Q4H:PRN seizure > 3 minutes or 3+ events in one hour 9. Heparin 5000 UNIT SC BID 10. Quetiapine Fumarate 25 mg PO QHS:PRN Agitation Please administer suspension via doboff 11. Senna 1 TAB PO BID:PRN constipation hold for more than 1 bowel movement [**Last Name (un) 5490**] 12. Aspirin 325 mg PO DAILY 13. Hydrochlorothiazide 25 mg PO DAILY 14. Levothyroxine Sodium 50 mcg PO DAILY 15. Metoprolol Tartrate 12.5 mg PO BID Hold for pulse less than or equal to 60 Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: right MCA territory ischemic stroke atrial fibrillation status epilepticus Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Neurology exam at discharge: Drowsy,lethargic, open her eyes to calling her name, moves her limbs to painful stimulileft leg more than left arm, does not speak , in response to painful stimuli makes some [**Hospital6 **] words, spastic tone in left arm. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2100-8-12**] Name: [**Known lastname 605**],[**Known firstname 606**] Unit No: [**Numeric Identifier 607**] Admission Date: [**2100-7-16**] Discharge Date: [**2100-8-12**] Date of Birth: [**2010-11-19**] Sex: F Service: NEUROLOGY Allergies: Bactrim Attending:[**First Name3 (LF) 608**] Addendum: Final report of Dobhoff placement is dictated but not yet transcribed. Dictated report was listened to and it reports that Dobhoff tube is in proper place and can start being used. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**] Completed by:[**2100-8-12**]

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icd9cm

[ [ [] ] ]

[ "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

20717, 20904

10466, 18335

264, 289

19641, 19641

4607, 4612

2580, 2631

18587, 19433

19543, 19620

18361, 18564

2646, 2660

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176, 226

317, 2290

3565, 4558

4627, 10443

19656, 19810

2312, 2470

2486, 2564

6,024

104,644

6018

Discharge summary

report

Admission Date: [**2124-12-31**] Discharge Date: [**2125-1-3**] Date of Birth: [**2057-7-6**] Sex: F Service: MEDICINE Allergies: Percocet / Codeine / Tylenol Attending:[**First Name3 (LF) 30**] Chief Complaint: Nausea and Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 67y/o AA female w/ a PMH of DM2, CAD, PVD, CVA, and HTN who presents to the ER after 3d of nausea, vomiting (NBNB), NP[**MD Number(3) 23674**], constipation, and "chills". She was then noted to be hypertensive to the 200s/120s. She received hydralazine 30mg iv, her scheduled labetalol 100po dose, and lopressor 5mg IV x1. These produced no BP change. She then received labetalol 20mg IV x1 which lowered the SBP to the 180s for ~1hr after which time it again rebounded to the 220s. She received a single dose of lisinopril 40mg PO w/out effect on her BP. During this time period, the patient noted mild pressure-type substernal CP w/out radiation or associated SOB, diaphoresis, or palpatations. The CP was easily reproducible w/ light palpation and the patient states that it is different from her past anginal pain which is L-sided non-radiating CP. EKG collected in the ER during her admission demonstrated STD in V4-6. . On admission to MICU the pt had BP in 160's and was weaned off labetolol drip. This was then restarted when her SBP increased to >180. Past Medical History: 1. Diabetes, diagnosed only earlier this year, but given her history of toe amputation, likely present for much longer than that. 2. Depression. 3. Hypothyroidism. 4. Hypertension. 5. Spinal stenosis s/p C4-C7 laminectomy 6. CAD, status post MI in [**2121-7-31**]. 7. Weakness leading to frequent falls. 8. Hyperlipidemia. 9. PVD s/p aortobifemoral bypass '[**09**] on L adn L toe amputations Social History: Patient smokes one-half pack per day. She lives at home independently with a roommate who helps her with her everyday needs such as getting dressed and getting washed Family History: NC Physical Exam: 98.6, 186/107, 91, 20, 100%2L HEENT: EOMI, PERRLA, MMM, O/P clear CV: RRR, S1/S2 wnl, -M/R/G Lungs: CTA b/l Abd: S/NT/ND, +BS, -HSM Ext: -C/C, chronic edematous changes to the LLE, multiple toe amputations on the L Neuro: CN 2-12 grossly intact, decreased strength in the LLE/LUE compared to the R side, appropriate in conversation Brief Hospital Course: MICU Course: On admission to MICU the pt had BP in 160's and was weaned off labetolol drip. This was then restarted when her SBP increased to >180. On day 2 Labetalol was again weaned, this time successfully (off gtt for > 48 hrs with stable BPs on tx from ICU), and pt's BPs were controlled on her normal PO regimen. Of note she had an episode of hypotension in the MICU which responded to IVF (pt. has a hx of Neuropathy and Gastroparesis [**2-1**] DM, and the team felt that autonomic neuropathy could be contributing to labile BPs). STDs seen on EKG were felt to be [**2-1**] demand, and resolved with BP control, and CEs were neg x 3. . She was then transferred to the floor and monitored overnight. Her pressures were well controlled (SBP 120s-150s) and he had no further sx of N/V/HA/CP. She was seen by Opthalmology, who recommended outpatient f/u for a floater she has had chronically, which was scheduled. In talking with pt. further she reported that she does not take her medications when she gets sick, and had not taken her BP meds for a few days prior to admission. This was felt to be the etiology of her HTN exacerbation, and a w/u of secondary HTN was not pursued. Medications on Admission: aspirin 81' plavix 75' lipitor 40' synthroid 25' labetalol 100'' protonix 40' nortryptyline 50' reglan 10'''' glucophage 500'' trazodone 100'' MVI tramadol 50'' neurontin 300'''' morphine 15'' cymbalta 20' Lisinopril 40' Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Atorvastatin 40 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. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 13. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 14. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 16. Trazodone 100 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as needed. Discharge Disposition: Home Discharge Diagnosis: Hypertensive Urgency Discharge Condition: Improved- SBPs 120s-150s Discharge Instructions: Please call your doctor or come to the ER if you have any headaches, nausea, vomiting, changes in your vision, chest pain, shortness of breath, or any other symptoms that concern you. It is very important that you take your blood pressure medication daily. Followup Instructions: Primary Care: Provider: [**Name10 (NameIs) 23675**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2125-1-12**] 2:00 Opthalmology: Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2125-1-5**] 3:00 Completed by:[**2125-1-4**]

[ "337.1", "276.52", "244.9", "401.9", "V49.72", "250.60", "536.3", "276.51", "285.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5211, 5217

2406, 3597

306, 312

5282, 5309

5615, 5929

2030, 2034

3869, 5188

5238, 5261

3623, 3846

5333, 5592

2049, 2383

247, 268

340, 1411

1433, 1829

1845, 2014

32,452

180,297

32314

Discharge summary

report

Admission Date: [**2111-12-15**] Discharge Date: [**2111-12-25**] Date of Birth: [**2072-5-17**] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin Attending:[**First Name3 (LF) 165**] Chief Complaint: Transferred from Outside Hospital for evaluation of [**First Name3 (LF) 75514**] RCA Major Surgical or Invasive Procedure: Repair of anomolous RCA [**12-21**] History of Present Illness: 39F with no significant PMH transferred for eval of [**Month/Year (2) 75514**] RCA causing exertional CP. Approx 4 months ago, pt began experiencing DOE associated with mild chest tightness; this began happening near the end of 2 mile daily walks that she had previously finished without difficulty. The DOE occured progressively sooner during the walks over the next few weeks and she saw her PCP, [**Name10 (NameIs) 1023**] suspect exercise induced asthma. When the DOE did not respond to asthma Rx and in fact progressed such that she had dyspnea and marked chest discomfort with routine daily activities, she saw a cardiologist. She eventually had a stress echo, which provoked symptoms at moderate exercise, with ST elevations in inferior leads and a brief period of 2:1 conduction block, and echo showed inf HK. Cath the same day showed no angiographic evidence of CAD in the LMCA/LAD/LCX, but the RCA was difficult to engage and seemed to arise anteriorly and course between the aorta and PA with non-selective angiography. She was then referred to [**Hospital1 18**] for further eval. Past Medical History: Spina Bifida Surgery as infant Raynaud's phenomenon Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: Her father had symptomatic CAD requiring stents at age 60. There is no family history of congenital heart disease. There is no family history of premature coronary artery disease or sudden death. Physical Exam: PHYSICAL EXAMINATION: VS - 99.2 123/69 96 16 99%RA Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of [**9-4**] cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: EKG demonstrated SR 79, no significant change to prior earlier same day at OSH. ETT performed on [**2111-12-15**], report from [**Hospital1 **]: Exercised 8min30secs of [**Doctor First Name **] protocol, stopped for chest pain and dyspnea. EKG showed transient 2:1 block during exercise and 8 beat run NSVT, 3-4mm downslopping STE in III, aVF, and V4-V6. Post-exercise echo with inf and inf-septal HK. . CARDIAC CATH performed on [**2111-12-15**], report from [**Hospital1 **]: Right dominant system, no flow limiting disease in the LMCA, LAD, or LCX. [**Hospital1 **] take off of the RCA visualized with non-selective angiography; take-off appears to be between the aorta and pulmonary artery anteriorly. [**2111-12-24**] 07:00AM BLOOD WBC-9.6 RBC-3.18*# Hgb-9.6*# Hct-27.9* MCV-88 MCH-30.1 MCHC-34.3 RDW-13.6 Plt Ct-224 [**2111-12-24**] 07:00AM BLOOD Plt Ct-224 [**2111-12-21**] 06:27PM BLOOD PT-14.0* PTT-33.7 INR(PT)-1.2* [**2111-12-23**] 11:00AM BLOOD K-4.0 [**2111-12-23**] 03:18AM BLOOD Glucose-80 UreaN-5* Creat-0.5 Na-138 K-4.0 Cl-109* HCO3-24 AnGap-9 [**2111-12-17**] 07:00AM BLOOD ALT-19 AST-18 LD(LDH)-147 AlkPhos-60 TotBili-0.5 MR CARDIAC/FUNCTION, COMPL [**2111-12-16**] 2:28 PM MR CARDIAC/FUNCTION, COMPL; MRA CHEST W/O CONTRAST Reason: eval coronary anatomy [**Hospital 93**] MEDICAL CONDITION: 39F with exertional CP, inf STE and inf wall HK on recent stress echo, with [**Hospital 75514**] RCA takeoff (unable to engage vessel) at cath REASON FOR THIS EXAMINATION: eval coronary anatomy CONTRAINDICATIONS for IV CONTRAST: None. Patient Name: [**Name (NI) **], [**Name (NI) 1060**] MR#: [**Numeric Identifier 75515**]Status: Outpatient Study Date: [**2111-12-16**] Indication: 39-year-old woman with chest pain and a stress echocardiogram revealing inferior ST-elevations and inferior hypokinesis with exercise as well as a difficult to engage right coronary artery on catheterization referred for assessment of [**Year (4 digits) 75514**] right coronary artery. Requesting Physicians: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6254**] Height (in): 63 Weight (lbs): 125 Body Surface Area (m2): 1.59 Hemodynamic Measurements Measurement Result Systemic Blood Pressure (mmHg) 114/69 Heart Rate (bpm) 80 Rhythm: Sinus CMR Measurements Measurement Result Female Normal Range LV End-Diastolic Dimension (mm) 49 <55 LV End-Diastolic Dimension Index (mm/m2) 31 <33 LV End-Systolic Dimension (mm) 32 LV End-Diastolic Volume (ml) 93 <143 LV End-Diastolic Volume Index (ml/m2) 59 <78 LV End-Systolic Volume (ml) 32 LV Stroke Volume (ml) 61 LV Ejection Fraction (%) 66 >56 LV Anteroseptal Wall Thickness (mm) 6 <10 LV Inferolateral Wall Thickness (mm) 5 <9 LV Mass (g) 69 LV Mass Index (g/m2) 44 <60 RV End-Diastolic Volume (ml) 84 RV End-Diastolic Volume Index (ml/m2) 53 <103 RV End-Systolic Volume (ml) 28 RV Stroke Volume (ml) 56 RV Ejection Fraction (%) 67 >49 QFlow Net Aortic Forward Stroke Volume (QS net, ml) 56 QFlow Net Pulmonary Artery Forward Stroke Volume (Qp net, ml) 55 QP/QS 1.0 0.8 - 1.2 QFlow Aortic Cardiac Output (l/min) 4.5 QFlow Aortic Cardiac Index (l/min/m2) 2.8 >2.0 QFlow Aortic Valve Regurgitant Volume (ml) 0 QFlow Aortic Valve Regurgitant Fraction (%) 0 <5 Mitral Valve Regurgitant Volume (ml) 5 Mitral Valve Regurgitant Fraction (%) *8 <5 Effective Forward LVEF (%) 60 >56 Pulmonic Valve Regurgitant Volume (ml) 2 Pulmonic Valve Regurgitant Fraction (%) 4 <5 Tricuspid Valve Regurgitant Volume (ml) 0 Tricuspid Valve Regurgitant Fraction (%) 0 <5 Aortic Valve Area (2-D) (cm2) 3.2 >3.0 Aortic Valve Area Index (cm2/m2) 2.0 Ascending Aorta diameter (mm) 24 <35 Ascending Aorta diameter Index (mm/m2) 15 <21 Transverse Aorta diameter (mm) 20 <31 Descending Aorta diameter (mm) 18 <25 Descending Aorta Index (mm/m2) 11 <15 Main Pulmonary Artery diameter (mm) 24 <27 Main Pulmonary Artery diameter Index (mm/m2) *15 <15 Left Atrium (Parasternal Long Axis) (mm) 27 <40 Left Atrium (4-Chamber) (mm) 45 <52 Right Atrium (4-Chamber) (mm) 38 <50 Pericardial Thickness (mm) 2 <4 Coronary Sinus diameter (mm) 8 <15 Length of Visualized Coronary Artery Left Main (mm) 77 Left Anterior Descending (LAD) (mm) 72 Left Circumflex (LCx) (mm) 74 Right Coronary Artery (RCA) (mm) 54 * = Mildly abnormal, ** =moderately abnormal, *** = severely abnormal CMR Technical Information: CMR Technologists: [**Doctor First Name **] Goddu, RT Nursing support: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 75516**], RN eGFR: N/A ml/min Total Gd-DTPA (Magnevist ) contrast: 0 ml (N/A mmol/kg) Injection site: N/A antecubital vein Complications: None. 1) Structure: Axial dual-inversion T1-weighted images of the myocardium were obtained without spectral fat saturation pre-pulses in 5 mm contiguous slices. 2) Function: Breath-hold cine SSFP images were acquired in the left ventricular 2-chamber, 4-chamber, horizontal long axis, short axis slices (8 mm slices with 2 mm gaps), sagittal and coronal orientations of the left ventricular outflow tract, and aortic valve short axis orientations. 3) Flow: Phase-contrast cine images were obtained transverse to the aorta (axial plane) and main pulmonary artery (oblique plane). 4) Coronary MRI ([**Last Name (NamePattern1) 75514**] screen): Free-breathing ECG-gated navigator gated/corrected T2 prep 3D SSFP coronary MRI of the aortic root and coronary ostia were obtained in the axial plane. Findings: Structure and Function There was normal epicardial fat distribution. The pericardial thickness was normal. There were no pericardial or pleural effusions. The origin of the left main was identified in its customary position. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was mildly increased. The left atrial AP dimension was normal. The right and left atrial lengths in the 4-chamber view were normal. The coronary sinus diameter was normal. The left ventricular end-diastolic dimension index and end-diastolic volume index were normal. The calculated left ventricular ejection fraction was normal at 66% with normal regional systolic function. The anteroseptal and inferolateral wall thicknesses were normal. The left ventricular mass index was normal. The right ventricular end-diastolic volume index was normal. The calculated right ventricular ejection fraction was normal at 67%, with normal free wall motion. The aortic valve was tri-leaflet with normal valve area. Quantitative Flow There was no significant intra-cardiac shunt. Aortic flow demonstrated no significant aortic regurgitation. The calculated mitral valve regurgitant fraction was consistent with mild mitral regurgitation. The resultant effective forward LVEF was normal at 60%. The right ventricular stroke volume and pulmonic flow demonstrated no significant pulmonic or tricuspid regurgitation. Coronary MR Imaging Normal origin and orientation of the left main coronary arteries. The left main coronary artery had normal signal characteristics and caliber with bifurcation into the LAD and LCx. The LAD and LCx had normal caliber and signal characteristics. The right coronary artery originates from the left coronary cusp, appears to narrow proximally, and courses anteriorly between the ascending aorta and main pulmonary artery before entering the right AV groove. Impression: 1. [**Last Name (NamePattern1) **] right coronary artery with origin from the left coronary cusp, luminal narrowing proximally, and anterior course between the ascending aorta and main pulmonary artery (malignant). 2. Normal left ventricular cavity size with normal regional left ventricular systolic function. The LVEF was normal at 66%. The effective forward LVEF was normal at 60%. 3. Normal right ventricular cavity size and systolic function. The RVEF was normal at 67%. 4. Mild mitral regurgitation. 5. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was mildly increased. Brief Hospital Course: Cardiac MR [**First Name (Titles) 75517**] [**Last Name (Titles) 75514**] right coronary artery. Cardiac surgery was consulted and on [**12-21**] she was taken to the operating room where she underwent repair of anomaolous RCA. She was transferred to the ICU in critical but stable condition on neo and propofol. She was extubated later that same day. She was transfused for HCT of 20. She was given 48 hours of perioperative vancomycin as prophylaxis as she was in the hospital preoperatively. She was transferred to the floor on POD #2. On POD #3, her epicardial wires were pulled and she underwent rest thallium study which was normal. She has remained stable, and is ready for discharge home today. Medications on Admission: OCP Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: [**Month/Year (2) **] right coronary artery now s/p unroofing PMH: Raynaud's Phenomenon Spina Bifida Surgery as Infant 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) 22980**] 2 weeks Dr. [**Last Name (STitle) 6254**] 2 weeks Dr. [**First Name (STitle) **] 4 weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2111-12-25**]

[ "413.9", "443.0", "746.85", "741.90" ]

icd9cm

[ [ [] ] ]

[ "36.99", "88.72", "39.61" ]

icd9pcs

[ [ [] ] ]

12240, 12274

10945, 11650

364, 402

12437, 12445

2840, 4120

12744, 12992

1744, 1943

11704, 12217

4157, 4300

12295, 12416

11676, 11681

12469, 12721

1958, 1958

1980, 2821

240, 326

4329, 10922

430, 1526

1548, 1602

1618, 1728

21,431

111,307

51313

Discharge summary

report

Admission Date: [**2139-11-3**] Discharge Date: [**2139-11-12**] Date of Birth: [**2083-6-22**] Sex: M Service: [**Hospital1 **] Medicine HISTORY OF PRESENT ILLNESS: This is a 56-year-old male with a history of severe peripheral vascular disease, diabetes mellitus type 1, secondary to alcohol abuse and pancreatitis, hypertension, end-stage renal disease status post kidney transplant in [**2133**], failing, DVT in the right upper extremity, GERD, MRSA, depression, chronic right leg ulcer with external fixation on [**10-25**], who presented to the Emergency Department in diabetic ketoacidosis and hyperkalemia. He was admitted to the MICU for diabetic ketoacidosis. PAST MEDICAL HISTORY: As above per history of present illness. ALLERGIES: No known drug allergies. MEDICATIONS UPON ADMISSION: 1. Folate 1 mg a day. 2. Multivitamin one a day. 3. Wellbutrin 100 mg 3x a day. 4. Protonix 40 mg once a day. 5. Neurontin 300 mg once a day. 6. Chlorhexidine 50 mg 3x a day. 7. Aspirin 81 mg once a day. 8. Vancomycin 1 gram q Monday and Friday. 9. Pancreatic enzymes. 10. Calcium carbonate 500 3x a day. 11. Amlodipine 5 mg two times a day. 12. Clonidine 0.3 mg 2x/day. 13. Lasix 60 mg 2x/day. 14. Hydralazine 75 mg 4x a day. 15. Lovenox 40 mg once a day. 16. Prednisone 5 mg once a day. 17. Celexa 20 mg once a day. 18. Metoprolol 100 mg twice a day. 19. OxyContin 40 mg twice a day. 20. Ceftaz 1 gram q.48h. 21. Insulin. ALLERGIES: The patient reported a history of swelling with codeine, however, has not had a problem during hospitalization. Also reported an allergy to FK-506. SOCIAL HISTORY: Twenty pack year smoker, quit six years ago. No alcohol x11 years, formally heavy use. PHYSICAL EXAMINATION: On admission, temperature is 96.9, pulse 63, blood pressure 190/110, satting 98% on room air. A thin male in no acute distress. Breathing comfortably. Answering all questions appropriately. Extraocular movements are intact. Anicteric sclerae. Moist mucous membranes. Oropharynx is clear with supple neck. Lungs are clear to auscultation bilaterally. Heart regular, rate, and rhythm with normal S1, S2, no murmurs, rubs, or gallops. Belly is soft, nontender, nondistended, positive bowel sounds. There is a left lower quadrant renal allograft, nontender. Extremities: No edema, cool. Left TMA, right toe amputations with external fixation device on the right. Neurologic: Alert and oriented times three. Cranial nerves II through XII intact. No asterixis. LABORATORIES UPON ADMISSION: Significant for a white count of 9, hematocrit 43, potassium of 6.3, BUN and creatinine of 80 and 9.5, bicarb 13, glucose 647. Had a gas with pH of 7.28, CO2 36, O2 109. Calcium was 7.5, phosphorus 8.9, magnesium 2.5. Urinalysis: Leukocyte esterase and nitrite negative, 0-2 white blood cells and occult bacteria. Chest x-ray showed no infiltrate and no CHF. HOSPITAL COURSE: 1. Diabetic ketoacidosis: Patient was admitted to the MICU, managed with IV insulin drip and IV fluids, which resolved. Initial triggers unclear. [**Name2 (NI) **] has a history of poor glycemic control and diabetic ketoacidosis with last admission in [**2139-8-24**]. The [**Last Name (un) **] endocrinologists were consulted and over the course of his hospitalization, had fine tuned his diabetes regimen to Glargine 12 units at night standing dose with a Humalog insulin-sliding scale. 2. Neurologic: This patient had a question of seizure-like activity, twitching, and apnea when called out from the MICU post hemodialysis on [**11-4**]. His electrolytes had shown a low ionized calcium of 0.99. Was in the process of getting repleted. Eventually normalized. Neuro was following. LP was unrevealing. Normal EEG. Tox screen negative. Unable to have a MRI due to metal in his legs external fixator. He was originally started on Dilantin, but then was felt that Dilantin was not needed as this was probably not a seizure disorder likely metabolic. Additionally, the patient's glucose was low during the time of the twitching activity. 3. End-stage renal disease: Failing transplant. Patient is on prednisone 5 mg a day and will be for life to prevent transplant rejection. Patient has undergone several hemodialysis sessions and should be continued 3x a week. 4. Chronic osteomyelitis: Patient completed his six week course of Vancomycin and ceftaz from [**9-26**] to [**11-8**], and patient is to followup with Orthopedics for removal of the external fixator. Pain control with OxyContin and prn oxycodone. Additionally, this patient was found to have a left rib fracture, ribs #9 and 10 pain control and calcium supplementation. 5. Hypertension: Patient is hypertensive upon admission. Now is running in the 130s. Patient was restarted on amlodipine 5 mg two times a day and is stable. Next medication to add if needed would be metoprolol. 6. Anemia chronic: Patient was on Epogen dosing, however, has been D/C'd per Renal. 7. Depression: Patient was stable on his home medication of Celexa. 8. Fluids, electrolytes, and nutrition: Patient is on a renal diabetic diet, hemodialysis for repletion and supplements. Patient is full code. Patient is to be discharged to [**Hospital1 **]. Important measures to followup at [**Hospital1 **] are: 1. Pain control: Patient has a history of drug seeking behavior and has a narcotics contract with Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **]. Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] is to be paged upon this patient's discharge at [**Telephone/Fax (1) **]. He will be discharged on 20 mg two times a day of OxyContin and prn oxycodone. 2. Electrolytes each week for this patient's renal failure and hemodialysis 3x a week. 3. Vital signs everyday. Patient's blood pressure is now stable, however, if increases, the next drug to add would be metoprolol. 4. Fingersticks: Patient is a very brittle diabetic and on a good regimen [**First Name8 (NamePattern2) **] [**Last Name (un) **] evaluation. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Diabetes type 1. 2. Osteomyelitis. 3. Hypocalcemia. 4. End-stage renal disease failing transplant. 5. Hypertension. 6. Seizure-like activity secondary to metabolic abnormalities. RECOMMENDED FOLLOWUP: 1. Dr. [**First Name (STitle) 3636**] with [**Last Name (un) **] Diabetes Center, please call [**Telephone/Fax (1) 2384**] for an appointment. 2. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the Transplant Center on [**2139-12-3**] 2 p.m. for dialysis access. Patient previously had vein mapping done at his last admission. 3. [**Hospital 5498**] Clinic appointment with Dr. [**First Name (STitle) **], [**Telephone/Fax (1) 1113**] at [**Hospital Ward Name 23**] [**Location (un) **] 10:45 a.m. on the [**11-24**]. Additionally, he has an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, [**Hospital Ward Name 23**] Center, [**12-9**] at 11:20 a.m., [**Telephone/Fax (1) 250**]. 5. Patient should follow up with his primary care doctor, Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **], and call for an appointment, [**Telephone/Fax (1) 250**]. She has a narcotics contract with this patient. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg once a day. 2. Colace 100 mg 2x/day. 3. Folic acid 1 mg one time a day. 4. Atorvastatin 10 mg at night. 5. VG capsule one capsule every day. 6. Pantoprazole 40 mg delayed release EC q.24h. 7. Chlorhexidine 0.12% liquid solution to be used two times a day swish mouth as needed. 8. Amylase, lipase, protease two tablets with meals. 9. Calcium carbonate 500 mg take two tablets 3x a day. 10. Prednisone 5 mg take one tablet once a day. 11. Oxycodone 5 mg tablets one tablet p.o. q.4-6h. as needed for pain. 12. OxyContin 20 mg 2x/day. 13. Calcitriol 0.5 mcg one capsule p.o. once a day. 14. Tylenol 500 mg p.o. q.6h. as needed for pain. 15. Amlodipine 5 mg twice a day. 16. Patient will be D/C'd with insulin-sliding scale and scheduled insulin as per the [**Last Name (un) **] recommendations. Very important, when patient is discharged, please page Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) **] to let her know when this patient is leaving so she can know when to prescribe his next narcotics as they have a narcotic contract. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2139-11-12**] 11:27 T: [**2139-11-12**] 11:30 JOB#: [**Job Number 106443**]

[ "780.39", "250.12", "401.9", "530.81", "996.81", "E878.0", "443.9", "496", "276.7" ]

icd9cm

[ [ [] ] ]

[ "03.31", "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

6087, 6096

6117, 7310

7333, 8698

2923, 6065

1741, 2526

188, 695

2541, 2906

718, 812

1630, 1718

27,047

108,553

32841

Discharge summary

report

Admission Date: [**2174-11-13**] Discharge Date: [**2174-11-27**] Date of Birth: [**2123-8-16**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 348**] Chief Complaint: respiratory failure/tylenol OD Major Surgical or Invasive Procedure: Endotracheal intubation arterial line History of Present Illness: This is a 51 y/o female with PMH significant for HTN, NIDDM, hypothyroidism, who presented to an OSH early this morning with URI sx and cough x 2 weeks. Per the patient's husband, and later verified by the patient, she had been having URI sx and a non-productive cough for 2 weeks and occasionally low-grade temperature. She saw [**Name8 (MD) **] NP recently, who recommended OTC meds and also prescribed a "cough medicine", the name of which is not known. Her symptoms did not improve however and her cough progressed with symptoms of respiratory distress as well, prompting her to present at an OSH early this AM around 3 am. At the OSH, she was noted to be tachypneic in moderate distress, with VS of T 97.7, HR 77, BP 120's systolic, RR 26, SaO2 91%/RA. Her labs there was significant for WBC 17, Hct 31, tylenol level of 70 (at 4:40 am), Na 115 and ABG of 7.4/28/48 on ?room air. She received 400 mg moxifloxacin there, 125 mg IV solumedrol x 1, unknown dose of lasix, and a loading dose of IV NAC (10.5 gm). . Upon further history, the husband states that the patient has been taking NyQuil frequently due to her symptoms, however he is not sure how much she was taking as he is at work most of the day when she is at home. He notes that he thinks she finished an entire bottle of NyQuil on Friday (300 mL) and another half a bottle on Saturday (150 mL). It is unknown what formulation of NyQuil this was. He also does not know whether she was taking other cough/URI medications containing tylenol. Patient has a history of depression, however the husband denies any prior SI and does not believe the patient was trying to hurt herself with the NyQuil. . The patient was transferred to the [**Hospital1 18**] ED at 7 am due to lack of ICU beds at the OSH. Initial VS were T afebrile, BP 120's, HR 80's, 95%/4 L. The patient was in moderate resp distress with somnolent MS, so was electively intubated and set at AC 450x16, PEEP 5, FiO2 100%. An ABG was unable to be obtained prior to intubation. Tylenol level in the ED at 7:30 am was 45 (3 hours later from the initial level). She received vancomycin and doxycycline in the ED for CAP/ca-MRSA coverage. The patient was sent to the MICU for further management. Upon arrival, her ABG was 7.23/65/400's on the initial vent settings, so her RR was increased and TV was decreased. IV NAC was also started. . ROS unable to be obtained at this time. Past Medical History: PMH (per husband) - DM II Hypothyroidism HTN Asthma Depression h/o Diverticulitis Social History: SH - Lives with her husband and son in [**Name (NI) **]. Does not work. Smokes 1 ppd x >20 years. Drinks approx 6 beers/week. Admits cocaine use, which was positive on tox screen at time of admission. Family History: FH - NC Physical Exam: VS: Tc 96.6, BP 111/59, HR 70, RR 24, SaO2 95% on AC 350x30/0.6/5 General: intubated, sedated female HEENT: Pupils pinpoint and minimally reactive. Anicteric sclerae. ETT in place. Neck: supple, no JVD Chest: diffuse rhonchi throughout, no wheezes CV: RRR distant, no m/g/r Abd: soft, NT/ND, NABS, no HSM Ext: 1+ pitting pedal edema Neuro: sedated, does not withdraw to pain Pertinent Results: [**11-13**] EKG - NSR at 70 bpm, normal intervals and axis. No ischemic changes noted. Compared to OSH EKG [**2174-11-13**]. No prior available for comparison. . [**2174-11-13**] BLOOD WBC-15.7* RBC-4.45 Hgb-11.0* Hct-34.5* MCV-78* MCH-24.7* MCHC-31.7 RDW-20.4* Plt Ct-245 Neuts-93.4* Bands-0 Lymphs-3.4* Monos-2.5 Eos-0.6 Baso-0 PT-21.3* PTT-33.0 INR(PT)-2.0* Glucose-108* UreaN-9 Creat-0.4 Na-118* K-4.2 Cl-83* HCO3-23 AnGap-16 ALT-25 AST-74* AlkPhos-150* Amylase-16 TotBili-2.1* DirBili-1.1* Lipase-18 Calcium-7.6* Phos-4.9* Mg-1.5* Albumin-2.2* Ammonia-41 TSH-0.44 HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE IgM HAV-NEGATIVE HCV Ab-POSITIVE AMA-NEGATIVE Smooth-NEGATIVE [**Doctor First Name **]-NEGATIVE AFP-1.7 IgG-2070* IgA-272 IgM-392* BLOOD ASA-NEG Ethanol-NEG Acetmnp-45.6* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [**2174-11-13**] BLOOD pO2-413* pCO2-65* pH-7.23* calTCO2-29 Base XS--1 [**2174-11-13**] URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-POS amphetm-NEG mthdone-NEG . [**2174-11-23**] BLOOD WBC-8.3 RBC-3.71* Hgb-9.2* Hct-29.9* MCV-81* MCH-24.7* MCHC-30.7* RDW-22.2* Plt Ct-136* PT-16.9* PTT-34.4 INR(PT)-1.5* Glucose-160* UreaN-11 Creat-0.5 Na-135 K-3.8 Cl-99 HCO3-34* AnGap-6* ALT-61* AST-154* AlkPhos-204* TotBili-1.6* Calcium-7.9* Phos-3.3 Mg-1.8 . [**2174-11-13**] URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-0.2 pH-7.0 Leuks-NEG RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0-2 Urine Osmolal-395 . HCV VIRAL LOAD (Final [**2174-11-21**]): 1,490,000 IU/mL. . HCV GENOTYPE (Final [**2174-11-23**]): Hepatitis C genotype, 1. . [**2174-11-13**] CXR: FINDINGS: A single AP upright view of the chest is lordotic. The lateral aspect of the right costophrenic angle is excluded from the film. The cardiac silhouette appears normal in size. There is significant prominence of the interstitial markings bilaterally. There are ill-defined fluffy airspace opacities throughout both lung fields. Fullness at the hila bilaterally could represent an element of pulmonary edema. There is significant scoliosis of the thoracic spine. IMPRESSION: Findings consistent with a diffuse bilateral, multifocal airspace process, such as ARDS or multifocal pneumonia. Component of interstitial edema is likely. . [**2174-11-13**] RUQ U/S: RIGHT UPPER QUADRANT ULTRASOUND: The liver is heterogeneous in echotexture and shrunken with a nodular contour, consistent with cirrhosis. A subcentimeter simple cyst is noted within the hepatic dome. Additionally, within the right lobe, there is a subtle, ill-defined hypoechoic lesion measuring 1.7 x 2.8 x 2.6 cm. Remaining liver appears unremarkable. The gallbladder displays evidence of cholelithiasis, along with mild-to-moderate wall thickening and wall edema. A moderate amount of ascites is noted surrounding the liver and within the lower quadrants bilaterally. DOPPLER ULTRASOUND: Portal vein is patent with normal hepatopetal flow. Hepatic venous and arterial systems display appropriate waveforms with a slightly increased resistive indices noted within the main hepatic artery, likely related to underlying parenchymal disease. Common bile duct is normal measuring approximately 0.35 and 0.5 cm. No intrahepatic ductal dilatation is identified. IMPRESSION: 1. Shrunken and nodular liver, consistent with cirrhosis. Cholelithiasis with wall thickening and wall edema, most likely secondary to third spacing from underlying liver disease. 2. Unremarkable hepatic vascular doppler ultrasound. 3. Moderate amount of intra-abdominal ascites. 4. Possible abnormal hypoechoic lesion within the right lobe. This could be further assessed with dedicated MRI or contrast-enhanced multiphasic CT. . [**2174-11-14**] TTE: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . IMPRESSION: Normal global and regional biventricular systolic function. No pathologic valvular abnormality seen. . [**2174-11-21**] CXR: CHEST PA AND LATERAL: There continues to be improvement of multifocal air space consolidation with residual areas of opacification. Diffuse bilateral reticular opacities are coarser with slightly improved aeration in the right lung base. This could represent the beginnings of a fibrotic repair with post-inflammatory bronchiectasis. No pleural effusion. Cardiomediastinal silhouette is unchanged. IMPRESSION: Diffuse bilateral reticular opacities with slight improved aeration of the right lung base, which could represent post-inflammatory bronchiectasis and beginnings of a fibrotic repair. Brief Hospital Course: # Respiratory failue - Bilateral airspace disease on CXR, most likely secondary to community acquired PNA, +/- [**Doctor Last Name **], given PaO2/FiO2 ratio. She was intubated and started on ABX (vancomycin and levofloxacin). Urine legionella was negative. After 4 days, vancomycin was discontinued as cultures remained negative. She was diuresed and treated for reactive airways with nebulizers and solumedrol. She was extubated on day 5, and did well. She completed a 7 day course of levofloxacin. Oxygen was gradually titrated down over the course of several days. Lasix (initially lasix gtt in ICU, then 40mg IV bid, then 80 PO BID at time of discharge) for component of pulmonary edema, with good effect and brisk diuresis. Subsequent CXR demonstrated improved aeration with coarsening of interstitial markings, perhaps indicating an element of fibrotic repair. By the time of discharge she was weaned off oxygen and able to ambulate without shortness of breath, though still satting only in the low 90's. She was discharged with the intent of continuing diuresis and with close follow-up in place. . # Tylenol toxicity - Initially treated with NAC protocol. After her history became more clear, it was felt that this was an accidental overdose. Psychiatry was consulted, who agreed there was no evidence of intention to harm. She should be instructed to limit her acetaminophen use in the future to 2gm/day. . # HCV cirrhosis - Imaging demonstrated a cirrhotic-appearing liver on RUQ ultrasound. Subsequent workup demonstrated that Mrs. [**Known lastname 5987**] was HCV positive, with HCV VL of 1.5 million, genotype 1. She was previously unaware of her HCV status or diagnosis of cirrhosis. She was HAV Ab negative, HBV sAB and cAB positive. She did have evidence of hepatic dysfunction, with INR between 1.5-2.0 (although component of acetaminophen toxicity makes it difficult to assess her baseline), albumin 2.2, and hyponatremia as below. AFP was 1.7. She was set up with an appointment with a hepatologist near her home, Dr. [**Last Name (STitle) **], on [**12-1**] for follow-up. An EGD was not done in-house to assess for varices. She did have moderate ascites, and was discharged on maintenance Lasix, though it is unclear whether she will need to remain on this long-term. Of note, RUQ U/S also demonstrated a 1.7 x 2.8 x 2.6 cm hypoechoic lesion in the right lobe of the liver, which will need to be followed up as an outpatient by CT or MRI. . # Hyponatremia - Markedly hyponatremic on admission to 118. Thought to be a mixed picture at first, and in retrospect likely complicated by concommittant cirrhosis. Urine Na was 10, elevated urine osms of 400, FeNa 0.1%. After a brief trial of normal saline, which did not raise her sodium, it was thought that she was hypervolemic, and diureseis was initiated via Lasix drip, with good effect. After cessation of Lasix drip, her sodium again began to drop to 130, and again responded to maintainance Lasix IV and then PO. . # DM - Metformin was held while in-house. She was initially covered with glargine and humalog sliding scale, but did require an insulin gtt while she was on solumedrol. After solumedrol was stopped, she was converted back to standing and sliding scale insulin. . # Hypothyroidism - The patient was continued on home dose of levothyroxine, 50mcg daily. . # HTN - Her home atenolol was held initially but restarted after her extubation and she became hypertensive. . # Depression/Delerium - Effexor were held during her ICU stay due to mild to moderate delerium, and was restarted at the time of discharge. The patient's mental status cleared significantly over the course of her hospital stay. . # F/E/N - Diabetic diet. Electrolytes were repleted as needed. . # Pneumoboots were used for DVT prophylaxis . . # Communication - With husband, [**Name (NI) **] [**Name (NI) 5987**] (c) [**Telephone/Fax (1) 76459**]; (h) [**Telephone/Fax (1) 76460**] . # The patient was a full code. Medications on Admission: (doses confirmed with the husband) Levothyroxine 50 mcg daily Singulair 10 mg po daily Atenolol 25 mg daily Lorazepam 2 mg PO QID prn (taking at least 3x/day) Metformin 500 mg [**Hospital1 **] Effexor XR 225 mg daily Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID prn as needed for anxiety or back spasm. Disp:*21 Tablet(s)* Refills:*0* 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*2 Disk with Device(s)* Refills:*2* 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation Every 4 hours as needed for shortness of breath, coughing or wheezing. Disp:*1 * Refills:*2* 8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Effexor XR 150 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: -respiratory failure -acetaminophen toxicity -hepatitis C -cirrhosis -hyponatremia -delerium -hypothyroidism -DM -HTN -depression/anxiety Discharge Condition: Good. Mental status improved, LFTs stable, respiratory status at baseline. Discharge Instructions: -It is important that you continue to take your medications as directed. - Your Effexor was stopped during your hospitalization and restarted at discharge at a lower dose. You should discuss with your new PCP whether this dose needs to be titrated. -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 39375**], internal medicine, [**12-12**] at 2pm. WE WOULD LIKE YOU TO SEE A DOCTOR WITHIN A FEW DAYS AFTER DISCHARGE. IF YOU ARE NOT GOING TO SEE DR. [**Last Name (STitle) **] ON [**2173-12-2**], PLEASE CALL DR. [**Last Name (STitle) **] AT [**0-0-**] FOR AN EARLIER APPOINTMENT. . You have an appointment with Dr. [**Last Name (STitle) **] in liver clinic on [**12-1**] at 4pm. Please call [**Telephone/Fax (1) 76461**] for directions. . Dr. [**Last Name (STitle) 497**] of the liver department at [**Hospital1 18**] will have his office call to schedule a follow up appointment with him in the next [**1-1**] wks.

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icd9cm

[ [ [] ] ]

[ "96.72", "96.04" ]

icd9pcs

[ [ [] ] ]

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39896

Discharge summary

report

Admission Date: [**2180-11-18**] Discharge Date: [**2180-12-8**] Date of Birth: [**2115-8-12**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7055**] Chief Complaint: Cardiogenic shock s/p STEMI and VF arrest Major Surgical or Invasive Procedure: Pulmonary Intubation Intracardiac Defibrillator implantation Cardiac catheterization with placement of three bare metal stents PICC line placement History of Present Illness: Mr. [**Known lastname 27063**] is 65 year-old man who does not regularly seek medical care a history of myocardial infarction and pulseless arrest five days prior to admission who was transferred to [**Hospital1 18**] early this AM for urgent CABG. Mr. [**Known lastname 27063**] was in his usual state of health until [**Known lastname 766**], [**11-13**]. On [**11-13**], after pt had been complaining of 3d chest pain, he had witnessed cardiac arrest. His female companion, a retired nurse, initiated CPR and performed until arrival of EMS 8-10min later. Found to be in agonal respirations, monitor showed VF, and pt was shocked twice --> en route to hospital, noted asystole --> epi and atropine --> A-fib --> amiodarone bolus --> ER, where intubated (sats 84%), in cardiogenic shock with SBPs in 90s, then in VF again, shocked once --> EKG revealed STEMI --> took to cath lab, where stented BMSx3 to LAD. Once opened LAD, went into VFib, shocked 360J x1 and given amiodarone bolus 450mg. Went to CCU with intra-aortic balloon pump, and began cooling protocol. CXR at that time showed multifocal lobar PNA (presumed aspiration PNA), and was started on Ceftriaxone and Unasyn. . On [**11-15**], pt was noted to have Torsades vs polymorphic VT, given K and Mg, and shocked with 200J. He was extubated [**11-17**]. Following extubation his family reports that his mental status gradually improved to baseline on Thursday evening. Early this AM, c/o 10/10 chest pain. EKG with ST elevatations in V1-4 --> heparin, plavix, morphine, SL nitro x3, taken to cath lab, where BMS placed to proximal LAD. Then dissected mid LAD, which required stenting of the dissected area. It was presumed that the culprit lesions were the proximal and mid LAD in-stent thromboses. . Neurology was consulted after admission given concern for anoxic brain injury. They had been following, and daughter expressed concern re: some difficulties with time perception (he thought that hours were passing when only minutes had passed) on morning of transfer. RNs also noted him to be less conversant, mumbling and unable to focus on their questions. . Note, pt also had episode of bloody secretions from OG tube at OSH . Transferred to CCU for management of cardiogenic shock. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: CAD, Smoker 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: **[**2180-11-13**], Cardiac Catheterization: LM: 50%, heavily calcified LAD, 100% proximal thrombotic occlusion, calcified LCX with 90% stenosis, 100% RCA occlusion, 55% LVEF, LV pressures 85/2, LVEDP 18 --> BMSx2 to ostium of LAD, BMSx1 to proximal LAD **[**2180-11-18**], Cardiac Catheterization: BMS placed to proximal LAD. Then dissected mid LAD, which required stenting of the dissected area. -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -At 3-4y of age, had severe pertussis with high fevers. Lapsed into a coma lasting weeks. Did not speak for three years but gradually resumed full childhood levels of activity. -Lifelong focal learning impairment presumed to be from the above-described encephalopathy. -? aortic aneurysm -PVD Social History: SOCIAL HISTORY: Son is [**Name2 (NI) 87760**] surrogate decision maker, but pt's siblings have been supportive and assist with decision making. One sister is [**Name8 (MD) **] RN and helps interpret medical information for pt's children. Children report pt lives alone at baseline, currently on disability. Pt was divorced when children were young, pt had minimal contact with them when they were growing up. Son sees pt once per month or so and takes pt shopping. [**Last Name (un) **] rarely sees pt. Son relayed hx of pt having anoxic brain injury as a child. Pt has residual cognitive impairment, notably impaired judgment. Children report pt has had a hard life. They report pt has a significant other, who is [**Name8 (MD) **] RN. Children express concern pt has always been avoidant of seeing doctors and taking [**Name5 (PTitle) 4982**], and fear he will not comply with treatment. Sister relayed life-long hx of familytrying to meet pt's care needs. She herself has made extensive attempts at arranging home care and psychiatric services, but pt never keeps appts, and often is not home to allow services in. Per family t has hx of 1 psych admission for SI in the past. Pt has extensive hx of impulsive behavior and poor judgement. Family relayed that they promised pt's mother they would look after him. SW advised family to allow professionals at rehab to help determine and plan for pt's long term care needs. Family History: per OSH records, strong family hx CAD, but details unknown Physical Exam: On Admission: GENERAL: Intubated, sedated. Withdrawing to pain HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink NECK: Supple with JVP to ears. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Mostly clear without crackles, wheezes or rhonchi except R lateral lung with decreased BS. ABDOMEN: Soft, NTND. No HSM. EXTREMITIES: Cool to touch. L 1st and 2nd toes blue, and 2nd toe with area of ulcer at tip of toe ~3/4 cm. SKIN: see above. PULSES: Carotid L 2+, R 1+; Radial L R ; Femoral L R ; DP L R On discharge: 97.3 (97.8 Max) 93/51 (90s/50s)- 60 (60s) 96% on 0.5L GENERAL: sitting up in bed eating, alert, NAD. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva pink, poor dentition CARDIAC: RRR, normal S1, split S2. [**1-29**] holosystolic murmur loudest at LLSB. No thrills, lifts. LUNGS: transmitted upper airway sounds bilaterally, Equal air entry BL. CHEST: L sided ICD in place. No erythema. ABDOMEN: Soft, ND. nontender. No HSM. EXTREMITIES: FROM. No edema. Warm, no cyanosis of toes, stable ulcer over L 2nd phalanx Neurologic: Alert and answering questions appropriately. Responding to simple commands, moving all extremities. Oriented x3. Pertinent Results: Admission Labs: [**2180-11-18**] 06:20AM PT-12.5 PTT-31.5 INR(PT)-1.0 [**2180-11-18**] 06:20AM WBC-13.9* RBC-3.91* HGB-12.1* HCT-35.9* MCV-92 MCH-31.0 MCHC-33.7 RDW-14.5 [**2180-11-18**] 06:20AM CALCIUM-8.2* PHOSPHATE-4.6* MAGNESIUM-2.1 [**2180-11-18**] 06:20AM CK-MB-GREATER TH cTropnT-20.83* [**2180-11-18**] 06:20AM GLUCOSE-152* UREA N-15 CREAT-0.7 SODIUM-137 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15 [**2180-11-18**] 06:30AM O2 SAT-86 [**2180-11-18**] 06:30AM GLUCOSE-141* LACTATE-2.5* K+-4.0 [**2180-11-18**] 06:30AM TYPE-ART TEMP-36.1 PO2-50* PCO2-34* PH-7.38 TOTAL CO2-21 BASE XS--3 [**2180-11-18**] 09:27AM URINE RBC->1000* WBC-59* BACTERIA-NONE YEAST-NONE EPI-0 [**2180-11-18**] 09:27AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM [**2180-11-18**] 09:27AM URINE COLOR-Red APPEAR-Hazy SP [**Last Name (un) 155**]-1.041* [**2180-11-18**] 11:23AM freeCa-1.15 [**2180-11-18**] 11:23AM LACTATE-3.0* K+-4.6 [**2180-11-18**] 11:23AM TYPE-ART PO2-58* PCO2-36 PH-7.40 TOTAL CO2-23 BASE XS--1 [**2180-11-18**] 03:05PM PT-14.0* PTT-35.5* INR(PT)-1.2* [**2180-11-18**] 03:05PM PLT SMR-NORMAL PLT COUNT-192 [**2180-11-18**] 03:05PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2180-11-18**] 03:05PM NEUTS-86* BANDS-0 LYMPHS-7* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2180-11-18**] 03:05PM WBC-12.0* RBC-3.91* HGB-12.3* HCT-35.8* MCV-92 MCH-31.4 MCHC-34.3 RDW-14.4 [**2180-11-18**] 03:05PM %HbA1c-5.9 eAG-123 [**2180-11-18**] 03:05PM ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-5.3* MAGNESIUM-2.7* [**2180-11-18**] 03:05PM CK-MB-423* MB INDX-5.1 cTropnT-20.85* [**2180-11-18**] 03:05PM LIPASE-13 [**2180-11-18**] 03:05PM ALT(SGPT)-720* AST(SGOT)-1152* LD(LDH)-2750* CK(CPK)-8221* ALK PHOS-80 AMYLASE-27 TOT BILI-0.8 [**2180-11-18**] 03:05PM GLUCOSE-144* UREA N-22* CREAT-0.9 SODIUM-139 POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-21* ANION GAP-16 [**2180-11-18**] 06:00PM O2 SAT-96 [**2180-11-18**] 06:00PM LACTATE-2.0 [**2180-11-18**] 06:00PM TYPE-ART TEMP-37.6 RATES-16/ TIDAL VOL-500 PEEP-5 O2-50 PO2-97 PCO2-39 PH-7.41 TOTAL CO2-26 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED . Labs on Discharge: [**2180-12-8**] 06:45AM BLOOD WBC-9.8 RBC-3.40* Hgb-10.2* Hct-31.3* MCV-92 MCH-30.1 MCHC-32.6 RDW-16.8* Plt Ct-220 [**2180-12-8**] 06:45AM BLOOD PT-34.4* PTT-35.6* INR(PT)-3.5* [**2180-12-8**] 06:45AM BLOOD Glucose-90 UreaN-24* Creat-0.8 Na-139 K-4.0 Cl-104 HCO3-28 AnGap-11 [**2180-12-8**] 06:45AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.2 ECHO [**11-18**]: The left atrium is normal in size. The right atrial pressure is indeterminate. Left ventricular wall thicknesses and cavity size are normal. There is severe regional left ventricular systolic dysfunction with akinesis of the anterior and anterolateral walls, dyskinesis of the anteroseptal wall, and hypokinesis of the mid inferoseptum and inferolateral walls. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). The estimated cardiac index is depressed (<2.0L/min/m2). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with moderate global free wall hypokinesis. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is at least mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. CT FINDINGS [**11-18**]: There is no evidence of intracranial hemorrhage, edema, mass effect, or large acute territorial infarction. There are diffuse periventricular, subcortical and semiovale hypodensities, slightly more focal left superior periventricular (series 2, image 22); all representing a sequela of chronic small vessel disease. The ventricles are minimally dilated, nonspecific. Incidental note is made of basal ganglia calcifications as well as calcifications of the left greater than right internal carotid arteries. Mild mucosal thickening of the maxillary sinuses bilaterally as well as the ethmoid air cell and the sphenoid sinus. Mastoid air cells are clear and well aerated. No suspicious lytic or sclerotic bony lesions. IMPRESSION: 1. No acute intracranial process. 2. Minimal, nonspecific dilatation of the ventricles. CXR [**11-18**]: Portable AP chest radiograph was reviewed with no prior studies available for comparison. Heart size is mildly enlarged. Mediastinum is unremarkable. Widespread alveolar opacities in the perihilar, upper lung, and lower lobe areas are most likely consistent with pulmonary edema giving patient's history. They are accompanied by minimal amount of pleural effusion. Otherwise, the differential diagnosis would include ARDS or extensive infections. Pulmonary contusions are less likely. . [**2180-11-23**]: Cardiac Catheterization: COMMENTS: 1. Limited selective coronary angiography showed two vessel coronary artery disease. The LMCA had 60% origin stenosis. The LAD had 50-60 origin calcified stenosis prior to previous stents. Prior LAD stents were patent. The LCx had 80-90% origin stenosis as well as a 70% mid LCx stenosis. The RCA was known to be totally occluded and fills via left to right collaterals and was not engaged. 2. Resting hemodyamics revealed elevated right and left sided filling pressure with RVEDP of 14 mmHg and mean PCWP of 25 mmHg. There was moderate pulmonary hypertension with pasp of 54/23 mmHg. There was borderline cardiac index of 2.4 L/min/m2 on dopamine. There was normal blood pressure of 106/67 mmHg, however in the setting of moderate dopamine. 3. Successful placment of IABP. 4. Successful placement of temporary pacemaker via right femoral vein. 5. Successful PTCA and stenting of mid LCx with a 3.0x18mm Vision bare metal stent and origin of LM into Lcx with a 3.0x23mm Vision bare metal stent. The LM stent segment was postdilated to 4.0mm. 6. Successful PTCA only rescue of LAD with 3.0x15mm NC balloon with 40% residual stenosis. . [**11-27**] ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. There is severe regional left ventricular systolic dysfunction with akinesis of the mid inferior and inferolateral wall, mid to distal anterior wall and anterior septum and all apical segments. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-25**]+) mitral regurgitation is seen. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severe regional LV systolic dysfunction consistent with mutli-vessel coronary artery disease. Mild to moderate mitral regurgitation. . [**12-4**]: CXR FINDINGS: As compared to the previous radiograph, there is a massive increase in density of the pre-existing relatively extensive bilateral apical opacities. Given the co-existing increase in size of the cardiac silhouette, increasing pulmonary edema must be suspected. On the right, a small pleural effusion could have newly occurred. . ECG [**12-5**]: Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Right axis deviation. Q waves with ST segment elevations in leads V1-V5 raise concern for evolving myocardial infarction with possible involvement of the conduction system. Clinical correlation is suggested. . Brief Hospital Course: A 65M with PVD, static encephalopathy [**1-25**] childhood pertussis, lost to medical care who presented to OSH in VF/asystolic arrest on [**11-13**] and s/p BMx3 to LAD on [**11-14**] c/b another VF arrest. Placed on cooling protocol and treated for pneumonia; shocked for torsades on [**11-15**], extubated on [**11-17**]. Had STEMI on [**11-18**] with LAD in-stent restenosis; placement of BMS c/b mid-LAD dissection; EF 20-25%. [**Hospital1 **] course since [**11-18**] c/b CHF (EF 20-25%, [**12-25**]+ MR) with difficulty weaning off pressors, ischemic right foot (improved on A/C), PEA arrest on [**11-22**], NSTEMI on [**11-23**] with LCx dz s/p POBA & BMSx2, VT/VF arrest on [**11-28**] on amio and s/p ICD on [**11-29**]. . # s/p STEMI x2, Vfib arrest, and cooling protocol, transferred to [**Hospital1 18**] for CABG. It was eventually determined that he is not a candidate for CABG. He was continued on ASA, Plavix, Atorvastatin 40 mg. While in the unit, on [**11-22**] he had a PEA arrest and was successfully resuscitated. EKG showed NSTEMI and he was taken to the cath lab which demonstrated LCx disease and he had 2 bare-metal stents placed. On [**11-28**] he had a VT/VF arrest and was cardioverted and loaded with amiodarone. On [**11-29**] he had an ICD device implanted and actively diuresed. He is on aspirin and Prasugrel and should remain on these medicines unless Dr. [**Last Name (STitle) 31888**] (out patient cardiologist) says that it is OK to stop them. Any discharge plan will need to include strict adherance to Prasugrel regimen. He was started on coumadin [**1-25**] low EF, INR 3.4 at time of discharge and warfarin held. Will need INR checked on Saturday [**12-9**] and restart Warfarin at low dose because of interaction with amiodarone and vancomycin, suggest 1-2 mg daily. He was discharged on Amiodarone 400mg [**Hospital1 **] and will need to decrease dose to Amiodarone 400mg daily x 3 weeks, final day [**2180-12-29**] then change to Amiodarone to 200mg daily. . # Acute systolic Congestive Heart Failure: On recent ECHO, overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). He was initially on dopamine for pressure support, weaned off of dopamine and diuresed when he presented with what was likely flash edema secondary to a panic attack. His weight at discharge is 59.6 (131 pounds) kg and he is euvolemic on 80 mg of Lasix daily. Lasix was decreased to 40 mg daily today and additional 40 mg can be given in pm if weight starts to increase. ACEi therapy has been held secondary to borderline BP. Lisinopril at 2.5 mg should be started when BP allows. . # Anoxic brain injury: suspected given amount of time with poor circulation. CT without acute inschemia, however, this does not rule out anoxic brain injury. As per family he was back to his baseline following extubation the second time. This baseline seems to be quite limited and has impaired his judgement and ability to care for himself in the past per family. He will need social service evaluation. . # Multilobar PNA concerning for aspiration PNA; unclear circumstances of re-intubation prior to arrival at [**Hospital1 18**], however, likely in setting of cardiogenic shock to preserve airway. He developed fever, leukocytosis, with productive cough and infiltrates on CXR and was treated with Cefepime/Vancomycin for health care assoicated pneumonia. Antibiotics now finished and stable on RA. . # Clostridium Difficile: Patient developed diarrhea and leukocytosis and was found to be c. diff positive. He was started on Metronidazole 500mg TID and chagned to vancomycin 250mg PO Q6H after ID consult. He will need a 2 week course of this medication. His stool is now formed and WBC trending down. . # H/o bloody secretions from OGT at OSH before admission. He was started on Pantoprazole 40 mg IV Q24H and then was transitioned to a PO regimen. Hct has been stable with no further evidence of GI bleed. . # Elevated LFTs, likely related to ischemic injury. These trended downwards. Admit to OSH: Pt had c/o 3 days of CP but refused to be evaluated. . # Peripheral Vascular Disease: After cardiac cath, left #1-#3 toes became acutely cyanotic likely related to pressors vs embolic phenomenon vs Intra aortic balloon pump-related. IABP was discontinued and he was started on heparin gtt with bridge to warfarin. Perfusion improved after pressors d/c and IABP d/c. Peripheral pulses palpable but faint at the time of discharge. He will need to continue warfarin with goal INR 2.0-2.5 for 3 months as above. He will need follow up with ankle brachial index measurement. [**Hospital1 **] on Admission: None Discharge [**Hospital1 **]: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**12-26**] Tablet, Sublinguals Sublingual PRN (as needed) as needed for chest pain. 5. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 8. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 3 weeks: Start [**2180-12-9**]. 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Start: [**2180-12-30**] after 400 mg daily is finished . 11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): Day #1 [**12-4**], needs total of 2 weeks course. 14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 15. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6 hours) as needed for pain. 16. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day: Please give additional 40 mg in afternoon if weight is trending up. Discharge Disposition: Extended Care Facility: [**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**] Discharge Diagnosis: ST Elevation Myocardial Infarction Ventricular Fibrillation Arrest C difficile colitis Multilobar Pneumonia Acute systolic Congestive Heart Failure Cardiogenic shock Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You had a cardiac arrest and a heart attack and needed shocks and CPR to start your heart again. Three bare metal stents were placed in your heart arteries. You underwent a cooling protocol to protect your brain after the heart attack. During your hospital stay, you developed a pneumonia from the cardiac arrest, and a bowel infection with a bacteria called c difficile. Your heart function is very weak and an internal defibrillator was placed so that it will shock your heart muscle if you ever have a cardiac arrest again. No lifting your left arm over your head for at least 6 weeks, you may shower and wash your hair. No lifting more than 10 pounds with your left arm for 6 weeks. You will need to stay on Plavix every day until Dr. [**Last Name (STitle) 31888**] tells you it is OK to stop. No not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]. Weigh yourself every morning, call Ddr. [**Last Name (un) 31888**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . Medication changes: (no prescriptions taken at home) 1. Start a multivitamin and folic acid to help your nutrition 2. Start Amiodarone and Metoprolol to control your heart rhythm 3. Start Atorvastatin to lower your cholesterol 4. Start Aspirin and Prasugrel to keep the stents open. Do not stop taking these medicines unless Dr. [**Last Name (STitle) 31888**] says that it is OK. 5. Start furosemide to keep fluid from accumulating 6. Start Imdur to prevent chest pain, take nitroglycerin if you have chest pain. Dr. [**Last Name (STitle) 31888**] should know about any chest pain. 7. Start Olanzapine to help you stay calm at night 8. Start pantoprazole to prevent bleeding 9. Start Vancomycin to treat the diarrhea 10. Start tylenol and oxycodone to help with any pain. Followup Instructions: Name: [**Last Name (LF) 31888**], [**First Name7 (NamePattern1) **] [**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**] Appointment: [**Last Name (LF) 766**], [**12-26**], 11AM .

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

20622, 20721

14406, 19036

347, 496

20931, 20931

6501, 6501

22913, 23273

5152, 5213

20742, 20910

21109, 22115

5228, 5228

2891, 3358

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266, 309

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524, 2789

6517, 8753

19050, 20599

20946, 21085

3389, 3685

2833, 2871

3718, 5136

31,880

137,656

32448

Discharge summary

report

Admission Date: [**2120-12-22**] Discharge Date: [**2121-1-14**] Date of Birth: [**2055-5-31**] Sex: F Service: MEDICINE Allergies: Vicodin Attending:[**First Name3 (LF) 1162**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: intubation s/p ERCP with double pigtail catheter placement s/p ERCP with stent placement History of Present Illness: 65 yo woman transferred from [**Hospital **] Hospital with RUQ pain. She has had this same pain intermittently since the summer, mostly after eating, but it had not remitted since [**Holiday 1451**]. She denied changes in her BM's (BRBPR, melena, acholic stools). She presented to [**Hospital **] Hospital on the day of admission and had an US showing 8mm CBD dilation at porta hepatis and 1.4mm CBD distal to PH with biliary sludge. She was noted to have elevated LFT's with bili 4. She was given Unasyn and an unknown amount of IVF and transferred here for ERCP. . In the ED, VS: T 98.2->T 102.3, BP 134/96 RR 20 HR 96 Sat 95% 2L NC. She was given zosyn 4.5gm iv, 2L NS, 400mg ibuprofen and dilaudid. Surgery and ERCP were consulted. She was transferred to the [**Hospital Unit Name 153**] for bedside ERCP. Past Medical History: Spina bifida, wheelchair bound Seizure disorder Gallstones Hypertension Anxiety GERD OA right knee Social History: Denies current tobacco, smoked previously ? 1PPD for several years, quit several years ago, occasional etoh (unspecified), denies illicit drug use. Family History: Father [**Name (NI) 75742**] MI age 75, sister deceased [**3-1**] CAD age 78 Physical Exam: Admission physical exam: vitals: T 97.0 oral BP 112/95 HR 105 RR 19 Sat 86% 2L->97% on 2L gen: NAD heent: PERRL, sclera anicteric, EOMI, OP clear neck: JVP 6cm, no LAD pulm: Decreased BS left base, exam limited by posterior mass, no wheezes, rales rhonchi cv: tachycardic but regular rhythm, no murmurs, rubs, gallops, 2+ DP pulses bilaterally abd: Slightly distended, TTP RUQ, rare BS, no masses extr: LLE slightly warm/erythematous diffusely, non-tender, no edema (per patient, baseline) neuro: A&Ox3, CN II-XII intact back: large, midline soft tissue prominance from T8 caudally Pertinent Results: [**2120-12-22**] 05:50PM BLOOD WBC-24.4* RBC-3.92* Hgb-13.0 Hct-36.6 MCV-93 MCH-33.0* MCHC-35.4* RDW-13.1 Plt Ct-360 [**2120-12-23**] 05:23AM BLOOD WBC-35.0* RBC-3.63* Hgb-12.0 Hct-35.6* MCV-98 MCH-33.0* MCHC-33.7 RDW-12.5 Plt Ct-412 [**2120-12-27**] 05:14AM BLOOD WBC-10.2 RBC-3.31* Hgb-10.7* Hct-31.3* MCV-95 MCH-32.4* MCHC-34.3 RDW-13.1 Plt Ct-317 [**2120-12-22**] 05:50PM BLOOD Neuts-75* Bands-17* Lymphs-1* Monos-3 Eos-1 Baso-0 Atyps-0 Metas-3* Myelos-0 [**2120-12-22**] 05:50PM BLOOD Glucose-106* UreaN-18 Creat-0.6 Na-138 K-3.6 Cl-99 HCO3-25 AnGap-18 [**2120-12-24**] 12:17PM BLOOD Glucose-116* UreaN-28* Creat-1.3* Na-138 K-3.9 Cl-110* HCO3-15* AnGap-17 [**2120-12-27**] 05:14AM BLOOD Glucose-88 UreaN-31* Creat-1.3* Na-138 K-3.6 Cl-107 HCO3-21* AnGap-14 [**2120-12-22**] 05:50PM BLOOD ALT-83* AST-150* AlkPhos-231* Amylase-24 TotBili-3.7* [**2120-12-25**] 03:07AM BLOOD ALT-52* AST-61* LD(LDH)-196 AlkPhos-214* TotBili-1.4 [**2120-12-26**] 02:04PM BLOOD ALT-40 AST-42* AlkPhos-205* TotBili-2.2* [**2120-12-27**] 05:14AM BLOOD ALT-43* AST-63* AlkPhos-267* TotBili-4.4* [**2120-12-23**] 03:10AM BLOOD Calcium-6.7* Phos-3.9 Mg-1.7 [**2120-12-27**] 05:14AM BLOOD Calcium-8.3* Phos-3.2# Mg-1.8 [**2120-12-23**] 05:23AM BLOOD Phenyto-9.9* [**2120-12-23**] 03:04AM BLOOD Type-ART Temp-35.8 pO2-58* pCO2-50* pH-7.16* calTCO2-19* Base XS--10 Intubat-NOT INTUBA [**2120-12-26**] 08:33PM BLOOD Type-ART Temp-37.4 Rates-/20 Tidal V-400 PEEP-8 FiO2-40 pO2-85 pCO2-33* pH-7.42 calTCO2-22 Base XS--1 Intubat-INTUBATED Vent-SPONTANEOU [**2120-12-27**] 10:15AM BLOOD Type-ART Temp-38.3 Rates-/18 Tidal V-380 PEEP-8 FiO2-40 pO2-102 pCO2-42 pH-7.30* calTCO2-21 Base XS--5 Intubat-INTUBATED Vent-SPONTANEOU [**2120-12-24**] 01:35AM BLOOD freeCa-1.04* . [**2120-12-22**] 5:50 pm BLOOD CULTURE 1ST SET. **FINAL REPORT [**2120-12-25**]** AEROBIC BOTTLE (Final [**2120-12-25**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 21-2261B ([**2120-12-22**]). ANAEROBIC BOTTLE (Final [**2120-12-25**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 241-2261B ([**2120-12-22**]). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC BOTTLE (Final [**2120-12-25**]): ESCHERICHIA COLI. SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. [**2120-12-26**] 1:01 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2120-12-26**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): OROPHARYNGEAL FLORA ABSENT. YEAST. SPARSE GROWTH. [**2120-12-22**] 09:20PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-15 Bilirub-MOD Urobiln-8* pH-6.5 Leuks-SM . [**12-27**] Echo There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no pericardial effusion. IMPRESSION: No pericardial effusion . PORTABLE AP CHEST RADIOGRAPH COMPARED TO [**2120-12-24**]. Low lung volumes are again noted with widespread bilateral pulmonary opacities predominantly in perihilar right lower lobe distribution but also with some asymmetric involvement of left upper lobe. Bilateral pleural effusion is noted as well as bibasilar atelectasis. The ET tube tip is 5 cm above the carina. The NG tube tip can be followed to the level of upper mid abdomen. Overall, there is no significant change compared to the previous film. . LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2120-12-26**] 3:59 PM LIVER OR GALLBLADDER US (SINGL Reason: CHOLANGITIS ? OBSTRUCTED CBD [**Hospital 93**] MEDICAL CONDITION: 65 year old woman with cholangitis REASON FOR THIS EXAMINATION: obstructed CBD? INDICATION: Cholangitis. Evaluate for obstructed CBD. COMPARISON: ERCP [**2120-12-22**]. FINDINGS: A very limited bedside portable evaluation was performed. The gallbladder demonstrates abundant echogenic material within which likely represents sludge and small crystals. No definite stones are identified. No gallbladder wall thickening or pericholecystic fluid is identified. There is limited evaluation of the common bile duct which is dilated to 1.3 cm and likely contains sludge. The duct could not be followed to the pancreatic head. A mild to moderate degree of central intrahepatic biliary ductal dilatation is noted. IMPRESSION: Limited bedside evaluation with abundant gallbladder sludge as well as common bile duct and intrahepatic biliary ductal dilatation. . LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2121-1-4**] 10:13 AM LIVER OR GALLBLADDER US (SINGL Reason: ? stent obstruction [**Hospital 93**] MEDICAL CONDITION: 65 year old woman with ascending cholangitis s/p ERCP x3 with stenting x3 and sphincterotomy with new fever and hypotension REASON FOR THIS EXAMINATION: ? stent obstruction INDICATION: 65-year-old with ascending cholangitis status post ERCP x3 with stenting and new fever and hypotension. Evaluate for obstruction. COMPARISON: Right upper quadrant ultrasound [**2120-12-26**]. RIGHT UPPER QUADRANT ULTRASOUND: Again seen is a large amount of sludge and stones within the gallbladder, which is non-dilated. There is no appreciable gallbladder wall edema or pericholecystic fluid. The common bile duct is not easily visualized and likely contracted around the stent which is seen as a hyperechoic linear focus in the porta hepatis. The portal vein is patent with antegrade flow. Previously visualized central biliary ductal dilatation within the liver is no longer apparent. There is no ascites. IMPRESSION: 1. Large amount of sludge and stones within a non-distended gallbladder. There is no gallbladder wall edema or pericholecystic fluid to suggest cholecystitis. 2. Resolution of previously seen central biliary ductal dilatation. 3. Patent portal vein, and no evidence of ascites. 4. Common bile duct stent is seen at the porta hepatis within a collapsed common duct. ERCP [**1-1**] A plastic stent was removed successfully with a snare. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Multiple stones and sludge were extracted successfully using a 15 mm balloon from the bile duct. One large stone was removed from the cystic duct. A 5 cm by 10 Fr double pig tail biliary stent was placed successfully using a OASIS stent introducer kit. Impression: 1. A plastic stent placed in the biliary duct was found in the major papilla which was removed successfully with a snare. 2. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. 3. A moderate diffuse dilation was seen at the biliary tree with the CBD measuring 15mm. 4. Many round stones ranging in size from 5mm to 10mm that were causing partial obstruction were seen at the middle third and lower third of the common bile duct. 5. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. 6. Multiple stones and sludge were extracted successfully using a 15 mm balloon from the bile duct. One large stone was removed from the cystic duct. Complete clearance of CBD was achieved but there are residual cystic duct stones. 7. A 5 cm by 10 Fr double pig tail biliary stent was placed successfully using a OASIS stent introducer kit in view of cystic duct stones. Recommendations: Return to ICU bed. Continue IV antibiotics Remain on antibiotics for total of 7 days Consider cholecystectomy as ductal clearance was achieved. Repeat ERCP with stent removal in 3 months Follow-up with Dr. [**Last Name (STitle) **] Avoid aspirin and aspirin like products for one week. Brief Hospital Course: 65 yo female admitted to our ICU initially with ascending cholangitis, increasing bilirubin, hypotension. 1. Ascending cholangitis: Patient presented from OSH with RUQ pain, CBD dilation and gall stones with sludge on RUQ US, elevated LFT's, and bilirubin of 4.0. She gradually improved after ERCP and stent placement on [**12-22**]. she developed a transient bilirubin increase on [**12-26**] which decreased later in the day. By [**12-27**], her bilirubin had increased once again from 2.2 to 4.6, in addition she became hypotensive to 60/40 with abdominal distension. Her blood pressure was initially responsive to fluids but then required pressors to maintain adequate systolics. Stat echo was negative for pericardial effusion or tamponade. She underwent repeat ERCP on [**12-27**] which showed occlusion of the stent. This stent was replaced. The patient underwent a third ERCP on [**1-1**], during which she recieved a sphincterotomy and a double pigtail catheter which was placed connecting the CBD to the duodenum. She will be followed up by the ERCP fellow for repeat ERCP in [**5-3**] weeks, and she will be followed by surgery for a cholecystectomy within 3 weeks of discharge. Blood cultures from [**12-22**] came back positive for pan sensitive e. coli. The patient was transitioned from zosyn to levofloxacin to complete a two week course. Her last dose of levofloxacin will be administered on [**2121-1-18**]. 2. Vent Associated Pneumonia: Patient developed ARDS and then worsening bilateral patchy infiltrates which raised concern of ventilator associated pneumonia. Vancomycin was started on [**12-26**], and discontinued on [**12-29**] after sputum cultures came back negative. Blood cultures grew only E.Coli. On [**1-4**] the patient spiked a fever once again and she was placed back on empiric coverage for vent associated pneumonia with vancomycin. She spiked again on [**1-5**] and cipro was added. Her CXR's remained dificult to interpret given patient's body positioning, low lung volumes, and volume status. She received a PICC on [**1-8**] for antiobiotic coverage of vent associated pneumonia. Sputum cultures from [**1-4**], [**1-5**] grew stenotrophomonas maltophila, sensitive to bactrim, levo, timentin, ceftazidime. Given that she was already on levofloxacin for the e.coli bacteremia, it was decided to continue this to cover teh VAP as well, again, last dose given on [**2121-1-18**]. She has remained afebrile on this regimen with no further leukocytosis. She is still requiring supplemental oxygen which should be weaned as tolerated. 3. ATN: Patient was in ARF on admission with a urine sediment revealing muddy brown casts, diminished urine output initially. She began putting out urine up to 1-2L/ by [**12-26**]. She continued with adequate urine output throughout her hospital stay, and her creatinine returned to baseline. . 4. Cyanotic right foot: Patient developed cyanotic toes with diminished pulses which were only dopplerable on [**12-23**]. Hands were also cool and mildly mottled. DIC labs negative, did not fit criteria for HIT. Vascular surgery did not recommend intervention given diffuse nature, and her pulses and color returned to her foot the following day with a warming blanket. 5. Seizure D/o: Was administered dilantin IV as she was NPO. On [**12-30**], dilantin level was low and so she was administered double her normal dose. Her dilantin was switched back to PO on [**1-5**]. Her dilantin levels on [**1-7**] were 9.9. 6. Hypertension: Held atenolol while acutely ill, restarted when clinical situation stabilized. 7. Anxiety: Held alprazolam during admission in [**Hospital Unit Name 153**]. Medications on Admission: alprazolam 0.25mg prn (not used daily) Dilantin 160mg qam, 100mg qpm atenolol 50mg daily darvocet 100-650 multivitamin with B vitmains prilosec 20mg daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 5. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO QAM (once a day (in the morning)). 6. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO QHS (once a day (at bedtime)). 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for back pain. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 12. oxygen Titrate nasal canula to keep O2 sats greater than 93% Discharge Disposition: Extended Care Facility: [**Hospital6 **] Hospital at [**Location (un) 4047**] Discharge Diagnosis: ascending cholangitis e. coli bacteremia septicemia VAP ATN history of seizure disorder Discharge Condition: stable, afebrile, tolerating regular diet Discharge Instructions: You were admitted with abdominal pain and found to have ascending cholangitis with subsequent septicemia requiring intubation. You also underwent ERCP with stent placement. You will need to return in [**5-3**] weeks for a repeat ERCP with stent removal. You will continue on your antibiotics until [**2121-1-18**]. You are being discharged to a rehab facility prior to returning home. Followup Instructions: You will need a follow up ERCP with stent removal in [**5-3**] weeks time. We are currently making arrangements to schedule your ERCP but please call [**Telephone/Fax (1) 45893**] next week to confirm your appointment. You will also need to call the surgery clinic to make a follow up appointment for future cholecystectomy. They can be reached at [**Telephone/Fax (1) 2359**].

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Discharge summary

report

Admission Date: [**2109-2-25**] Discharge Date: [**2109-3-4**] Date of Birth: [**2045-4-2**] Sex: F Service: MEDICINE Allergies: Lisinopril / Kefzol / Sulfa (Sulfonamide Antibiotics) / Shellfish Derived Attending:[**First Name3 (LF) 6378**] Chief Complaint: Fatigue, Renal Failure, Low Hematocrit Major Surgical or Invasive Procedure: Central Line Placement Arterial Line Placement Blood Transfusions (6 units) History of Present Illness: 63yof w h/o severe diastolic CHF, pulmonary HTN, afib, possible ulcerative colitis, recent LGIB, prior h/o bleeding duodenal ulcers presented 3 days ago from an outpatient renal appointment with a HCT of 17 and a creatinine of 3. She has a history of chronic anemia likely [**1-22**] CKD and chronic inflammation, with baseline HCT of 22-25. She previously had a baseline creatinine of ~1.5 but bumped up to a new baseline of ~2-2.5 since having acute decompensated diastolic heart failure 3 months ago. She was previously admitted last month for hematochezia with a HCT=19, and was found to have bleeding colonic angioectasias that were cauterized on colonoscopy. She also has a history of recurrent UGIB from duodenal ulcers, though her most recent EGD during the last admission was normal. Per pt, she had been having diarrhea for ~2 wks before admission (2 loose BMs/day), with some red blood in the stool (denies melena). She also had some nausea and vomiting 1-2 days prior to admission, with small blood in her very last episode of emesis. She had also fallen 2 days prior to admission due to tripping on her nightgown as she was getting undressed, with resulting bruises and bilateral leg pain that she self-treated with oxycodone. . In ED, initial VS= 97.8 60 109/52 16 96%/RA. On exam she was clinically fluid overloaded and guiac+ with melenic stool. NG lavage was negative. Coags were normal. +Eos in her urine. She was made NPO, given Protonix 40 mg IV x1, transfused 2U pRBCs, and admitted to the MICU. . In the MICU, she was lethargic and complained of leg, low back, and arm pain. She was hypotensive with SBP in the 80s and was started on pressors. HCT initially did not bump with transfusion, so CT of torso and lower extremities was obtained, showing no retroperitoneal bleed or significant hematoma. Pt received an additional 4U pRBCs, with HCT stabilizing at ~23. Her BP improved but dropped back to the 80s with morphine 0.5 mg for pain, requiring her to transiently be back on pressors. She had one BM yesterday that she did not look at. She did not have vomiting. She was not scoped in the MICU as apparently she needs to be intubated for this (unclear why). NG lavage today revealed no blood, and pt was started on a clear diet and transferred to the floor. . Currently, pt complains of leg, low back, and arm pain. She denies nausea or abdominal pain. . Review of systems: (+) Spontaneous nosebleeds x past 2 weeks, up to several per day. DOE (including walking on level ground). Gained ~50 lbs over past 2 yrs (was 135 lbs previously). Has palpitations likely from afib. Has intermitent dry cough. Has wheezing/SOB that she attributes to heart failure, but for some reason she takes albuterol for this. Thinks her skin has been getting diffusely darker recently. (-) Denies fever, chills, night sweats, recent URI symptoms, chest pain, dysuria, rash. Past Medical History: # Diabetes # Dyslipidemia (TG 53, Chol 145 HDL 71 LDL 63 on [**10/2107**]) # Hypertension # atrial fibrillation; coumadin stopped [**1-22**] h/o GI bleed # severe diastolic dysfunction w/ right sided heart failure # severe pulmonary hypertension # severe tricuspid regurg (eval by card [**Doctor First Name **], not op candidate) # EtOH remote history # PFO closure ([**2108-3-21**]) # ulcerative colitis # intermittent hyponatermia # elevated LFTs Social History: -Married, separated from husband who is mentally ill, living with son and his family currently (supportive) -Tobacco history: No -ETOH: +prior h/o heavy EtOH use, current intermittent EtOH use -Illicit drugs: No Family History: -Father with MI at age 68 -Mother breast cancer at age 52 No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: General Appearance: Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, NG tube Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), elevated JVP Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished), edema difficult to palpate pulse, but faintly present Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ), clear to auscultation bilaterally Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: 3+, Left lower extremity edema: 3+, L leg with swollen and warm knee, hematoma; secondary to trauma Musculoskeletal: Unable to stand Skin: Cool Pertinent Results: [**2109-2-25**] 12:25PM WBC-4.6 RBC-2.00*# HGB-5.1*# HCT-17.3*# MCV-86 MCH-25.6* MCHC-29.8* RDW-19.9* . [**2109-2-25**] 12:25PM UREA N-123* CREAT-3.2* SODIUM-135 POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-33* ANION GAP-13 [**2109-2-25**] 05:00PM PLT COUNT-215 [**2109-2-25**] 05:00PM PT-14.0* PTT-29.0 INR(PT)-1.2* . ECHO: The left atrium is elongated. The right atrium is markedly dilated. A septal occluder device is seen across the interatrial septum. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The right ventricular cavity is markedly dilated with mild global free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a very small pericardial effusion. IMPRESSION: Markedly dilated right ventricular with mild global hypokinesis. Mildly depressed left ventricular function. Severe triscuspid regurgitation. At least mild pulmonary hypertension (likely UNDERestimated). Very small pericardial effusion around the atria. . CT left lower extremity: 6.6 x 2.7 x 12.0 cm subcutaneous hematoma in the lateral proximal thigh. . CT right lower extremity: 1. Soft tissue edema. 2. No large hematoma. 3. No acute fracture. 4. Small [**Hospital Ward Name 4675**] cyst. . CT torso: 1. No evidence of retroperitoneal or other hematoma. 2. Extensive subcutaneous edema and bilateral pleural effusions as well as trace ascites. 3. Atherosclerotic disease. 4. Degenerative changes of the spine including compression deformities, one of which appears slightly progressed from the chest CT done in [**2107**]. 5. Biliary sludge . Tib/fib films: No fracture . Renal ultrasound: The right kidney measures 8.5 cm in length. The left kidney measures 9.3 cm in length. Each kidney appears normal without stones, masses, or hydronephrosis. The partly full pre-void bladder is unremarkable. The postvoid residual is negligible, measuring about 10 mL. IMPRESSION: Unremarkable study. . EKG: Atrial fibrillation, mean ventricular rate 63. Low ARS voltage diffusely. Right ventricular conduction delay. Prolonged QTc interval. Compared to the previous tracing of [**2109-1-24**] multiple abnormalities as previously noted persist without major change. Brief Hospital Course: #) Acute on chronic anemia--Hematocrit was 17 on admission, from baseline of 25. As patient was guiac positive with melenic stool and previously had bleeding colonic angioectasias on colonoscopy [**2109-1-30**], it was felt that the hematocrit drop was due to recurrent lower GI angioectasia bleeding. Pt's fall prior to admission may also have contributed some blood loss, as a large left calf hematoma was noted (no enlargement over hospital course). Patient was transfused 6U pRBC for a hematocrit goal of 23. NG lavage was negative for upper GI bleeding. CT of chest/abdomen/pelvis and lower extremities revealed no additional sources of bleed. Gastroenterology was consulted and followed the patient actively, ultimately deciding against inpatient colonoscopy given stable hematocrits and recent scope. Hematocrits were trended at least daily and remained stable at 24-27 after transfusion. Patient was guiac negative upon discharge. . #) Hypotension--patient was hypotensive on admission, likely secondary to combination of blood loss and heart failure. In the MICU, a central line and arterial line were placed, and norepinephrine was given for pressure support with a goal MAP of >60. Norepinephrine was successfully weaned on HD3 (was intially weaned on HD2, but had to be restarted after SBP dropped to 78 with morphine). Central and arterial lines were discontinued. On the floor, patient's home beta blocker and diuretics were restarted, and she maintained SBP above 100 on this regimen. . #) Diastolic right-sided heart failure--although patient was hypotensive and appeared intravascularly dry upon presentation, she was total body fluid overloaded as evidenced by significant JVD and lower extremity edema. Her home diuretics were initially held given hypotension. A central line was placed for better hemodynamic monitoring. She was given lasix 80mg IV x1 in conjunction with her blood transfusions. A transthoracic echocardiogram showed a markedly dilated right ventricle with mild global hypokinesis, mildly depressed left ventricular function compared to [**2108-12-6**] study, severe triscuspid regurgitation, pulmonary hypertension, and a very small pericardial effusion around the atria. When better BP control was achieved on HD4, spironolactone was restarted per home regimen. Torsemide and metolazone were eventually re-started per home regimen with good diuresis (patient was negative 1-1.5 liters/day x last 3 days of hospital course, though weight did not decrease with diuresis). Systolic BP remained >100 on home diuretics and metolazone eventually increased from 2.5mg daily to 5mg twice daily. Electrolytes and CBC check on Friday, [**3-8**] by VNA ordered. Upon discharge, pt still had significant lower extremity edema. Cardiology considered ultrafiltration, but ultimately decided that it would not be done during this inpatient stay. . #) Acute on chronic renal failure--baseline creatinine 1.5-2.0 but on admission was 3.3. It was felt this was due to pre-renal azotemia in the setting of hypotension. Her creatinine began to improve with BP optimization and transfusion, and trended down to 2.4 on HD4, close to her baseline. However, further urine studies revealed urine positive for eosinophils. She was not on any antibiotics to suggest acute interstitial nephritis, and more detailed medication review revealed that one potential cause of interstitial nephritis was mesalamine. In this setting, mesalamine was held even after her diet was advanced, and both renal and GI recommended continued holding of mesalamine at least until her renal function had further stabilized. On discharge, her Creatinine was at baseline (1.7/1.8) and so Mesalamine was restarted. - Patient has an appointment with Dr. [**First Name (STitle) 2643**] in GI to follow-up on her ulcerative colitis and angioectasias. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2987**], her GI doctor, does not have any openings until [**Month (only) **] [**2108**]. . #) Fall--patient had stable hematoma of L lower extremity, which did not increase in size during the duration of her hospital stay. Further imaging showed no other signs of bleeding as discussed above. Given concern for domestic abuse, social work was consulted and assessed the patient to have a safe and stable living situation with her children. Physical therapy evaluated pt and recommended that she continue working with them as outpatient and use a rolling walker whenever possible. - Discharged home with VNA services including home safety evaluation, physical therapy, medication check, blood pressure and weight checks. . #) Ulcerative colitis--did not have any active symptoms of ulcerative colitis during hospital stay, denying abdominal pain, cramping, diarrhea, or fever. Mesalamine was held while NPO and continued to be held due to concern that it may have contributed to renal failure. Eventually, this was restarted shortly prior to discharge. . #) Atrial fibrillation--beta-blocker initially held due to hypotension, with heart rate ranging 70-105. Metoprolol later resumed with good rate control and systolic blood pressure maintained >100. Monitored on telemetry throughout hospital course. No anticoagulation at baseline given history of GI bleeds. Aspirin was held on admission and continued to be held at discharge pending follow-up with pt's primary care doctor and/or cardiologist. Medications on Admission: # Torsemide 40 mg [**Hospital1 **] # ASA 81 mg daily # Albuterol PRN # Prilosec 20 mg [**Hospital1 **] # Promethazine 25 mg q6hrs PRN nausea # Potassium Choloride 20 meq [**Hospital1 **] # Spironolactone 25 mg daily # Metorpolol 25 mg [**Hospital1 **] # Asacol 800 mg TID # Trazadone 25 mg qHS PRN # Oxycodone 5 mg q6hrs # Ferrous Sulfate 325 mg [**Hospital1 **] # Gabapentin 200mg qHX # Metalazone 2.5 mg daily Discharge Medications: 1. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime) as needed for leg spasms. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 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. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 8. Promethazine 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 9. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 10. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 11. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please take morning dose 30 minutes before taking Torsemide. Disp:*60 Tablet(s)* Refills:*2* 12. Asacol 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO three times a day. 13. Outpatient Lab Work Please draw blood for Chem 10 and CBC on Friday, [**3-8**] Send fax results to patient's primary care doctor, Dr. [**Last Name (STitle) 838**] at [**Telephone/Fax (1) 4776**] Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Anemia likely from colonic angioectasias (GI bleed), acute renal failure Secondary: Diabetes, hyperlipidemia, hypertension, atrial fibrillation, severe diastolic dysfunction w/ right sided heart failure, pulmonary hypertension, ulcerative colitis Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (rolling walker or cane) Discharge Instructions: -You were admitted with very low red blood cell counts (anemia) likely due to bleeding from your gastrointestinal tract, perhaps from the collections of blood vessels you have in your colon (angioectasias) that are prone to bleeding. You were transfused with 6 units of blood, to good effect. Due to the amount of blood that you lost, your kidneys started to function poorly so we temporarily stopped some of your diuretic medications. Your kidney function has since improved, and you have been placed back on your home diuretics. . -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission. --> STOP aspirin 81mg until you see Dr. [**Last Name (STitle) 838**] and Dr. [**First Name (STitle) 2643**] (works with Dr. [**Last Name (STitle) 2987**] and discuss with them. --> STOP Potassium Chloride 20mEq twice daily until you see Dr. [**Last Name (STitle) 838**] --> INCREASE Metolazone to 5mg twice daily . -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. ** Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: ** Please make an appointment to see your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 838**] within 2 weeks. You can reach his office at [**Telephone/Fax (1) 4775**] ** You should also call your GI doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2987**] to make an appointment to see her within 2 weeks. You can reach her office at: ([**Telephone/Fax (1) 10499**] . Other appointments: . Department: CARDIAC SERVICES When: MONDAY [**2109-3-18**] at 9:30 AM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: ADULT SPECIALTIES When: THURSDAY [**2109-5-2**] at 11:15 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 8645**] Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6384**] MD, [**MD Number(3) 6385**]

[ "416.8", "E885.9", "924.10", "250.00", "584.9", "785.59", "556.9", "428.0", "427.31", "285.1", "585.9", "285.21", "278.00", "569.85", "397.0", "428.32", "276.52", "272.4" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

15438, 15487

8107, 13525

371, 448

15787, 15787

5101, 8084

17305, 18508

4097, 4270

13987, 15415

15508, 15766

13551, 13964

15975, 17282

4285, 5082

2893, 3379

293, 333

476, 2874

15802, 15951

3401, 3852

3868, 4081

59,829

110,560

16467

Discharge summary

report

Admission Date: [**2141-11-8**] Discharge Date: [**2141-11-10**] Date of Birth: [**2093-10-7**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Poor balance Major Surgical or Invasive Procedure: Suboccipital Craniotomy History of Present Illness: [**Known firstname **] [**Known lastname 22552**] is a 48 year-old right-handed woman with breast cancer and metastasis to the brain, lungs, bone and liver. She is here with her husband for [**Name2 (NI) **] head MRI. She continues to feel well without any headache, weakness or dizziness. For the past few weeks she does think that her balance has not been as good but no falls or veering to one side. She has had two resections in [**2137**] by Dr [**First Name (STitle) **]. Past Medical History: Her oncologic problems began in [**2136-9-25**] with a left breast lump. An open biopsy revealed infiltrating lobular carcinoma, ER negative and Her2/neu positive. A left-modified mastectomy was done by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 46810**], MD on [**2136-12-27**]. There were 14/16 positive lymph nodes. She received 4 cycles of neoadjuvant cyclophosphamide and Adriamycin followed by 4 cycles of Taxotere. She completed chest irradiation by Dr. [**Last Name (STitle) 46811**] at [**Hospital 1474**] Hospital on [**2137-8-22**]. She was restaged on [**2139-2-4**] because of right upper quadrant tenderness and right rib pain. She had extensive metastasis to liver, bone and lungs. Her neurological problem began in [**2138-4-26**] with gradually worsening headaches that were constant, dull, throbbing and located in the left occipital region. The headache was not positional but coughing and sneezing aggravated it. She went to [**Hospital3 417**] Hospital on [**2138-5-12**] with severe headache, nausea and vomiting. She was transferred to [**Hospital1 18**] and a MRI revealed a solitary left cerebellar lesion. A suboccipital craniotomy was done on [**2138-5-15**] by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) 151**] [**Last Name (Titles) 31255**] consistent with breast metastasis. 1. Resection of left cerebellar metastasis on [**2138-5-15**] by Dr. [**First Name (STitle) **] 2. SRS to the tumor bed on [**2138-6-25**] to 1500 cGy by Dr. [**Last Name (STitle) 3929**] 3. Resection of left cerebellar recurrence on [**2138-10-22**] by Dr. [**First Name (STitle) **] 4. Radiotherapy boost to 4000 cGy from [**Date range (1) 46812**] 5. Cyberknife SRS to 2 right cerebellar mets (1600 & 1800 cGy) on [**2140-6-27**] 6. Lapatinib and Xeloda started on [**2141-4-15**] Social History: Effexor XR 75 mgs daily, Neurontin 300 mg TID, Ativan 0.5 mg PRN, Xeloda 1000 mg [**Hospital1 **], Tykerb/lapatinib 1250 mg daily, Zometa monthly. Family History: Works full time, married with children Physical Exam: Physical Exam: BP is 118/82, P-72, R-16. HEENT is unremarkable. Heart has a regular rate and rhythm. Lungs are clear. Abdomen is soft nontender. Extremities are without edema. Neurological Exam: Karnofsky score is 100. She is alert and oriented times three. Language is clear and fluent with good comprehension. Pupils are 5 mm and equally reactive. Visual fields and EOM's are full without nystagmus. Hearing is intact to finger rub. Face is symmetric and sensation is intact. Tongue is midline. Palate rises symmetrically. Shoulder shrug is strong. There is no drift. Strength is [**4-29**] throughout. Sensation is intact to light touch. Reflexes are 2+ in the upper extremities, 1+ at the knees and absent ankle jerks. Coordination is intact. Romberg has slight sway. Tandems fair. Gait is normal based Brief Hospital Course: She was admitted and brought to the operating room on [**2141-11-8**] where under general anesthesia she underwent a left suboccipital craniotomy with removal of tumor. She tolerated this procedure well and was transferred to the PACU where she remained overnight for close neurosurgical monitoring. Postoperatively, she was alert and oriented. Pupils were equal, round, and reactive to light and accommodation. She had no drift. Her postoperative examination showed that she was awake, alert and oriented. Cranial nerves II through XII were grossly intact. She had no drift. She has fullrange of motion of all extremities with normal strength. She continued to do well postoperatively; and on the first postoperative day, her A line was removed, her Foley was discharged. She was transferred to the floor. She was weaned off of her Decadron. Her activity and diet were both increased. She did also undergo a postoperative MRI scan of the head. Her incision was clean, dry and intact. She continued to do well and was discharged to home after being cleared by PT on: [**11-10**] Medications on Admission: Effexor XR 75 mgs daily, Neurontin 300 mg TID, Ativan 0.5 mg PRN, Xeloda 1000 mg [**Hospital1 **], Tykerb/lapatinib 1250 mg daily, Zometa monthly. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): use while on percocet. Disp:*40 Capsule(s)* Refills:*1* 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): use while on decadron. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*25 Tablet(s)* Refills:*0* 7. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO three times a day for 2 days. Disp:*12 Tablet(s)* Refills:*0* 8. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO tid for 2 days then [**Hospital1 **] until brain tumor clinic followup: start after 3mg dose. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Metastatic Breast CA Discharge Condition: Neurologically stable Discharge Instructions: ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Follow up in the brain tumor clinic on: [**2141-12-11**] at 2pm Have staples out at Dr[**Name (NI) 9034**] office on Monday [**2141-11-20**] between 0900-1200 Completed by:[**2141-11-10**]

[ "198.3", "V10.3", "198.5", "197.7", "197.0" ]

icd9cm

[ [ [] ] ]

[ "02.12", "01.59" ]

icd9pcs

[ [ [] ] ]

6135, 6141

3825, 4905

333, 358

6206, 6230

7565, 7756

2935, 2975

5102, 6112

6162, 6185

4931, 5079

6254, 7542

3005, 3168

3187, 3802

281, 295

386, 866

888, 2755

2771, 2919

56,892

187,493

34822+57992

Discharge summary

report+addendum

Admission Date: [**2131-9-18**] Discharge Date: [**2131-10-10**] Date of Birth: [**2049-9-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: shortness of breath, chest pain Major Surgical or Invasive Procedure: [**2131-9-19**] Cardiac Catheterization [**2131-10-2**] Coronary Artery Bypass Grafting Surgery x 6 (LIMA to LAD, SVG to D1 to D2, SVG to OM1 to OM2, SVG to PDA), Left Carotidid Endarterectomy History of Present Illness: 81 yo M w/ history of DMII, hypertension, hypercholesterolemia, and CRI who presented with SOB. Pt reports being physically quite active his entire life, but noted increasing SOB and DOE over the past 5 years. Yesterday, he was taking out the trash and noted worsened DOE and non-radiating chest tightness while lifting the trash bin and walking down the street. Denies palpitations, nausea, vomiting, LOC. Never experienced this chest tightness before. Chest tightness resolved with rest. Pt took no medications to palliate his symptoms, but reports orthopnea that night (slept in his chair). Pt was concerned about these symptoms and presented to OSH ED the next AM. At [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], VS were 99.5 100 115/78 18 98% on 2 L NC. He was noted to be in new AF w/ RVR with HRs in 140's and CHF (BNP 2200). He was also found to have an NSTEMI (Trop-T 0.55 => 0.15, EKG with minor ST depressions). He remained hemodynamically stable. He received Lasix 40 mg IV x1, potassium chloride 20 mEq x1, was started on nitro gtt, 15mg cardizem x1. He was also noted to have occasional episodes of bradycardia btw 20-30's. He was then transferred to the [**Hospital1 18**] ED for further care and admission to the cardiology service. Past Medical History: Diabetes Mellitus Type II Hypertension Hyperlipidemia Chronic Renal Insufficiency History of stroke 8 years ago Acute diastolic heart failure Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death -- his father died of an MI at the age of 87. Lives in [**Location 686**] with his sister. [**Name (NI) 1403**] as a financial advisor. Family History: Father died of MI at age 87 Physical Exam: On admission: VS - 100.3 87 159/69 20 93% on 2 L NC FS: 274 Gen: WDWN middle aged male in NAD, sitting upright. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 5 cm at 30 degree angle. No thyromegaly. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. No carotid bruits. Chest: +crackles at lower lung bases bilaterally, R slightly greater than left. no wheezing. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: 2+ lower extremity edema bilaterally up to ankles. DPs, PTs [**11-22**]+ BL. Skin: + well demarcated area of erythema with central ulceration over L tibial area. Pertinent Results: [**9-19**] Cath: 1. Coronary angiography of this right dominant system revealed severe 3 vessel coronary disease poorly suitable for PCI. The LMCA had mild disease. The LAD had a 70% stenosis after D2. D1 had a proximal stenosis up to 70% and D2 had a proximal 70% stenosis as well. The LCX had a small OM1 with a proximal 70% stenosis and another small OM2 with a proximal 80% stenosis. The RCA had diffuse mild disease with severe calcification. There was a focal mid lesion up to 90% stenotic with distal lesions with an 80% stenosis in the RPDA and RPL. 2. Limited resting hemodynamics revealed elevated systemic arterial pressure with an SBP of 175 mm Hg. The LVEDP was severely elevated at 30 mm Hg indicative of diastolic dysfunction. There was no evidence of aortic stenosis with pullback across the aortic valve. 3. Left ventriculography was deferred. [**9-21**] Carotid U/S: Significant left-sided plaque with 70-79% carotid stenosis. Of note, the technologist felt that there was mobile plaque in the common carotid bulb. This could not be visualized based on scanned images. On the right there is less than 40% carotid stenosis. [**9-21**] Chest CT: 1. Extensive atherosclerosis as described. Questionable focal dissection of upper abdominal/lower thoracic aorta. Further evaluation with contrast-enhanced CT or MRA is recommended or comparison to prior studies if available. 2. Left kidney cysts, one of them calcified. 3. Bilateral pleural effusions, improved right lower lobe consolidation. 4. Two focal ground-glass opacities in the right lower lobe, 4:125, and in the right upper lobe as described, may represent areas of infection, but followup in three months for documentation of complete resolution is highly recommended. 5. Degenerative changes of thoracic spine, extensive, with no evidence of metastasis. [**10-1**] Abd CT: 1. Stable left retroperitoneal hemorrhage, some interval contraction is seen. 2. Aneurysmal dilation of the infrarenal abdominal aortic. [**10-2**] Echo: PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler.Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. 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. An eccentric, posteriorly directed jet of Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the results on [**Known firstname 429**] [**Known lastname **] at 12noon. Post_Bypass: Preserved biventricular systolic function. LVEF 55%. Otherwise, exam is unchanged from pre bypass. [**10-4**] Head CT: There is no evidence of hemorrhage, mass, mass effect, or large acute territorial infarction. Areas of low attenuation are visualized in the subcortical and periventricular white matter, likely consistent with chronic microvascular ischemic changes. Dense arteriosclerotic calcifications are demonstrated in the carotid siphons and in the vertebral arteries. Brief Hospital Course: 81 yo M with multiple risk factors for CAD including HTN, HLD, DM, and PVD who presented to the hospital with shortness of breath and chest tightness, found to have new onset CHF and transient in AF w/ RVR. Was found to have ischemic congestive heart failure (Grade I Diastolic HF EF > 55%) and 3VD on cardiac cath. Patient was medically managed, including diureses, and awaited CABG. During pre-operative work-up, hospital course was complicated by acute on chronic renal failure and a spontaneous L-sided RP bleed. Underwent carotid U/S pre-op which revealed 70-70% stenosis of left carotid. Both of those complications resolved and the patient was taken to the operating room on [**10-2**] for a coronary artery bypass graft x 6 and left carotid endarterectomy. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day two chest tubes were removed. Patient had some right-sided weakness along with altered mental status and underwent Head CT. CT revealed no evidence of CVA. Also on post-op day two he had episodes of atrial fibrillation and was started on Amiodarone and Coumadin. He remained on Neo for BP support for several days but on was eventually weaned and started on beta-blockers. Epicardial pacing wires were removed per protocol. His weakness and mental status improved and on post-op day six he was transferred to the telemetry floor for further care. During his post-op course he worked with physical therapy for strength and mobility. By post-operative day 8 he was ready for transfer to a rehab facility. Medications on Admission: Zantac 150 mg PO BID Felodipine SR 5 mg PO daily Atenolol 50 mg PO daily Glyburide 5 mg PO daily Valsartan PO daily (unknown dose) Procrit 10,000 U/mL 1 solution q2 weeks Gemfibrozil 600 PO BID Atorvastatin 40 mg PO daily Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. wound care pls place adaptic/non-adherent dressing to pressure ulcer at L calf until healed 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. Disp:*40 ML(s)* Refills:*0* 8. 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* 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 13. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 14. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: titrate for an INR goal of [**12-23**].5 for atrial fibrillation. Disp:*30 Tablet(s)* Refills:*0* 15. Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Bostonian - [**Location (un) 86**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 6 Carotid Stenosis s/p Left Carotidid Endarterectomy Congestive Heart Failure Myocardial Infarction Retroperitoneal Bleed Acute on Chronic Renal Failure Secondary Diagnosis Atrial Fibrillation Hypertension Hypercholesterolemia Diabetes Mellitus Stroke 8 years ago Discharge Condition: Good Discharge Instructions: Please shower daily , no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 100.5 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 one month and off [**Doctor Last Name **] narcotics No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns: [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 68865**] in [**11-22**] weeks Dr. [**Last Name (STitle) 79742**] [**Name (STitle) 79743**] in [**12-24**] weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2131-10-10**] Name: [**Known lastname 5405**],[**Known firstname 326**] Unit No: [**Numeric Identifier 12813**] Admission Date: [**2131-9-18**] Discharge Date: [**2131-10-10**] Date of Birth: [**2049-9-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 265**] Addendum: Discharge summary should be ammended to include a follow-up appointment with Dr. [**Last Name (STitle) **] in 4 weeks. ([**Telephone/Fax (1) 12932**] Discharge Disposition: Extended Care Facility: Bostonian - [**Location (un) 42**] Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks. ([**Telephone/Fax (1) 12932**] Dr. [**First Name (STitle) **] in 4 weeks. ([**Telephone/Fax (1) 2125**] Dr. [**Last Name (STitle) 12933**] in [**11-22**] weeks Dr. [**Last Name (STitle) 12934**] [**Name (STitle) 12935**] in [**12-24**] weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2131-10-10**]

[ "272.4", "427.31", "441.02", "568.81", "428.31", "250.40", "458.29", "414.01", "285.21", "433.10", "584.9", "410.71", "585.9", "707.12", "428.0", "403.90" ]

icd9cm

[ [ [] ] ]

[ "37.22", "39.61", "36.14", "38.93", "88.56", "38.12", "36.15", "00.40" ]

icd9pcs

[ [ [] ] ]

12061, 12122

6596, 8313

353, 547

10669, 10675

3251, 6204

12145, 12553

2369, 2398

8585, 10218

10323, 10648

8339, 8562

10699, 11167

2413, 2413

282, 315

575, 1847

6213, 6573

2427, 3232

1869, 2012

2028, 2353

14,715

173,979

418

Discharge summary

report

Admission Date: [**2132-10-6**] Discharge Date: [**2132-10-12**] Date of Birth: [**2058-10-28**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 1283**] Chief Complaint: CP / CAD Major Surgical or Invasive Procedure: Iliac and aortic stent placement [**2132-10-6**] Re-do CABG X 4, AVR(tissue) [**2132-10-7**] History of Present Illness: This is a 73-year-old male who had a history of coronary artery disease and had underwent a left internal mammary artery H grafted with a radial artery to the left anterior descending artery through a left anterior thoracotomy many years ago. He had progressive shortness of breath and was found to have critical aortic stenosis with aortic valve area of 0.8 cm squared and moderate mitral regurgitation. His ejection fraction was estimated to be about a 25%. He also underwent a cardiac catheterization which demonstrated that his H graft to the left anterior descending artery was patent. He had a totally occluded left anterior descending artery proximally. He also had significant stenosis of his left circumflex artery and right coronary artery. It was recommended that he undergo a coronary artery bypass grafting, aortic valve replacement, and possible mitral valve repair/replacement. After the risks and benefits were explained to the patient he agreed to proceed. Past Medical History: lisinopril 30', coreg 3.125", norvasc 5', lipitor 40', coumadin Social History: retired electrical engineer with 7 children Pertinent Results: [**2132-10-7**] 01:37PM BLOOD WBC-9.7# RBC-2.61*# Hgb-8.1*# Hct-23.2* MCV-89 MCH-31.1 MCHC-34.9 RDW-14.1 Plt Ct-95*# [**2132-10-10**] 07:15AM BLOOD WBC-11.0 RBC-4.05* Hgb-12.9* Hct-37.0* MCV-91 MCH-31.7 MCHC-34.7 RDW-13.9 Plt Ct-137* [**2132-10-11**] 05:10AM BLOOD PT-11.5 INR(PT)-1.0 [**2132-10-10**] 07:15AM BLOOD Plt Ct-137* [**2132-10-12**] 05:25AM BLOOD Glucose-111* UreaN-20 Creat-1.0 Na-140 K-4.5 Cl-102 HCO3-28 AnGap-15 Conclusions: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Resting regional wall motion abnormalities include hypokinesis of septum, anterior, posterior and lateral walls at the bases, and akinesis of all mid-segments and apex. There is moderate global right ventricular free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. There are three thickened aortic valve leaflets. There is moderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**2-11**]+) mitral regurgitation with a central jet is seen. There is no pericardial effusion. Post-CPB: A well-seated and functioning prosthetic aortic valve is seen. There are no leaks. No AI. MR is 1+. Aorta is intact. Both ventricles show slight improvement in global systolic fxn. (The patient is on low-dose epinephrine.) Other parameters as pre-bypass. Brief Hospital Course: Patient was admitted after cardiac cath overnight, then underwent an uncomplicated AVR with 23mm pericardial valve and redo cabgx3. Patient came of CPB in the OR without incident, and was treansferred to the csru intubated. pressors were weaned that nights, and patient was extubated on POD1 after ppf was switched to precedex for agitation when weaning. CTs were dc'd on POD1, bblocker and asa started. He was then transferred to the floor on POD2 after doing very well. Lopressor was gradually increased for sinus tachycardia but was then swtiched to carvedalol (his home med) to better control his HR&BP. Patient was tolerating a regular diet ambulating well when he was discharged home on POD5. Medications on Admission: lisinopril 30', coreg 3.125", norvasc 5', lipitor 40', coumadin Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. 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* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Carvedilol 12.5 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 119**] Homecare Discharge Diagnosis: AS CAD MR [**First Name (Titles) 3593**] [**Last Name (Titles) **] hypercholesterolemia Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no driving for 1 month no lifting > 10# for 10 weeks [**Last Name (NamePattern4) 2138**]p Instructions: with Dr. [**Last Name (STitle) **] in [**3-14**] weeks with Dr. [**Last Name (Prefixes) **] in 4 weeks Completed by:[**2132-10-12**]

[ "V10.11", "V45.81", "440.21", "440.0", "414.01", "427.89", "401.9", "272.0", "396.2", "412", "V15.82", "997.1" ]

icd9cm

[ [ [] ] ]

[ "00.42", "36.15", "39.61", "39.90", "99.20", "00.47", "89.60", "35.21", "99.04", "39.50", "36.12", "00.33" ]

icd9pcs

[ [ [] ] ]

5126, 5184

3092, 3792

331, 426

5316, 5323

1598, 3069

3906, 5103

5205, 5295

3818, 3883

5347, 5496

5547, 5682

283, 293

454, 1431

1453, 1518

1534, 1579

6,275

173,440

22994

Discharge summary

report

Admission Date: [**2122-8-11**] Discharge Date: [**2122-8-15**] Date of Birth: [**2057-4-4**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Asymptomatic; known mitral valve prolapse Major Surgical or Invasive Procedure: [**2122-8-11**] Minimally Invasive Mitral Valve Repair utilizing 32 millimeter Annuloplasty Band [**2122-8-12**] Right sided VATS History of Present Illness: This is a 65 year old male with history of hypertension. He was found to have a new murmur approximately six months ago. He was asymptomatic at that time and continues to deny chest pain, SOB, PND, orthopnea, syncope, pedal edema and palpitations. An echocardiogram revealed severe mitral valve prolapse with 4+ regurgitation. Cardiac MRI showed an LVEF of 68% and effective for an LVEF of 36%. A stress test in [**2122-1-13**] was negative for ischemia. Subsequent cardiac catheterization found normal coronary arteries. He was admitted for cardiac surgical intervention. Past Medical History: Mitral Valve Prolapse with severe mitral regurgitation Hypertension Hypercholesterolemia Gout History of Kidney Stones Social History: He is a veterinarian. Married with three children. He denies tobacco and ETOH. He remains very active - runs 3 to 4 miles without difficulty. Family History: Denies premature coronary disease. Physical Exam: GENERAL: He is a well-appearing male, looking younger than stated age. VITAL SIGNS: Weight 185 pounds, his blood pressure is 172/90, heart rate of 80. He breathing comfortable. HEENT: PERRLA, EOMI, NC/AT NECK: Supple, FROM, No Carotid Bruit, No adenopathy. No thyromegaly. LUNGS: Clear to auscultation bilaterally. Normal diaphragmatic excursion. HEART: There is a 4/6 systolic ejection murmur, best auscultated at the apex. ABDOMEN: Soft, nontender, nondistended, no bruits auscultated. No hepatosplenomegaly. EXTREMITIES: 2+ femoral pulses, 2+ popliteal, DP and PT bilaterally. DTRs 2+ bilaterally. No Varicosities. NEUROLOGIC: A&Ox3, MAE, non-focal Pertinent Results: [**2122-8-11**] 06:00PM BLOOD WBC-7.0 RBC-2.97*# Hgb-9.5*# Hct-27.4*# MCV-92 MCH-31.9 MCHC-34.5 RDW-13.0 Plt Ct-81* [**2122-8-14**] 06:45AM BLOOD WBC-7.0 RBC-3.46* Hgb-10.8* Hct-31.5* MCV-91 MCH-31.1 MCHC-34.3 RDW-14.2 Plt Ct-117* [**2122-8-11**] 06:00PM BLOOD PT-17.5* PTT-34.1 INR(PT)-2.1 [**2122-8-14**] 06:45AM BLOOD PT-12.4 PTT-30.5 INR(PT)-1.0 [**2122-8-11**] 06:49PM BLOOD UreaN-11 Creat-0.7 Cl-112* HCO3-23 [**2122-8-14**] 06:45AM BLOOD Glucose-83 UreaN-15 Creat-0.8 Na-136 K-3.9 Cl-101 HCO3-29 AnGap-10 Brief Hospital Course: Mr. [**Known lastname 59339**] was admitted and underwent a minimally invasive mitral valve repair utilizing a 32mm [**Doctor Last Name 405**] Annuloplasty band. Surgery was uneventful and he transferred to the CSRU. Please see op note for details. He developed significant postoperative bleeding and required re-exploration on postoperative day one. This was performed via redo thoracotomy and thoracoscopy. Please see op note. Clot was evacuated and hemostasis was obtained. No further bleeding was noted. He was eventually extubated on POD #1 without difficulty. He maintained stable hemodynamics and transferred to the SDU on postoperative day two. Diuretics initiated. Chest tubes and Foley catheter were removed without complication on POD #3. On POD #4, pt was doing well, hemodynamically stable, physical exam unremarkable, and cleared level 5. He was discharged home with VNA services and appropriate follow-up appointments. Medications on Admission: Avapro 300 qd, Lipitor 10 [**Last Name (LF) **], [**First Name3 (LF) **] 81 qd, Folate Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 2 weeks. Disp:*60 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day) for 1 weeks. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Mitral Valve Prolapse with Mitral Regurgitation s/p Minimally Invasive Mitral Valve Repair utilizing 32 millimeter Annuloplasty Band Postoperative Bleeding s/p Right sided VATS Hypertension Elevated Cholesterol History of Gout History of Kidney Stones Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams or lotions to incisions. No driving for 4 weeks. Continue lift restrictions. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in 4 weeks Dr. [**Last Name (STitle) **] in 2 weeks Completed by:[**2122-9-9**]

[ "E878.8", "424.0", "998.11", "511.8" ]

icd9cm

[ [ [] ] ]

[ "35.12", "34.21", "34.09" ]

icd9pcs

[ [ [] ] ]

4662, 4668

2673, 3608

362, 493

4963, 4970

2137, 2650

5135, 5251

1413, 1449

3745, 4639

4689, 4942

3634, 3722

4994, 5112

1464, 2118

281, 324

521, 1096

1118, 1238

1254, 1397

4,916

130,079

30319+57693

Discharge summary

report+addendum

Admission Date: [**2182-10-29**] [**Month/Day/Year **] Date: [**2182-12-19**] Date of Birth: [**2109-11-29**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: fever, hypotension, free air Major Surgical or Invasive Procedure: [**2182-10-29**] Exploratory laparotomy. Repair of the anastomosis. Irrigation of the peritoneal cavity. Placement of [**Doctor Last Name 406**] drain in the left pelvis and a proximal transverse loop colostomy. . [**2182-11-12**] CT-guided catheter placement into R and L fluid collections. History of Present Illness: 72F with h/o perforated sigmoid diverticulitis s/p ex lap, sigmoid resection, Hartmann procedure [**2182-3-13**], s/p L colectomy and colostomy closure [**2182-10-15**], who was seen in Dr.[**Name (NI) 15146**] office on [**2182-10-24**], where she was noted to have unremarkable vital signs and a normal postoperative examination. She was tolerating regular diet and having bowel movements. Her daughter-in-law reported having seen her at her rehab facility on [**2182-10-26**] and found her unremarkable. She gradually deteriorated and presented to the emergency department on [**2182-10-30**] febrile and unresponsive. Her WBC was 23.9. CT revealed free intraperitoneal air and suspected extraluminal pelvic feces. Past Medical History: PMH: DMII, CAD, dementia, HTN, hypercholesterolemia, perforated sigmoid diverticulitis, ?endometrial hyperplasia PSH: 1. CABG, 2. L TKR, 3. exploratory laparotomy, sigmoid resection, Hartmann procedure [**2182-3-13**], 4. left colectomy, colostomy closure [**2182-10-15**] Social History: Currently lives in rehab facility following relocation from [**State 108**] due to illness. No recent history of alcohol, tobacco, or recreational drug use. Family History: Non-contributory Physical Exam: On admission: VS T 104 HR 120 BP 100/70 RR 18 O2 95%NRB Gen: disoriented, no jaundice HEENT: NCAT, OP dry CVS: sinus tachy Pulm: coarse BS Abd: soft, distended, mild tenderness, no rebound, mild guarding, guiaic +, no inguinal LAD, mild L groin crepitus Ext: 1+ edema b/l LE, strength 4/5 On [**2182-12-15**]: VS T97.1 HR 61 BP 136/74 RR 16 O2 99%RA Gen: NAD CVS: RRR, nl S1S2, no m/r/g Pulm: CTA b/l, poor inspiratory effort, no r/r/c Abd: soft, ND, NT, +BS, midline incision granulating & contracting well, ostomy pink & viable with gas & stool in bag Ext: warm, well perfused, trace edema b/l LE Pertinent Results: On admission: [**2182-10-29**] 02:30PM BLOOD WBC-23.9*# RBC-3.91* Hgb-11.6* Hct-36.2 MCV-93 MCH-29.7 MCHC-32.1 RDW-14.5 Plt Ct-895*# [**2182-10-29**] 02:30PM BLOOD Neuts-62 Bands-22* Lymphs-5* Monos-6 Eos-1 Baso-0 Atyps-0 Metas-4* Myelos-0 [**2182-10-29**] 02:30PM BLOOD PT-16.2* PTT-34.2 INR(PT)-1.5* [**2182-10-29**] 02:30PM BLOOD Glucose-273* UreaN-37* Creat-2.1*# Na-145 K-4.8 Cl-105 HCO3-21* AnGap-24* [**2182-10-29**] 02:30PM BLOOD ALT-7 AST-22 CK(CPK)-15* AlkPhos-74 Amylase-98 TotBili-0.4 [**2182-10-29**] 08:23PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.8* [**2182-10-29**] 02:30PM BLOOD Albumin-2.5* . [**2182-10-29**] urine culture: GNR >100,000 org/ml [**2182-10-29**] MRSA screen: positive . CT abd/pelvis [**2182-10-29**]: 1. Interval colectomy and colostomy takedown with a large amount of intraperitoneal free air and fecalized material throughout the abdomen, especially within the left paracolic gutter and pelvis, most consistent with anastomostic dehiscence. 2. Gas dissecting into the soft tissues of the pelvic side walls and extending into the left groin and anterior abdominal wall which may be related to extension of intraperitoneal gas; however, necrotizing fasciitis cannot be excluded. 3. Distended gallbladder containing layering high-density material, which may be related to milk of calcium. 4. Opacity within the left lower lung which may represent atelectasis versus airspace consolidation. . [**2182-11-2**] C.diff: positive . CT abd/pelvis [**2182-11-11**]: 1. Interval development of three dominant discrete abdominal fluid collections, which are suspicious for abscesses. 2. Interval increase in bilateral lower lobe consolidation, which is suspicious for pneumonia, given relative [**Name (NI) 20534**]. 3. Interval resolution of the left groin and pelvic sidewall air. . CT-guided procedure [**2182-11-12**]: Patient status post CT-guided catheter placement into right and left-sided fluid collections, the right suggestive of hematoma and the left compatible with abscess , without immediate complication. . [**2182-11-13**] L IR drain: >3 colony types, rare Pseudomonas [**2182-11-13**] R IR drain: rare Pseudomonas (R to cipro, otherwise pan-sensitive) . CT abd/pelvis [**2182-11-17**]: 1. Polypoid filling defect within the distal rectum, most likely representing sequlae of recent reanastomosis (possible blood clot), as it was not seen on the prior scan. There is no definite evidence of a leak although the rectal contrast does not flow proximal to the anastomosis inspite of rectal distention with contrast and repeat/delayed scanning. 2. Interval decreased size of the abdominal collections are described above. 3. Interval improvement in the consolidations at the lung bases. 4. Increased stranding in the mesentry of the abdomen and pelvis. 5. Enlarged uterus which may represent uterine fibroids and can be assessed further with a pelvic ultrasound as per clinical need. . CTA chest [**2182-11-19**]: 1. Very small right middle lobar pulmonary embolus unlikely large enough to account for the patient's clinical symptoms. 2. Dilated fluid-filled esophagus and stomach with patulous GE junction, and retrograde flow of contrast to the lung apices, placing the patient at risk for aspiration. Removal of gastric contents would be advised. 3. Extensive new portal venous gas. Correlation with recent lactate, and abdominal exam. . CT abd/pelvis [**2182-11-19**]: 1. No free air or pneumatosis. 2. Stranding of the mesentery in abdomen and pelvis is unchanged since [**2182-11-17**]. 3. Marked decrease in amount of portal venous air since [**86**] hours ago. 4. Interval decrease in size of abdominal collections as described above. . [**2182-11-19**] MRSA screen: positive [**2182-11-19**] urine culture: E.coli (S to gentamicin, imipenem, meropenem, nitrofurantoin, Zosyn, Bactrim) [**2182-11-19**] drain culture: >3 colony types, heavy Pseudomonas (R to cipro, otherwise pan-sensitive) . LENI [**2182-11-20**]: No evidence of DVT involving the right or left lower extremities. . [**2182-11-20**] C.diff: positive . Pelvic US [**2182-11-28**]: Markedly limited examination due to the patient's clinical status and mobility as described above. While no frank uterine abnormalities were identified, the examination was not sufficient to evaluate the endometrium for the presence or absence of malignancy. . LUE US [**2182-11-29**]: Deep venous thrombosis involving the left basilic, brachial, and axillary veins. The subclavian vein is inadequately evaluated and therefore the proximal extent of the thrombus is not determined. . [**2182-12-5**] C.diff: negative . LUE US [**2182-12-9**]: Recanalization of the brachial and axillary veins with chronic basilic vein occlusion. . R wrist XR [**2183-12-15**]: Osteopenia. No fracture detected. Probable faint chondrocalcinosis, which can be seen with CPPD arthritis. Brief Hospital Course: Patient was started on vanc/levo/Flagyl and taken to the OR for urgent exploratory laparotomy on [**10-29**]. Findings included leakage between two sutures of the anterior wall of the anastamosis, a well-developed abscess cavity in the L pelvis, and fecal peritonitis. She underwent repair of the anastamosis, irrigation of the peritoneal cavity, placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain into the L pelvis, and a proximal transverse loop colostomy. Please see the operative note for further details. . She was admitted to the TSICU postoperatively on sepsis protocol. She remained sedated & intubated, requiring HD support. She was started on TPN on [**10-30**]. She was weaned off pressors following crystalloid resuscitation and PRBC/FFP transfusions. Her lactate began to decrease. Metoprolol was added for tachycardia. Gentle diuresis was begun on [**11-1**]. She was extubated on [**11-2**]. Her WBC increased from 14.4 to 24.1. A stool sample was positive for C.diff, and PO vanc was added on [**11-3**]. Flagyl was switched to PO and insulin gtt was weaned off on [**11-4**]. On [**11-5**], PICC was placed, vanc and cipro were d/c'd (she remained on PO Flagyl for C.diff), and a small amount of gas was noted in the ostomy bag. On [**11-6**], Lasix was d/c'd (she was allowed to auto-diurese), and tube feeds were started. TPN was weaned down accordingly. . On [**11-7**], she was transferred to the floor on tele. A Dobhoff was placed and her NGT was d/c'd on [**11-9**]. Her leukocytosis was persistent despite treatment for C.diff; a CT scan on [**11-11**] demonstrated 3 probable abscesses. She underwent CT guided drainage/catheter placement on [**11-12**]. See radiology report for further details. She was transfused afterwards. Flagyl was d/c'd to complete a 10 day course. On [**11-13**], a swallow evaluation cleared her for thin liquids and ground solids with assistance, which she tolerated. ASA was started on [**11-14**] for platelets >1000. Her WBC normalized. A repeat CT performed on [**11-17**] demonstrated interval improvement in the size of her abdominal fluid collections and no anastamotic leak. Drain cultures grew rare Pseudomonas; antibiotics were held. . On [**11-19**], she became tachycardic (120-135), hypertensive (180s/100s), and hypoxic (O2 82% on RA, 94% on 2L), wiht low UOP (10-15cc/hr). A CTA torso demonstrated a new very small RML PE, unlikely to account for her presentation, and portal venous gas. She was transferred to the TSICU. Heparin gtt was started for the PE. She was bolused and transfused with good response. She was made NPO (including TF) and a new NGT was placed. Her WBC increased to 24.5; Zosyn was started for heavy Pseudomonas (from her drain cultures) and E.coli (urine culture). Repeat CT abdomen later in the day demonstrated a marked decrease in the amount of portal venous gas. LENIs performed the following day were negative for DVT. C.diff was again positive, so PO vanc/Flagyl were started on [**11-20**]; she eventually completed a 14 day course. . She was transferred back to the floor with telemetry on [**11-21**]. Tube feeds were restarted on [**11-23**]. Heparin gtt was d/c'd, and SQH was started on [**11-24**]. On [**11-25**], Zosyn was d/c'd, JP was d/c'd, and she was switched to PO medications. On [**11-26**], a swallow evaluation cleared her for thin liquids and ground solids with assistance. Her tube feeds were cycled at night. Calorie counts were as follows: [**11-30**] 242 calories + 0 g. protein, [**12-1**] 269+4, [**12-2**] 1044+30. Megace was started on [**12-2**]. Dobhoff was d/c'd on [**12-3**]. Calorie counts were repeated as follows: [**12-7**] <300+0, [**12-8**] 653+33, [**12-9**] 555+18. Remeron was added for appetite on [**12-12**]. . On [**11-28**], bleeding was noted from her vagina. A transvaginal ultrasound failed to visualize the endometrial stripe and adnexa. A pelvic exam performed by Ob/Gyn did not include a bimanual and failed to visualize the cervix. Ob/Gyn recommended outpatient endometrial biopsy upon [**Month/Year (2) **] to rule out endometrial cancer. She had a questionable history of endometrial hyperplasia which is to be clarified by Ob/Gyn. . LUE swelling was noted on [**11-29**]. An ultrasound demonstrated DVT of the L basilic, brachial, and axillary veins. Her L basilic PICC was d/c'd. Heparin gtt and Coumadin were started on [**12-1**]. On [**12-3**], Lovenox was started and heparin gtt was d/c'd. ASA was also added for high platelet count. Lovenox was d/c'd on [**11-5**] when INR became therapeutic (>1.5). A repeat ultrasound on [**12-9**] demonstrated recanalization of her brachial & axillary veins, with chronic occlusion of her basilic vein. Coumadin became supratherapeutic and was held on [**12-13**]. It was not restarted, given her high fall risk. SQH was restarted when her INR was 2.0. ASA was continued. . Nutrition, Ostomy/Wound RN, Physical Therapy, and Occupational Therapy followed her from admission to [**Month/Year (2) **]. [**Last Name (un) **] was consulted on [**11-28**] for BS management and remained involved throughout the remainder of her hospital course. . On [**Month/Year (2) **], patient was afebrile off antibiotics, with stable vital signs. She was tolerating regular diet. She was out of bed to chair TID. Medications on Admission: [**Last Name (un) 1724**]: Lantus 17U/d, metformin 500''', ASA 325', Colace 100", Cymbalta 20", Prilosec 20', Risperdal 0.5'", simvastatin 40', Toprol 100', Tramadol 25", Zetia 10' [**Last Name (un) **] Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs PO Q4H (every 4 hours) as needed. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed. 9. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 13. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 14. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Metoprolol Tartrate 25 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day): hold for SBP<100, HR<55. 16. insulin sliding scale Insulin SC . Fixed Dose Orders Bedtime Glargine 26 Units . Humalog Insulin SC Sliding Scale BS Breakfast Lunch Dinner Bedtime 0-80 mg/dL 1/2ampD50 1/2ampD50 1/2ampD50 1/2ampD50 81-120 mg/dL 4 Units 4 Units 6 Units 0 Units 121-160 mg/dL 8 Units 6 Units 8 Units 0 Units 161-200 mg/dL 10Units 8 Units 10 Units 0 Units 201-240 mg/dL 12Units 11 Units 12 Units 2 Units 241-280 mg/dL 14Units 13 Units 14 Units 4 Units 281-320 mg/dL 16Units 14 Units 16 Units 6 Units 321-360 mg/dL 18Units 16 Units 18 Units 8 Units 361-400 mg/dL 20Units 18 Units 20 Units 10 Units > 400 mg/dL Notify MD Notify MD Notify MD Notify MD [**Last Name (un) **] Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] [**Location (un) **] Diagnosis: Anastomotic leak anterior portion of the anastomosis, diffuse fecal peritonitis, and a well-developed abscess cavity in the left pelvis [**Location (un) **] Condition: Afebrile, vital signs stable, tolerating regular diet [?and tube feeds], colostomy functioning, wound granulating well. [**Location (un) **] Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your 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. * Continue to ambulate several times per day. Followup Instructions: Please call Dr.[**Name (NI) 15146**] office at [**Telephone/Fax (1) 600**] to schedule a follow-up appointment in 2 weeks. . You have an appointment with Geriatric Medicine: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2183-1-1**] 9:30 . Please call the OB/[**Hospital **] clinic at [**Telephone/Fax (1) 2664**] to arrange for an endometrial biopsy. Completed by:[**2182-12-15**] Name: [**Known lastname 3936**],[**Known firstname 1677**] Unit No: [**Numeric Identifier 12070**] Admission Date: [**2182-10-29**] Discharge Date: [**2182-12-19**] Date of Birth: [**2109-11-29**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11689**] Addendum: Patient underwent barium enema just prior to discharge; findings below: COLON (BARIUM ENEMA) [**2182-12-18**] 3:14 PM Reason: Assess for any further leak or other processes. [**Hospital 5**] MEDICAL CONDITION: 73 year old woman with h/o perf diverticulitis; s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11066**] [**2-21**]; s/p colostomy reversal [**10-16**] c/b leak, rpr of anastomosis [**10-30**] REASON FOR THIS EXAMINATION: Assess for any further leak or other processes. Requesting exam to be done [**2182-12-18**]. HISTORY: Perforated diverticulitis, status post [**Doctor Last Name 11066**] procedure, colostomy, repair of leak at anastomosis, assess for further leak. COMPARISON: CT abdomen and pelvis [**2182-11-19**]. FINDINGS: Initial scout supine AP radiograph shows unremarkable bowel gas pattern. No definitive free air seen. There is mild dextroscoliosis of the upper to mid lumbar spine with asymmetric degenerative changes. Rectal tube was placed and balloon inflated. Hypaque (water soluable contrast) was used under gravity. Active leak was noted during the procedure from the presumed anastomotic site in the remainder of sigmoid colon, with contained contrast collection to the left and anterior of the anastomotic site. IMPRESSION: Contrast leak at the presumed anastomotic site, with contained collection measuring 2.1 cm. No further intervention warranted given her stable hemodynamic status. She will follow up with Dr. [**Last Name (STitle) **] in [**12-18**] weeks. Discharge Disposition: Extended Care Facility: [**Hospital1 **] of [**Location (un) 729**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 11690**] MD [**MD Number(2) 11691**] Completed by:[**2182-12-19**]

[ "294.0", "V45.81", "008.45", "562.11", "414.01", "272.0", "V09.0", "567.21", "623.8", "599.0", "415.19", "997.4", "250.02", "453.8" ]

icd9cm

[ [ [] ] ]

[ "96.6", "54.19", "54.91", "99.15", "38.93", "46.03" ]

icd9pcs

[ [ [] ] ]

19113, 19343

7448, 12837

358, 652

2545, 2545

16700, 17744

1892, 1910

12863, 15275

1925, 1925

15307, 15445

290, 320

18015, 19090

15477, 15599

15634, 16677

17780, 17986

680, 1404

2559, 7425

1426, 1701

1717, 1876

77,469

164,145

29630

Discharge summary

report

Admission Date: [**2154-7-24**] Discharge Date: [**2154-8-8**] Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 4588**] Chief Complaint: alteration in mental status Major Surgical or Invasive Procedure: central venous line History of Present Illness: 85 yo F with h/o DM2, HTN, PVD, AV block s/p PPM and CM w/ ICD in place who was found with AMS at home. The patient was initially admitted after being found in her home, where she lives with her schizosphrenic son. [**Name (NI) **] [**Name2 (NI) 802**] [**Name (NI) 1154**] is her HCP, and is a [**Name (NI) 42137**] at [**Hospital1 18**]. She reports that the patient has been declining over past few months, and has refused nursing home. On admission, patient was found to have UTI (>100K micrococci) and was started on ampicillin. She was also noted to have left ankle venous ulcer, which has been seen by podiatry and vascular surgery. She was given 1 dose of vanco and zosyn but concern for infection of ulcer was low so these were stopped. She had an episode of hypotension to SBP 70's despite aggressive IVF, also with tenous IV access, and was transferred to MICU. Upon arrival to MICU, IJ was placed and blood pressure improved without any futher intervention. A foley catheter was placed to assess urine output, which has been adequate. The patient had low grade fevers initially, now afebrile. She complains only of back pain which is chronic, although communication is difficult due to severe loss of hearing. Past Medical History: 1. PVD s/p bypass [**2151**] 2. DM2 with complications neuropathy 3. HTN 4. Cardiomyopathy - systolic CHF with EF 35-40% 5. chronic LE edema 6. hyperlipidemia 7. osteoporosis 8. GERD 9. s/p appy 10. B12 deficiency 11. vertebral disc surgery - hardware in lumbar spine & chronic lbp 12. Pacemaker - [**Hospital3 9642**] in [**2149**] for intermittent AV block and bradycardia Social History: She lives with her son, who has mental illness. Denies any tobacco, alcohol or IVDU. Her [**Last Name (LF) 802**], [**Name (NI) 1154**] [**Name (NI) 23531**] is a nurse [**First Name (Titles) **] [**Last Name (Titles) 71026**] here at [**Hospital1 18**] and is her HCP. She has a visiting nurse once weekly. Family History: There is no family history of premature coronary artery disease or sudden death Physical Exam: VS: T97.4, HR 76, BP 113/66 (110-128/66-75), RR 24, O2sat 100%/RA Gen: arousable, NAD HEENT: mmm, JVP 6cm, no LAD CV: difficult to auscultate, ? irregular vs. physiologic variation, no m/r/g pulm: CTAB anteriorly ab: soft, NT/ND, pos BS, no HSM GU: foley in place extrem: venous stasis changes, shallow ulcer on left shin, ulcer on left ankle wrapped. neuro: moves all extremities, follows commands, possible decreased strength in L vs R UE Pertinent Results: [**2154-7-24**] . 11.8 7.3 >---< 235 35.9 NEUTS-54.2 LYMPHS-35.7 MONOS-6.7 EOS-3.0 BASOS-0.4 139 | 105 | 23 / 194 4.2 | 19 | 1.2 \ . LACTATE-3.0* ALBUMIN-3.7 CALCIUM-9.7 PHOSPHATE-2.0* MAGNESIUM-1.7 . COAGs: PT-12.7 PTT-20.4* INR(PT)-1.1 . CE: cTropnT-0.03* . LFTs: ALT(SGPT)-17 AST(SGOT)-23 LD(LDH)-283* CK(CPK)-87 ALK PHOS-73 TOT BILI-0.7 Brief Hospital Course: 85F with DM, PVD, CHF and deafness, admitted for altered mental status, found to have UTI. . #. AMS/UTI: The patient was initially agitated and complaining of back pain, which is apparently chronic for her. She was given levaquin given her history of legionella pneumonia. Her CXR was unremarkable. Her head CT did not show any new lesions. UA normal but urine culture grew micrococcus/stomatococcus >100,000. This was considered a UTI and patient was treated with ampicillin for 7 days. Blood cx all neg. Repeat urine culture was negative. WBC was normal and patient remained afebrile. . The patient's mental status began to return to her baseline. She demonstrated a significant level of underlying dementia, but also brief episodes of delirium. During these, the patient would look around the room, respond to paranoid delusions, and refuse treatment. It was thought that the patient's underlying dementia, deficiency in sensory input (severe hearing loss), resolving infection, and hospital environment all contributed to delirium. TSH was wnl. RPR was negative. B12 was normal. Vitamin D levels were pending at discharge, and the patient was treated empirically with Vitamin D and thiamine supplements. She was treated with standing Zyprexa zydis in morning and bedtime. The patient's Lasix was D/Ced since she was felt to be dry, complaining of thirst and increased BUN. Her Lasix could be restarted as outpatient if necessary. Appears euvolemic on discharge. At discharge, patient was agreeing to treatment, calm, cooperative, with no complaints. She benefitted from amplification headphones and may benefit from hearing aids if she agrees. . #. hypotension: On the medicine floor, the patient had an episode of hypotension with SBP 70's. The patient was given several IVF boluses, and when hypotension did not resolve, MICU was called to place central line and arrange transfer. Left IJ was placed and fluid resusitation continued during transfer. The patient was started on vanco/zosyn. When the patient arrived in the MICU, hypotension had resolved without any further intervention. Blood pressure remained stable for remainder of course. Vanco/Zosyn were D/Ced, and patient returned to medicine floor. She remained hemodynamically stable and afebrile for remainder of course. . # Decubitus left heel ulcer The patient was noted to have a left heel ulcer, unable to be staged without debridement. Both vascular surgery and podiatry were consulted. Both recommended holding off debridement or more extensive treatment until patient's infection resolved and placement situation stabilized. The patient is known to have severe PVD, likely not a candidate for revascularization. Dressing changes with collagenase ointment and multipodus boots should be continued, feet should be elevated. The patient should follow-up with podiatry and vascular surgery. . # DM The patient's home oral anti-hyperglycemics were held. The patient was controlled on HISS, and standing Lantus and Humalog with meals was added for improved glycemic control. . # HTN The patient's home antihypertensives were held with hypotensive episode. Home dose of lisinopril and half home dose of metoprolol was eventually restarted without issues. The patient was on Lasix at home, but in setting of hypotensive episode, this was held. A small dose (5 mg [**Hospital1 **]) was tried, but patient seemed dry and BUN increased. We will hold off Lasix for now since patient euvolemic. . # Chronic systolic CHF. The patient had a TTE which showed worsening EF from 35-40% in [**2151**] to 20-25%. The patient was continued on lisinopril and metoprolol. Home Lasix was held. The patient did not demonstrate signs of volume overload on physical exam. The patient was restarted on ASA 81 mg. Ezetimibe was D/Ced since of little benefit to patient at this stage. . # Hypothyroidism. TSH normal. Continued home dose levothyroxine. . # Depression Continued duloxetine . #. Psychosocial: The patient had been cared for by her son, who suffers from mental illness. It was unclear if she was reliably receiving her medications or food. Social work and elder care were involved in her course. Her [**Year (4 digits) 802**] [**Name (NI) 1154**] is her HCP. The patient's son should not be responsible for care decisions. . The patient was discharged to rehab facility (Roscommons) Medications on Admission: Duloxetine 20mg [**Hospital1 **] Ezetimibe 10mg daily Furosemide 40mg daily Glipizide 2.5mg daily Hydrocodone-acetaminophen 5/500 QID PRN Levabunolol 0.25% eye gtt OU [**Hospital1 **] Levothyroxine 75mg daily Lisinopril 2.5mg daily Metoprolol Succinate 25mg daily Acetaminophen 325mg daily Aspirin 325mg daily Cyanocobalamin 1000mcg daily Docusate 100mg [**Hospital1 **] Ergocalciferol 400 units daily Ferrous Sulfate 325mg daily Senokot 2 tabs daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). 6. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.25 Tablet, Rapid Dissolve PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 10. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 11. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 16. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 17. Insulin Lispro 100 unit/mL Solution Sig: Four (4) Subcutaneous with breakfast. 18. Insulin Lispro 100 unit/mL Solution Sig: Six (6) Subcutaneous with lunch. 19. Insulin Lispro 100 unit/mL Solution Sig: Six (6) Subcutaneous with dinner. 20. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous qACHS. Discharge Disposition: Extended Care Facility: Roscommon Discharge Diagnosis: primary diagnosis: UTI . secondary diagnosis: DM2 chronic systolic CHF PVD with left heel ulcer Discharge Condition: stable, afebrile Discharge Instructions: You were admitted for confusion and found to have a urinary tract infection. You were treated with antibiotics. . You had an episode of low blood pressure, which was treated with fluids. . The following changes were made to your home medications: --> You will stop taking Lasix until restarted by physician. Please adhere to a low-sodium diet. Check daily weights. . You should seek medical attention if you experience fevers, chills, cough, shortness of breath, chest pain or any other new symptoms. Followup Instructions: MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Podiatry Date and time: [**Last Name (LF) 2974**], [**9-6**] at 2:30PM Location: [**Hospital1 18**] [**Hospital Ward Name 517**], [**Hospital Ward Name 121**] Bldg [**Location (un) **] Phone number: ([**Telephone/Fax (1) 4335**] . . MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] Specialty: Vascular Surgery Date and time: Wednesday, [**10-9**] at 9:00AM Location: [**Hospital1 69**], [**Hospital Ward Name **] Bldg [**Last Name (NamePattern1) 71027**] Phone number: ([**Telephone/Fax (1) 4852**]

[ "707.25", "428.0", "564.09", "458.9", "733.00", "293.0", "440.23", "276.52", "294.8", "V45.02", "428.22", "707.07", "244.9", "599.0", "250.62", "389.9", "782.3", "440.4", "425.4", "401.9", "311" ]

icd9cm

[ [ [] ] ]

[ "86.28", "38.93" ]

icd9pcs

[ [ [] ] ]

9715, 9751

3188, 7529

242, 263

9891, 9910

2812, 3165

10460, 11076

2255, 2336

8030, 9692

9772, 9772

7555, 8007

9934, 10163

2351, 2793

10181, 10437

175, 204

291, 1514

9818, 9870

9791, 9797

1536, 1913

1929, 2239

29,732

178,308

5694

Discharge summary

report

Admission Date: [**2159-12-9**] Discharge Date: [**2160-1-2**] Date of Birth: [**2084-11-24**] Sex: F Service: MEDICINE Allergies: Keflex Attending:[**First Name3 (LF) 99**] Chief Complaint: Nausea, diarrhea Major Surgical or Invasive Procedure: Intubation History of Present Illness: History of Present Illness 75 F h/o AF, CHF, bioprosthetic aortic valve. Presents with 1 week h/o nausea & watery diarrhea. Also had one episode of emesis. Otherwise, has been able to tolerate POs, denies f/c/s. No sick contacts. [**Name (NI) **] BRBPR. Baseline dark stools, as she takes Pepto Bismol. (+) lightheaded, but no syncope . ROS otherwise significant for chronic incisional chest pain, described as a midsternal, radiating to back and neck, unchanged in the last 6 years since her aortic valve replacement. No assoc SOB, n/v, diaphoresis. Past Medical History: Past Medical History s/p bio-prosthetic aortic valve replacement Edema Sciatica h/o Breast Cancer, s/p L mastectomy Back Pain Hyperlipidemia Hypertension Osteoporosis Congestive Heart Failure Renal Insufficiency Gout Social History: Social History Lives with husband. Previous 1.5 PPD x 40 yr smoker, quit 20 yr ago. Occas EtOH Family History: Family History Noncontributory Physical Exam: Physical Examination VS - T 97.3, BP 81/47, HR 104, RR 27, O2 sat 96% 2L NC General - elderly female, pleasant, conversant, in no acute distress HEENT - PERRL, OP clr, no LAD, MM dry; JVP flat CV - tachy, irreg Chest - s/p L mastectomy; small pinpoint skin defect draining serosanguinous, dressed; lungs CTAB Abdomen - NABS, soft, NT/ND, no g/r, no CVAT Neuro - A&O x 3 Pertinent Results: LABS: [**2159-12-8**] 11:03PM BLOOD WBC-16.1*# RBC-3.57* Hgb-12.1 Hct-35.9* MCV-101* MCH-33.9* MCHC-33.7 RDW-16.1* Plt Ct-201 [**2159-12-31**] 03:53AM BLOOD WBC-12.5* RBC-2.96* Hgb-9.7* Hct-31.0* MCV-105* MCH-32.6* MCHC-31.2 RDW-18.1* Plt Ct-716* [**2159-12-9**] 04:09PM BLOOD Neuts-76* Bands-6* Lymphs-4* Monos-12* Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2159-12-9**] 04:09PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Burr-2+ [**2159-12-9**] 03:45AM BLOOD PT-15.7* PTT-37.7* INR(PT)-1.4* [**2159-12-30**] 03:09AM BLOOD PT-12.8 PTT-30.7 INR(PT)-1.1 [**2159-12-29**] 05:48PM BLOOD Ret Aut-3.4* [**2159-12-10**] 03:01AM BLOOD Ret Man-1.2 [**2159-12-8**] 11:03PM BLOOD Glucose-70 UreaN-137* Creat-9.0*# Na-116* K-7.5* Cl-82* HCO3-14* AnGap-28* [**2159-12-31**] 03:53AM BLOOD Glucose-112* UreaN-37* Creat-1.9* Na-143 K-3.6 Cl-98 HCO3-33* AnGap-16 [**2159-12-8**] 11:03PM BLOOD CK(CPK)-247* [**2159-12-9**] 03:45AM BLOOD ALT-52* AST-45* AlkPhos-178* Amylase-19 TotBili-0.6 [**2159-12-31**] 03:53AM BLOOD ALT-30 AST-31 AlkPhos-150* TotBili-1.1 [**2159-12-29**] 02:56AM BLOOD ALT-23 AST-22 LD(LDH)-200 AlkPhos-110 TotBili-1.4 [**2159-12-8**] 11:03PM BLOOD CK-MB-11* MB Indx-4.5 [**2159-12-8**] 11:03PM BLOOD cTropnT-0.02* [**2159-12-9**] 03:45AM BLOOD CK-MB-8 cTropnT-<0.01 [**2159-12-9**] 12:05AM BLOOD Calcium-7.7* Phos-4.7* Mg-1.9 [**2159-12-31**] 03:53AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.9 [**2159-12-29**] 05:48PM BLOOD calTIBC-172* Ferritn-330* TRF-132* [**2159-12-21**] 02:21AM BLOOD VitB12-1073* Folate-10.0 [**2159-12-20**] 02:40AM BLOOD Hapto-144 [**2159-12-10**] 03:01AM BLOOD Hapto-201* [**2159-12-18**] 01:45AM BLOOD Triglyc-126 [**2159-12-9**] 03:45AM BLOOD Osmolal-304 [**2159-12-9**] 03:45AM BLOOD Cortsol-51.5* [**2159-12-9**] 08:00AM BLOOD Type-ART pO2-102 pCO2-30* pH-7.26* calTCO2-14* Base XS--12 [**2159-12-29**] 04:10AM BLOOD Type-ART Temp-36.2 pO2-142* pCO2-44 pH-7.45 calTCO2-32* Base XS-6 [**2159-12-9**] 12:40AM BLOOD K-5.7* [**2159-12-9**] 03:09AM BLOOD Lactate-0.4* [**2159-12-28**] 09:12AM BLOOD Lactate-0.6 . MICRO: Blood Cx ([**12-8**], [**12-9**]): MSSA Urine Cx ([**12-9**]): E. coli, pansensitive Chest Wall wound Cx ([**12-10**]): MSSA Sternotomy Wire Cx ([**12-11**]): MSSA . RADIOLOGY: CXR ([**12-8**]): IMPRESSION: Patchy retrocardiac opacity may represent consolidation or atelectasis. There is also a small left pleural effusion. . Chest U/S ([**12-9**]): IMPRESSION: Fluid/debris containing collection within the subcutaneous tissues of the sternum in the region of the patient's chest wall defect which may represent an abscess or hematoma. Ultrasound-guided aspiration could be performed, as clinically indicated, for therapeutic/diagnostic purposes. . CT Torso ([**12-10**]): IMPRESSION: 1. New, multiple foci of gas seen within the sternal soft tissues, with a small focus of gas seen in the left superior mediastinum. Findings are concerning for underlying infection. No drainable collection is identified. 2. Large bilateral pleural effusions with associated atelectasis and infiltrate. Underlying pneumonia cannot be excluded. 3. Distended gallbladder, with evidence of sludge and stones within. Clinical correlation recommended. Ultrasound would be recommended for further evaluation if there is concern for cholecystitis. This was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10752**] at 3:30 p.m. [**2159-12-11**]. 4. Moderate amount of free fluid seen is within the abdomen and pelvis. Soft tissue stranding suggesting anasarca. 5. Coronary calcifications, prosthetic aortic valve noted. . Renal U/S ([**12-10**]): IMPRESSION: No hydronephrosis. Normal-sized kidneys. Mild amount of ascitic fluid. . TTE ([**12-10**]): 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%) The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2158-7-17**], the rhythm now appears to be atrial fibrillation, the right ventricular cavity is now dilated, and the severity of pulmonary artery systolic pressure is now lower. The bioprosthetic mitral valve gradient and severity of aortic regurgitation are similar. . TEE ([**12-11**]): Overall left ventricular systolic function is normal. There is symmetric LVH. Right ventricular function may be depressed (not fully visualized). There are complex (>4mm) non-mobile atheroma in the descending thoracic aorta. A bioprosthetic aortic valve prosthesis is present and appears well seated. The aortic valve prosthesis leaflets appear to move normally. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**2-13**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. IMPRESSION: No vegetation or abscess identified . Abdomen Film ([**12-12**]): FINDINGS: Supine and upright abdominal radiographs. Nonspecific bowel gas pattern with residual contrast seen within the colon. Tip of NG tube is seen within the stomach. There is no evidence of intra-abdominal free air. There is right basilar atelectasis and pleural effusion. Median sternotomy wires and Foley catheter are identified. IMPRESSION: No evidence of obstruction. . Liver/GB U/S ([**12-15**]): IMPRESSION: 1. Distended gallbladder containing sludge with trace pericholecystic fluid. Although there are no specific signs for acute cholecystitis, a HIDA scan would be necessary to exclude the possibility of acalculous cholecystitis. 2. Right pleural effusion and atelectasis. . CXR ([**1-1**]): FINDINGS: In comparison with the study of [**12-31**], there has been a substantial increase in opacification bilaterally, especially on the left, consistent with rapid accumulation of pleural fluid. The status of the underlying lung is difficult to evaluate in the absence of either a lateral view or CT. There is further engorgement of the pulmonary vessels consistent with increasing pulmonary venous pressure. The nasogastric tube has been removed. The endotracheal tube is difficult to see and may have been removed, though the patient's head somewhat obscures the upper thorax. The fragmented wires in this upper sternum are again appreciated. Brief Hospital Course: Patient is a 75 year old female with AF, CHF, bioprosthetic aortic valve, admitted with ARF after 1 week of diarrhea, MSSA bacteremia from sternal wound infection, intubated for respiratory distress and acidosis, unfortunately failed extubation and at this time not an ideal candidate for trachestomy. . # Respiratory failure and Metabolic Acidosis: Initially intubated for worsening acidosis and respiratory fatigue, also appeared to have pulmonary edema on CXR. Failed attempted extubation on [**12-20**], as she became tachycardic, tachypneic, hypertensive, using accessory muscles and unable to clear secretions or cough, and was subsequently re-intubated. It was thought that she failed likely due to deconditioning/overall weakness, likely component of restrictive lung disease, given kyphosis, and overloaded fluid status. CXR continued to demonstrate pulmonary edema and vascular congestion, along with pleural effusions, however her CXR did seem improved when compared to several days ago; we were continuing to monitor CXR to help with assessment of fluid status. Overall appears less fluid overloaded on exam, with much improvement in edema. She was continued on a lasix gtt, having successfully removed 1 L/day, but lasix gtt was eventually held as she became hypotensive. The initialy plan was that if the patient failed extubation, Dr. [**Last Name (STitle) 2230**] had been contact[**Name (NI) **] and would start arrangements for tracheostomy. Patient extubated [**12-31**], initially did well then became increasingly uncomfortable, felt short of breath. The patient wished not to be re-intubated and did not want a tracheostomy.. After extensive discussions with family and patient, decision was made for patient to be comfort measures only, as patient did not want to be re-intubated or placed on non-invasive ventilation. Family at bedside and in agreement with plans for CMO. Morphine gtt was initiated, and patient passed away on [**1-2**]. . # MSSA infection/sepsis of sternal wound: Her shock was secondary to staph aureus wound infection in her sternum (from previous mitral valve surgery) and subsequent bacteremia. Family declined any surgical intervention or drainage/debridement of wound. Initially on neo, but then weened to vasopressin, now off all pressors for several days. Blood Cx ([**12-8**], [**12-9**]) MSSA, Wound Cx ([**12-10**]) MSSA, Sternotomy Wire ([**12-11**]) MSSA, which was treated with nafcillin. LFTs were monitored daily. Also Previous + urine culture for E. coli; treated with 7 days of cipro. TEE did not demonstrate any vegetations. . # Chronic back pain: Patient has related chronic back pain that is likely exacerbated by prolonged stay in bed. Patient not on any significant pain management medications at home. As discussed earlier, osteomyelitis is less likely, and work up would not change management. Pain control adequate at present, likely improved with OOB to chair and working with PT. Fentanyl patch of 25 mcg initiated, using boluses as fentanyl needed, however not needed for quite some time. Tylenol ATC and Lidoderm patch added. . # Anxiety: Patiend had severe anxiety regarding extubation. Family relates that patient is a "worrier" at baseline, but otherwise manages her anxiety on her own, and does not seek medications. We had attempted to maximize medical management of her anxiety to assist with success of weaning from vent. To decreased anxiety, only the on-call team would see the patient on daily rounds, and only the attending and respiratory therapist were in the room for extubation. She was given Klonopin 0.5 mg [**Hospital1 **] to help with significant anxiety, Ativan PRN for additional anxiety. Re-assuring, supportive care from family, staff. . # Elevated LFTs/Cholestasis: Resolved. Previous US showed mild gallbladder distension. Will continue to monitor trend, LFTs (except alk phos, trending down) and T. Bili within normal limits. . # Abdominal discomfort: Resolved, was likely secondary to irritation from heparin injections. Attempted to transition to lovenox, so patient would only get one daily injection, however pharmacy concerned given patient's low weight and low creatinine clearance. D/ced heparin SC as patient promised to keep on pneumoboots. . # AF w/RVR: Patient developed AF w/RVF, was on amiodarone drip, and was successfully cardioverted back in to NSR, flips back into AF occasionally. Restarted ASA for anticoagulation (outpatient regimen, was not on Coumadin or any other [**Doctor Last Name 360**] as outpatient). Continued on amiodarone PO 400 mg TID for 2 weeks, then changed on [**1-1**] to 400 mg [**Hospital1 **] for 2 weeks (with plans to then change to 400 mg daily. Metoprolol was d/c'ed, given low bp, will favor diuresing in lieu of beta blocker, as patient has not been able to tolerate both. . # Anemia: No clinical evidence of bleeding. Continued B12, Folate supplementation. Received 1 U PRBCs on [**12-28**]. CT abd/pelvis showed no rp bleed. . # Renal failure: Presented with cr 9.0, from baseline cr 2.5-2.6; presumed prerenal from diarrhea, also likely worsened by hypotension. Improved with iv hydration. Renal U/S completed, no evidence of hydronephrosis or obstruction. E coli UTI treated with 7 days cipro. Urine lytes, sediment have been unremarkable. Creatinine improved to 1.8-1.9, lower than prior baseline. Diuresed as tolerated by b.p. with lasix gtt. . # Right arm erythema, left arm edema: Patient with redness at area of prior PICC in R arm, which was d/c'd as it was cracked. Area was marked, and has not extended beyond mark. No warmth or fluctuance. Suspect that as diuresis has occurred, patient's left arm has more residual edema in light of prior masectomy and lymphedema she has chronically had on that arm, and at this time in light of her total body edema, she has proportionally more in her left arm which is now more noticable as diuresis continues. Will continue to monitor, no lines, pain, or palpable cords in arm to suspect DVT. . # FEN: Started TFs. Monitored lytes [**Hospital1 **] with diuresis. Hypernatremia resolved, d/c'ed free water flushes Medications on Admission: Medications [**Doctor First Name **] 60 q12h prn Allopurinol 100 qd ASA 325 po qd Calcitriol 0.25 po qod Colchicine 0.6 qmwf Compazine prn Fosamax 70 qwk Lasix 20 po qmwf Maxzide (Triamterene-Hydrochlorothiazid) 75/50mg po qd Toprol XL 100 po qd . Allergies Keflex Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: None Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None

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icd9cm

[ [ [] ] ]

[ "96.72", "88.72", "96.6", "96.04", "34.01", "38.93" ]

icd9pcs

[ [ [] ] ]

15177, 15186

8692, 14833

282, 294

15234, 15243

1680, 8669

15296, 15303

1243, 1275

15148, 15154

15207, 15213

14859, 15125

15267, 15273

1290, 1661

226, 244

322, 874

896, 1115

1131, 1227

40,132

114,856

40161+58354

Discharge summary

report+addendum

Admission Date: [**2148-8-1**] Discharge Date: [**2148-8-6**] Date of Birth: [**2096-5-16**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Vicodin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion, Fatigue & Palpitations Major Surgical or Invasive Procedure: Closure of ASD and baffling of anaomolous pulmonary vein [**2148-8-1**] History of Present Illness: 52 year old female with history of hypertension, non-ST segment elevation MI in [**2147-11-6**] treated with a drug-eluting stent in the mid RCA and PTCA of the posterolateral branch at [**Hospital3 **] Hospital. Was also found to have a dilated right ventricle on a TEE, but without clear-cut left to right shunting at a degree that would cause such a dilation of the right ventricle. For further exploration she underwent a cardiac MRI at [**Hospital1 18**] on [**2-16**] that showed a significant left to right shunting with Qp/Qs flow at 2.6. However, the level of the shunting was not able to be identified clearly. As a result, she then underwent a chest CTA on [**4-11**], which conclusively showed the presence of anomalous pulmonary vein return with the right superior pulmonary vein draining into the right atrium and also the right inferior pulmonary vein being confluent with the left atrium and right atrium. The patient reports having an episode week prior to cath where her heart "was racing" and she was feeling lightheaded/dizzy for about an hour and a half. She did not have any chest pain but she took 2 SL nitroglycerin and then took her night dose metoprolol finally with improvement. This is the only episode of palpitations she has had since having the MI. She continues to complain of feeling extremely fatigued. She denies any chest pain. She did report dyspnea in the hot weather and a one week history of LE edema, worsening at night. Her activity level has been low. She presented for cardiac catherization prior to correction of her anomalous pulmonary veins which showed no significant coronary artery disease. She had an E coli urinary tract infection which was treated prior to her same day admission for surgery. Past Medical History: Coronary artery disease s/p Non-ST segment elevation MI in [**2147-11-6**] treated with a drug-eluting stent in the mid RCA and PTCA of the posterolateral branch at [**Hospital1 **] Episode of Atrial Fibrillation following PCI/stenting, s/p DCCV Hypertension Obesity Past Surgical History: s/p Left ankle surgery s/p C-sections x 2 s/p Tonsillectomy Social History: Race: Caucasian Lives with: Husband Occupation: Currently unemployed Tobacco: Never smoked ETOH: Rare Family History: Remarkable for early coronary artery disease. Her brother had quintuple CABG at age 50. Her father had an MI in his 60's and her mother had an MI in her 70's Physical Exam: Pulse: 67 Resp: 13 O2 sat: 100% RA B/P Right: 139/83 Left: Ht: 5'8" Weight 115.2 kg General: No acute distress, pleasant Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Obese Extremities: Warm [x], well-perfused [x] trace LE edema Varicosities: Both GSV were suitable without varicosities, varicose veins bilaterally behind knees Neuro: Grossly intact Pulses: Femoral Right: cath site Left: 1 DP Right: 1 Left: 1 PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 1 Left: 1 Carotid Bruit Right: none Left: none Pertinent Results: [**2148-8-5**] 04:42AM BLOOD WBC-12.8* RBC-3.19* Hgb-10.0* Hct-29.3* MCV-92 MCH-31.2 MCHC-34.0 RDW-13.9 Plt Ct-176 [**2148-8-5**] 04:42AM BLOOD Glucose-106* UreaN-16 Creat-0.6 Na-138 K-4.3 Cl-102 HCO3-29 AnGap-11 [**2148-8-4**] 05:31AM BLOOD WBC-15.9* RBC-3.14* Hgb-9.8* Hct-28.8* MCV-92 MCH-31.1 MCHC-33.9 RDW-14.0 Plt Ct-151 [**2148-8-4**] 05:31AM BLOOD UreaN-18 Creat-0.6 Na-135 K-4.2 Cl-102 [**2148-8-6**] 06:32AM BLOOD WBC-12.8* RBC-3.39* Hgb-10.5* Hct-30.4* MCV-90 MCH-31.0 MCHC-34.5 RDW-13.5 Plt Ct-241 [**2148-8-6**] 06:32AM BLOOD Glucose-97 UreaN-17 Creat-0.7 Na-136 K-3.9 Cl-97 HCO3-28 AnGap-15 [**2148-8-3**] 06:41AM BLOOD PT-12.3 INR(PT)-1.0 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 88206**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 88207**] (Complete) Done [**2148-8-1**] at 9:56:57 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2096-5-16**] Age (years): 52 F Hgt (in): 68 BP (mm Hg): 149/92 Wgt (lb): 253 HR (bpm): 69 BSA (m2): 2.26 m2 Indication: Intraoperative TEE for repair of ASD, repair of anomalous pulmnonary veins ICD-9 Codes: 746.9, 424.1, 424.2 Test Information Date/Time: [**2148-8-1**] at 09:56 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: Saline Tech Quality: Adequate Tape #: 2011AW2-: Machine: U/S 6 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 65% >= 55% Aorta - Ascending: 2.3 cm <= 3.4 cm Aorta - Descending Thoracic: 1.6 cm <= 2.5 cm Aortic Valve - Peak Velocity: 2.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 16 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 8 mm Hg Aortic Valve - LVOT diam: 1.6 cm Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. At least one pulmonary vein entering the right atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Sinus venosus ASD. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function. AORTA: Focal calcifications in aortic root. Normal ascending aorta diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AS. Mild to moderate ([**1-7**]+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Trivial MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Mild to moderate [[**1-7**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. There is a congenital defect. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE BYPASS No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. At least one pulmonary vein may be entering the right atrium. A patent foramen ovale is present. A sinus venosus atrial septal defect is present. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated with normal free wall contractility. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**1-7**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is atrially paced. There is normal biventricular systolic function. The mitral regurgitation is now mild. The sinus venosus defect has been closed though small residual flow can not be completely ruled out. The foramen ovale has also been closed. Very small pin-hole flow can be seen in the area of the foramen ovale. The thoracic aorta is intact after decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2148-8-1**] 11:36 ?????? [**2140**] CareGroup IS. All rights reserved. Brief Hospital Course: Ms.[**Known lastname **] presented for cardiac catherization prior to correction of her anomalous pulmonary veins which showed no significant coronary artery disease. Her preoperative workup revealed an E coli urinary tract infection which was treated prior to her same day admission for surgery. On [**2148-8-1**] she was taken to the operating room and underwent repair of partial anomalous pulmonary venous return and sinus venosus atrial septal defect, and closure of patient foramen ovale. Please see operative report for further details. She tolerated the procedure well and was transferred to the CVICU intubated and sedated. She awoke neurologically intact and was extubated without difficulty. Beta-blocker/Statin/Aspirin was initiated. Diuresis was initiated. Plavix was resumed for her history of stents. All lines and drains were discontinued when criteria was met. POD#1 she was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. She continued to progress and was cleared for discharge to home on POD# 5. All follow up appointments were advised. Medications on Admission: Lisinopril 20 mg daily Aspirin 81 mg daily - has not been taking consistently recently secondary to GI irritation - instructed to take daily with PPI Plavix 75 mg daily Metoprolol 25 mg [**Hospital1 **] Simvastatin 80 mg daily Fish oil 1000 mg TID Allergies: Sulfa - rash 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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). Disp:*120 Tablet Extended Release(s)* Refills:*2* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Closure of ASD and baffling of anaomolous pulmonary vein [**2148-8-1**] Coronary artery disease s/p Non-ST segment elevation MI in [**2147-11-6**] treated with a drug-eluting stent in the mid RCA and PTCA of the posterolateral branch at [**Hospital1 **], Episode of Atrial Fibrillation following PCI/stenting, s/p DCCV, Hypertension, Obesity, s/p Left ankle surgery, s/p C-sections x 2, s/p Tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tylenol 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 and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Wound check in the cardaic surgery office [**Hospital Unit Name **] Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on *********** in the [**Hospital **] medical office building [**Hospital Unit Name **]. Cardiologist: [**Doctor First Name **] [**Doctor Last Name 1911**] Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 88208**] in [**4-9**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2148-8-6**] Name: [**Known lastname 13988**],[**Known firstname 13989**] Unit No: [**Numeric Identifier 13990**] Admission Date: [**2148-8-1**] Discharge Date: [**2148-8-6**] Date of Birth: [**2096-5-16**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Vicodin Attending:[**First Name3 (LF) 741**] Addendum: simvastatin was resumed upon discharge. 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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). Disp:*120 Tablet Extended Release(s)* Refills:*2* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 10. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Company 720**] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2148-8-6**]

[ "V45.82", "412", "747.42", "414.01", "V85.42", "745.5", "401.9", "745.8", "278.00" ]

icd9cm

[ [ [] ] ]

[ "35.61", "39.61", "35.91" ]

icd9pcs

[ [ [] ] ]

15391, 15561

8958, 10100

351, 425

11997, 12164

3645, 7141

13089, 14227

2712, 2872

14250, 15368

11569, 11976

10126, 10400

12188, 13066

2514, 2576

7190, 8935

2887, 3626

267, 313

453, 2202

2224, 2491

2592, 2696

66,409

100,470

36901

Discharge summary

report

Admission Date: [**2147-7-6**] Discharge Date: [**2147-7-17**] Date of Birth: [**2090-10-5**] Sex: F Service: MEDICINE Allergies: Bactrim Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Ascites, need for transplant workup Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: 56 yo female with HepC cirrhosis, esophageal varices, h/o SBP, HTN, presented to [**Hospital 792**]Hospital on [**6-25**] with abdominal pain, nausea, and vomiting. While there, she underwent a CT abd/pelvis with contrast which showed choledocholithiasis and CBD dilation. She then underwent ERCP, the first one was unsuccesful, second one monday with papillotomoy and drainage of stones/bile. During her hospitalization there, her T.bili continued to rise and last was 22 (up from 16). Also, during that hospitalization, her creatinine bumped from baseline of 1.0 to to 2.6 (lab results unavailable currently). Renal had seen her there, felt this was likely ATN, and she was oliguric with daily UOP 450-650. She had muddy brown casts on the urine microscopy. After her ERCP, she had FFP, and then developed hypoxia, tachypnea, and bilateral infiltrate. This was thought to potentially be pulmonary edema, but TRALI was also possible. Also, she had urine/blood cultures which were negative, and 2 paracenteses that were negative for SBP. She was transferred here to [**Hospital1 18**] for further transplant eval. Prior to transfer, she was hemodynamically stable, and was on 4L O2 with high 90s sats. . Here, the patient states that she has abdominal bloating. She denies fevers, chills. Denies headache. She does report some mild nausea. She has no other complaints. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea. She does report significant constipation. Past Medical History: HCV cirrhosis Esophageal varices (grade unknown) HTN h/o SBP Social History: Lives in RI with husband. [**Name (NI) **] 2 grown children. Daughter listed as POA in RI. She denies history of alcohol, tobacco, or drug use. Currently unemployed. Family History: No history of liver disease. Mother deceased- had DM2 Physical Exam: On admission: General: Alert, oriented. somnolent but wakes up easily and answers questions appropriately HEENT: Sclera icteric, MM slightly dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: bibasilar crackles, no rhonci, no wheezes CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur at base Abdomen: soft, distended, bowel sounds hypoactive, no rebound tenderness or guarding. + fluid wave Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: jaundiced, no rash, no spider angiomas, no palmar erythema Neuro: A/O x 3; asterexis present Pertinent Results: On admission [**2147-7-7**]: WBC-5.9 RBC-2.66* Hgb-9.5* Hct-27.5* MCV-103* MCH-35.8* MCHC-34.6 RDW-17.8* Plt Ct-100* PT-23.6* PTT-44.5* INR(PT)-2.2* Glucose-74 UreaN-43* Creat-1.8* Na-135 K-5.0 Cl-104 HCO3-25 AnGap-11 ALT-45* AST-131* LD(LDH)-260* AlkPhos-95 TotBili-21.8* transplant labs: HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE HCV Ab-POSITIVE* AMA-NEGATIVE [**Doctor First Name **]-POSITIVE * Titer-1:40 [**Last Name (un) **] CEA-4.7* CA [**57**]-9 -64 IgG-2251* IgA-1000* IgM-213 HIV Ab-NEGATIVE EBV IgG-POSITIVE CMV IgG-POSITIVE VZV IgG- POSITIVE Rubella- Positive RPR- Negative ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG VITAMIN D 25 HYDROXY-7 Hct trends prior to MICU transfer ([**Date range (1) 9458**]): 24.4 -> 22.2 -> 23.5 -> 23.3 -> 21.8 -> 25.5 -> 21.7 -> 31.3 plt trends: 44 -> 90 -> 126 -> 46 Studies: [**7-6**] CXR: Lung volumes are somewhat low, but interstitial markings appear prominent and the pulmonary vasculature is indistinct. The cardiac silhouette appears large, although cardiac size may be exaggerated by AP technique. Mediastinal structures are otherwise unremarkable. The bony thorax is grossly intact. IMPRESSION: Increased interstitial markings which may represent mild edema. [**7-7**] Doppler abdominal ultrasound: The nodular liver is seen without focal lesion. There is a moderate amount of ascites. There are also bilateral pleural effusions. The hepatic vasculature is patent without evidence of thrombosis. The gallbladder is contracted, without stones. No evidence of intrahepatic or extrahepatic biliary ductal dilatation. The right kidney measures 10 cm, and the left kidney measures 9.3 cm. There is no evidence of hydronephrosis or renal calculi. In the left upper pole, there is a 5mm echogenic focus, without posterior shadowing, most likely representing a congenital AML. IMPRESSION: 1. Patent hepatic vasculature without evidence of thrombosis. 2. Moderate ascites. 3. Bilateral pleural effusions. 4. Nodular liver without focal lesions. [**7-8**] EKG: Sinus rhythm with sinus arrhythmia. Left axis deviation. Possible anteroseptal anterior and lateral myocardial infarction, age undetermined. Possible inferior myocardial infarction, age undetermined. Possible left ventricular hypertrophy [**7-9**] EKG: Sinus rhythm. Left axis deviation. Probable left ventricular hypertrophy. [**7-9**] CXR: Single portable upright chest radiograph is compared to the prior study from [**2147-7-6**]. Since prior study, interstitial edema has diminished and appears resolved. Heart and mediastinum are within normal limits. Lungs are clear. [**7-13**] MRCP: There is a cirrhotic, nodular liver. No focal liver lesions are identified. The umbilical vein is recanalized. No filling detects are visualized within the hepatic vasculature; the portal vein is patent. No evidence of gastroesophageal varices. Assessment of the MRCP is severely limited due to technical factors related to 3T artifacts from the patient's ascites. There is, however, no biliary ductal dilatation and no definite evidence of retained stones. Spleen, pancreas, kidneys, and adrenal glands show no abnormalities. No significant lymphadenopathy. Visualized bowel shows no abnormalities. No abnormal marrow signal is evident. IMPRESSION: 1. Cirrhotic liver with severe ascites. 2. MRCP limited by 3T artifact due to degree of patient's ascites. However, no definite evidence of retained stones or biliary ductal abnormalities. For subsequent examinations for this patient, suggest that studies be performed on a 1.5 Tesla magnet. [**7-14**] ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The 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. 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: Normal global and regional biventricular systolic function. No diastolic LV dysfunction, pulmonary hypertension, or clinically-significant valvular disease seen. Multiplanar 2D and 3D reformations provided multiple perspectives for the dynamic series. [**7-16**] CT abdomen and pelvis: There is gross ascites. The majority of the fluid in the abdomen and pelvis measures in the region of 10 Hounsfield units, compatible with simple fluid. There is, however, some minimal amount of dependent higher attenuation material in the free fluid in the pelvis (series 2, image 75), raising the possibility of a small amount of intraperitoneal hemorrhage or debris. The liver is small and nodular in contour, compatible with given history of cirrhosis. The spleen is normal in size. The pancreas is normal in morphology and attenuation. The adrenal glands are normal. There is a small calculus in the interpolar region of the left kidney measuring 5 mm in diameter. There is a tiny [**Doctor Last Name **] of calcification measuring approximately 1 mm in the lower pole of the right kidney (series 2, image 41). There is no significant retroperitoneal lymphadenopathy. The bowel caliber is normal in appearance. There is no evidence of free air in the abdomen or pelvis. There is patchy atelectasis in the lower lobes bilaterally. No focal bone lesion or fracture is seen. IMPRESSION: 1. Gross ascites, predominantly with simple-appearing fluid, but some dense material in the dependent portion of the fluid in the pelvis raises the possibility of a small amount of intraperitoneal hemorrhage or debris. 2. Nodular low volume liver compatible with cirrhosis. 3. Small interpolar region of left kidney calculus. 4. Bibasilar atelectasis. Brief Hospital Course: # HCV Cirrhosis: Decompensated liver failure with encephalopathy on admission; likely after ERCP and cholelithiasis. INR elevated, T.bili elevated from baseline in the 3s. Abdominal ultrasound on admission to [**Hospital1 18**] showed no thrombosis, macronodular liver contour without focal lesion, contracted gallbladder, ascites and pleural effusion. MRCP also found no retained stones or biliary distention. No SBP. She received aldactone, lactulose, rifaxamin and nadalol. Transplant workup was initiated but on hold pending insurance activation. #. Coagulopathy: She had low platelet count and elevated INR secondary to her liver disease which was the likely cause of her previous limited episode of bright red blood per rectum, mild hemoptyosis and hematuria. Throughout these previous episodes, she remained hemodynamically stable and asymptomatic. She received blood products, PPI and octreotide. Did not attribute this bleeding to variceal bleeds although she had a history of this with subsequent banding back in [**Month (only) **]. On the day of transfer to the MICU, she was hypotensive in the morning and had a bloody paracentesis. She was given more blood products and albumin, and had a CT that was negative for bleeding source. However, she had another lower GI bleed overnight and was transferred to the MICU where she was resuscitated with pRBC, FFP, Platlets, Cryo and taken to IR to attempt to find a source of the bleeding which was unsucessful. After returing to the MICU from IR Ms. [**Known lastname 4186**] continued to have copious bright red blood per rectum. She became bradycardic and then became pulseless and was found to be in asystole. Despite continued resuscitation efforts with blood product and following ACLS attempts at resuscitation were unsucessful and Ms. [**Known lastname 4186**] died at 0822hrs. # Cholelithiasis: Had two ERCPs at [**Hospital 792**]Hospital with improvement of pain, though elevating t.bili which may be secondary to worsening hepatic failure. Her baseline t bili in the 3s. Resolving ascending cholangitis. MRCP shows no further stones or duct dilation. Covered with Zosyn as she had been on ppx Cipro. She was also on ursodiol. # Acute Kidney Injury: Thought to be ATN secondary to relative hypotension. [**Name2 (NI) **] baseline creatinine is 1.0 but was elevated up to 2.7 in [**Doctor Last Name **]. Her Cr improved over time with maintaining equal, normal volume status. # Hypoxia: Mild hypoxia on admission that resolved over her hospital stay. Unclear etiology- could have been fluid overload from blood products or possible TRALI. Unlikely infectious given negative workup thus far and afebrile. # Blood pressure: Had some hypotensive episodes attritubuted to low intravascular volume. Her pressure responded to IVFs and albumin. Her diuretics were held during hypotensive periods. Medications on Admission: Medications on Transfer from RIH: Ciprofloxacin 400 mg daily Propranolol 20 mg TID Lactulose TID Spironolactone 25 mg daily Furosemide 40 mg [**Hospital1 **] MVI Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Hepatitis C Cirrhosis Gastrointestinal Bleed Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "518.81", "785.59", "574.20", "789.59", "571.5", "401.9", "576.1", "584.5", "070.44", "578.9", "287.5", "537.89", "456.21" ]

icd9cm

[ [ [] ] ]

[ "38.93", "54.91", "88.47" ]

icd9pcs

[ [ [] ] ]

12011, 12020

8899, 11770

310, 324

12108, 12118

2957, 8876

12170, 12312

2274, 2329

11983, 11988

12041, 12087

11796, 11960

12142, 12147

2344, 2344

1742, 1990

235, 272

352, 1723

2359, 2938

2012, 2075

2091, 2258

22,955

125,884

2427

Discharge summary

report

Admission Date: [**2110-5-30**] Discharge Date: [**2110-6-9**] Date of Birth: [**2040-1-26**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 70 year old male who was diagnosed with high grade T1 bladder cancer. He subsequently underwent six cycles of BCG and Interferon. Surveillance cystoscopy after that showed multiple reoccurrences and he was subsequently counseled for surgical therapy. PAST MEDICAL HISTORY: 1. Hypertension. 2. Nephrolithiasis. 3. Memory loss secondary to small lacunar infarct. 4. Pernicious anemia. 5. Bladder cancer. HOME MEDICATIONS: 1. Hesperidin 1 mg once daily. 2. Hydrochlorothiazide 25 mg once daily. 3. Vitamin B12 intramuscularly q.month. 4. Iron supplements once daily. 5. Multivitamin ALLERGIES: Iodine which causes rash. SOCIAL HISTORY: The patient does not drink alcohol. He quit smoking twenty years ago. HOSPITAL COURSE: The patient was admitted on [**2110-5-30**], and taken directly to the operating room where a radical cystoprostatectomy, bilateral pelvic lymph node dissection and neo-bladder creation was performed. During the procedure, the patient had a 20French Foley catheter placed. He also received two units of autologous red blood cells and one unit of packed red blood cells for an estimated blood loss of 1300cc. The patient also had renal stent placed which postoperatively was confirmed in place by KUB. The patient received three days of perioperative Cefazolin and Flagyl. He also had an epidural in place and a nasogastric tube in place as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain. The patient tolerated the procedure quite well and was sent to the Intensive Care Unit for overnight observation secondary to the large amount of fluid the patient received intraoperatively. The patient was seen by vascular surgery service secondary to continued appearance of abdominal aortic and common iliac aneurysm. The vascular team did not feel that there was anything immediate that needed to be done although did request that he follow-up in [**Hospital **] Clinic. The patient was also seen by pulmonary and critical care medicine who indicated the patient may have been showing signs of sympathetic overactivity and recommended the beta blocker if hypertension developed. Over the course of the first night, it was evident that the patient's baseline mental status deteriorated secondary to the surgery and the patient managed to pull his nasogastric tube, [**Location (un) 1661**]-[**Location (un) 1662**] tube, intravenous out as well as his Foley partially out. The Foley was gently replaced by the urology team. The patient was subsequently moved to the regular urology floor with a 24 hour sitter to insure the maintenance of his Foley catheter. The patient received p.r.n. Haldol for behavior. He also received another unit of packed red blood cells secondary to anemia. The patient's Foley catheter was flushed q.shift while on the floor. The patient's epidural was eventually accidentally pulled and nonfunctioning and was removed. Subsequently, the patient received only the rare p.r.n. Percocet. Otherwise, he did not require a large amount of pain medication. The patient was slowly started on sips, however, his bowel function was slow to return and the patient did not advance his diet in an expected fashion. The patient spiked a temperature on postoperative day three for which chest x-ray was performed which was clear. On postoperative day four, the neurology service was consulted to evaluate the patient for mental status. It was their opinion it was secondary to his surgery and partly on the medications that he was on. The patient's medication list was strictly cut down to the bear minimal medications. Haldol and narcotics were avoided as much as possible. They did, however, feel his mental status would improve on its own over time. On postoperative day five, it was noted that the patient had mild abdominal distention and was complaining of some abdominal pain. A KUB was performed which showed no obstruction and a CT was performed which showed no collection but there was a possible small hematoma on the abdominal wall. The patient's wound began to express a larger amount of serous material when his abdomen became distended. It was closely watched and never became purulent and his wound never became erythematous. Finally on postoperative day nine, the patient had a bowel movement and his diet was advanced. The sitter was discontinued and the patient appeared to tolerate the independence well without causing problems with his Foley catheter. Periodically, the Foley catheter did have to be manipulated secondary to poor urine flow resulting in pelvic pain. It continued to flow, however, adequately. However, on postoperative day eight, the patient spiked a fever once again. Urine culture and blood cultures, chest x-ray, and urinalysis were all performed. Cultures are currently pending. Chest x-ray was free of pneumonia and his urinalysis indicated that the patient was positive for a urinary tract infection. The patient was started on Levofloxacin on which he will continue for one week. It is now [**2110-6-8**], and the patient will be discharged to rehabilitation tomorrow. He will be discharged in good condition. He will be required to have a Foley catheter in place for approximately another two weeks. At rehabilitation, he will continue to have Foley catheter flushed. The patient may shower but should not take any baths, may not drive while on pain medication, should avoid strenuous activity. He will follow-up with Dr. [**Last Name (STitle) 12484**] in approximately two weeks to have his Foley catheter removed. MEDICATIONS ON DISCHARGE: 1. Hesperidin 1 mg once daily. 2. Hydrochlorothiazide 25 mg once daily. 3. Vitamin B12 intramuscularly q.month. 4. Iron supplements once daily. 5. Multivitamin 6. Levofloxacin 500 mg p.o. once daily to complete a seven day course. 7. Ranitidine 150 mg p.o. twice a day. 8. Tylenol 500 to 1000 mg p.o. q4-6hours p.r.n. 9. Heparin 5000 units subcutaneous q12hours. 10. Colace 100 mg p.o. twice a day. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 12485**], M.D. [**MD Number(1) 12486**] Dictated By:[**Last Name (NamePattern4) 12487**] MEDQUIST36 D: [**2110-6-8**] 11:04 T: [**2110-6-8**] 12:17 JOB#: [**Job Number 12488**]

[ "441.4", "293.9", "997.5", "442.2", "188.8", "599.0", "281.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "40.3", "56.51", "57.71" ]

icd9pcs

[ [ [] ] ]

5810, 6503

916, 5784

604, 809

159, 429

451, 586

826, 898

9,151

197,077

26481

Discharge summary

report

Admission Date: [**2133-12-20**] Discharge Date: [**2133-12-24**] Date of Birth: [**2056-8-17**] Sex: F Service: NEUROSURGERY Allergies: Quinidine/Quinine & Derivatives Attending:[**First Name3 (LF) 1835**] Chief Complaint: Fall; Head CT shows large irregular calcified mass 2.7cm in diameter in the left frontoparietal region and SAH. Major Surgical or Invasive Procedure: cerebral angiogram right craniectomy with evacuation of SDH and lobectomy History of Present Illness: Pt was leaving the beauty salon this am walking and looking in purse for her keys. The next thing she remembers was waking up i n the ambulance. Pt reports no recent illness and she said she felt fine this am. She does not recall feeling dizzy, light- headed, sweating or nauseaus prior. She does say that she felt "light-headed" upon awakening in the ambulance. Denies any previous episodes of syncope. Pt was transported to [**Hospital 1474**] Hospital where Head CT showed large irregular calcified mass 2.8 x 3.0cm in diameter in the left frontoparietal region and some SAH. Other findings at [**Hospital 1474**] Hospital include left minimally displaced fracture of the lateral malleolus. Of note blood sugar at [**Hospital 1474**] Hospital was 111, Hct 43.1 and first set of cardiac enzymes were (-) w/ trop <0.1. Pt was transferred to [**Hospital1 18**] for further work up and eval. Past Medical History: Afib HTN Hypercholesterolemia Chronic Kidney Disease Osteoporosis Cholecystectomy Tonsillectomy Social History: Married; Lives at home with her husband and adult son. [**Name (NI) 4906**] is currently an inpatient at the [**Location 1268**] VA s/p VP shunt placement for NPH. Quit smoking; Denies ETOH Family History: noncontributory Physical Exam: PE: General: Pleaseant female awake and alert sitting up on strecher. HEENT: NC;AT, No abrasions, lacerations or hematomas noted. No drainage from ears or nose noted. CV: RRR, S1S2 No murmurs, rubs or gallops. Pulm: Lungs clear to auscultation; Chest symmetrical with expansion. Abd: Abd soft, NT (+)BS. No pain to palpation. Ext: Extremities war m with swelling an daircast to left ankle and small amount of swelling and abrasion to right malleolus Neuro: Pt awake, alert and oriented to person, place and time. PERRL 3mm-->2mm brisk. EOMI. Visual Fields intact. Face symmetrical. Tongue midline. Speech clear and appropriate. Palate raise symmetrical. Facial sensation intact to light touch. Decreased hearing to finger rub in right ear. Lateral head rotation and shoulder shrug intact. Strength: (Pt with bilateral ankle injuries) [**Doctor First Name **] [**Hospital1 **] Tri IP H Q TA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] Right 5 5 5 5 5 5 4+ 4+ 5 Left 5 5 5 5 5 5 3+ 3+ 5 Vital Signs P 67 BP 153/72 RR 14 Pertinent Results: [**2133-12-19**] 07:30PM PT-12.5 PTT-22.7 INR(PT)-1.0 [**2133-12-19**] 07:30PM WBC-12.5* RBC-4.15* HGB-12.8 HCT-35.9* MCV-87 MCH-30.9 MCHC-35.6* RDW-15.3 [**2133-12-19**] 07:30PM CK-MB-2 cTropnT-<0.01 [**2133-12-19**] 07:30PM GLUCOSE-163* UREA N-33* CREAT-1.1 SODIUM-140 POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16 Brief Hospital Course: Pt was admitted to neuro step down unit for close neurological monitoring. It was discussed with pt and her family that her mass could be removed electively, did not need emergent/urgent craniotomy. She remained awake and alert and agreed with the plan. She had a workup for primary cancer but CT of chest,abdomen and pelvis showed no malignancies but rather multiple renal lesion and liver hemangioma. Her diet and activity were advanced. There was concern of trauma to her right leg but Xrays of her right lower leg were negative. She was found to have some confusion and was slow to follow commands on [**12-23**], she had a stat head CT which showed a large right subdural hematoma with effacement of the right hemisphere. She then emergently had a cerebral angiogram to r/o AVmalformation vs AV fistula/aneurysm. Results showed decreased flow of right MCA. She was then taken emergently to OR for right craniectomy with evacuation of subdural and right frontal lobectomy. Post op CT showed massive edema and infarction of entire right hemisphere. Pt expired [**2133-12-24**]. Medications on Admission: Procrit 5000 units weekly Norpace 150mg TID Zetia 10mg Qd Lipitor 80mg Qd Metoprolol 50mg [**Hospital1 **] Digoxin 0.125mg 1 tablet every other day Norvasc 5mg Qd Multi-vit w/ Iron Qd Asa 81mg Qd Avapro 300mg Qd Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: acute subdural hematoma left fronatl brain tumor left lower leg fracture Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2134-3-17**]

[ "824.2", "286.9", "518.81", "348.4", "432.1", "225.0", "427.31", "585.9", "780.2", "E888.9", "401.9", "852.02" ]

icd9cm

[ [ [] ] ]

[ "96.71", "03.31", "96.04", "88.41", "38.93", "99.04", "01.59", "93.54" ]

icd9pcs

[ [ [] ] ]

4581, 4590

3201, 4289

410, 485

4706, 4715

2845, 3178

4768, 4803

1751, 1768

4552, 4558

4611, 4685

4315, 4529

4739, 4745

1783, 2826

259, 372

513, 1408

1430, 1527

1543, 1735

21,037

162,302

5538

Discharge summary

report

Admission Date: [**2109-4-25**] Discharge Date: [**2109-5-2**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3507**] Chief Complaint: Fevers, cough Major Surgical or Invasive Procedure: Intubation, Central Line placement History of Present Illness: This is an 85 year-old woman with CAD s/p CABG, COPD, hypertension who presents with fevers and cough x 5 days. Patient was in her USOH until 5 days prior to admission when she began to have largely non productive cough and low grade fevers. In the past 2-3 days she has had increasingly productive cough and fevers up to 101-102. She also reports shortness of breath with the cough as well as generalized malaise/lethargy. Before this past week she had been working with a personal trainer and had been climbing [**11-27**] flights of stairs with limited difficulty and minimal shortness of breath but now is having shortness of breath even at rest. She denies chest pain, pnd, orthopnea, increased lower extremity edema. . Denies abdominal pain, diarrhea, vomiting, constipation, dysuria, irritative urinary symptoms, new rashes. She had a left lower extremity ulcer which has now healed. . Patient has help with ADL's at home. History obtained with son in the room who confirms recent illness. . Travel to [**Location (un) 7349**], no exotic travel, no sick contacts. . Pulmonary meds recently changed to advair/tiotropium. Had not needed inhalers recently. . In the emergency department blood pressure to high 70's, improved to 100's with 4+ liters of fluid. Mildly tachypneic with oxygen saturation 88% room air, mid 90's on [**2-28**] liters. Lactate 2.8 to 0.9 with fluids. Low grade temp to 99 max in ER. At home reportedly 101. Ceftriaxone/azithromycin and nebs. Central line placed. Past Medical History: 1. CAD s/p CABG-[**2095**] MI and then LIMA to LAD, SVG to circumflex marginal and RCA--? cathed again in [**2103**] for positive stress but no interventions--at [**Hospital3 **] in [**Location (un) 22341**] unclear 2. hypertension 3. hyperlipidemia 4. GERD 5. Gastric Ulcer 6. Hypothyroidism 7. Anxiety 8. Osteoporosis 9. COPD 10. Left TKR 11. Chronic Back Pain 12. Hearing Loss 13. Cataracts 14. [**Doctor Last Name 7820**] Syndrome Social History: Former heavy smoker, quit in [**2095**]. Rare alcohol. Widowed two years ago. Good family support. Other as per HPI Family History: NC Physical Exam: VS: Temp: 99/98.9 BP:110/73 HR:88 RR: 16 95% 5 litersO2sat I/O 4 liters/>1liter, CVP 12-14 . general: pleasant, comfortable, shovel mask in place, some increased work of breathing HEENT: PERLLA, EOMI, anicteric, no sinus tenderness, MMdry, op without lesions, no supraclavicular or cervical lymphadenopathy,RIJ in place lungs: expiratory wheezes throughout heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly extremities: no cyanosis, clubbing or edema skin/nails: no rashes/no jaundice/no splinters neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. rectal: lg external hemorrhoid, brown stool with streaks of red blood, guaic + Pertinent Results: [**2109-4-25**] 02:38PM BLOOD Lactate-2.4* [**2109-4-26**] 05:20PM BLOOD Lactate-0.9 [**2109-4-25**] 05:30PM BLOOD CRP-278.2* [**2109-4-30**] 06:55AM BLOOD calTIBC-231* VitB12-1899* Folate-16.4 Ferritn-168* TRF-178* [**2109-4-26**] 03:16AM BLOOD CK-MB-4 cTropnT-0.01 [**2109-4-26**] 01:35PM BLOOD CK-MB-4 cTropnT-<0.01 [**2109-4-25**] 02:00PM BLOOD Glucose-105 UreaN-35* Creat-2.1* Na-138 K-4.4 Cl-103 HCO3-22 AnGap-17 [**2109-5-2**] 06:35AM BLOOD Glucose-110* UreaN-30* Creat-1.2* Na-145 K-3.9 Cl-105 HCO3-28 AnGap-16 [**2109-4-25**] 02:00PM BLOOD WBC-16.6* RBC-3.20* Hgb-11.2* Hct-32.5* MCV-102* MCH-34.9* MCHC-34.4 RDW-13.3 Plt Ct-240 [**2109-5-2**] 06:35AM BLOOD WBC-7.4 RBC-2.96* Hgb-10.0* Hct-29.3* MCV-99* MCH-33.7* MCHC-34.0 RDW-12.9 Plt Ct-361 [**2109-4-25**] 06:15PM URINE RBC-0 WBC-[**1-28**] Bacteri-MANY Yeast-NONE Epi-0 . CXR [**4-25**] FINDINGS: There is diffuse patchy opacity restricted to the lingular segment with resultant obscuration of the left heart border. This is highly consistent with a lobar pneumonia. More linear opacity is noted in the right lung base likely related to atelectasis. Finally, there is retrocardiac opacity with air bronchograms. A multifocal infectious process cannot be excluded. There is no superimposed edema. There is evidence of prior median sternotomy and CABG. The aorta is tortuous with atherosclerotic disease and the cardiac silhouette size is enlarged with a left ventricular configuration. No definite pleural effusion is seen. Please note the extreme right costophrenic angle has been excluded. There is no pneumothorax. . IMPRESSION: Definite lingular infectious process. Question possible involvement of the left lower lobe as well. Likely atelectasis at the right base. Followup radiographs to document resolution following appropriate therapy recommended . CXR [**5-2**]: Status post CABG. Heart size is within upper limits of normal allowing for technique. Possible slight prominence of the LV contour but no definite CHF/pulmonary edema. There is persistent patchy opacity consistent with infection in the left mid and lower zones with a small left pleural effusion, but the consolidation in the left lower lobe has significantly improved since the prior study of [**2109-4-27**]. There has also been partial resolution of the right basilar atelectasis since the prior film with residual linear atelectasis in this location as well as linear atelectasis in the right upper lobe.Prominent carotid calcifications. Brief Hospital Course: #Hypotension/Fevers/PNA: Improved with aggressive iv hydration and pressors in ICU. Eventually pressors weaned and patient extubated. BPs remained stable on floor and pt gently diuresed given some volume overload from resuscitation. Blood and sputum cultures negative; pt clinically improved on Levofloxacin. Will complete a total of 2 weeks of abx. . #CV: ECG withou acute changes, serial CE negative. Discharged on home regimine. . #Renal: Cr improved with IVF; likely pre-renal +/-ATN. . #Heme: Fe studies c/w ACD. HCT stable in house. Medications on Admission: 1. Aspirin 81 mg daily 2. Atenolol 12.5mg daily 3. Cozaar 50mg daily 4. Imdur 30mg daily 5. Lasix 20mg daily 6. KCL 20meq QOD 7. Advair 8. tiotropium 9. lipitor 40mg daily 10. loratidine 10mg daily 11. famotidine 20mg [**Hospital1 **] 12. Buspar 15mg [**Hospital1 **] 13. Benadryl 25mg qhs 14. Alprazolam 0.25 [**Hospital1 **] prn 15. Combivent 16. vicodin prn Discharge Medications: 1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO once a day. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. Combivent 103-18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation twice a day as needed for shortness of breath or wheezing. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day. 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 13. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 15. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO every other day. Tab Sust.Rel. Particle/Crystal(s) Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Community Acquired PNA Sepsis Acute Renal Failure, resolved Anemia of Chronic Disease Secondary Diagnoses 1. CAD s/p CABG 2. Hypertension 3. Hyperlipidemia 4. GERD 5. Gastric Ulcer 6. Hypothyroidism 7. Anxiety 8. Osteoporosis 9. COPD 10. Left TKR 11. Chronic Back Pain 12. Hearing Loss 13. Cataracts 14. [**Doctor Last Name 7820**] Syndrome Discharge Condition: stable Discharge Instructions: Please contact Dr. [**Last Name (STitle) **] should you develop any fevers, chills, sweats, nausea, worsening shortness of breath, fevers, chills, sweats, or any ohter complaints. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2109-5-20**] 10:20 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] ([**Doctor Last Name **] PRACTICE) THE DOCTORS [**Name5 (PTitle) **] ([**Doctor Last Name **] PRACTICE) Date/Time:[**2109-7-11**] 12:50

[ "530.81", "496", "995.92", "518.81", "401.9", "038.9", "584.9", "785.52", "285.29", "733.00", "486", "V45.81", "276.2", "V43.64", "244.9", "272.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8156, 8214

5698, 6245

275, 312

8608, 8617

3195, 5675

8845, 9198

2444, 2448

6657, 8133

8235, 8587

6271, 6634

8641, 8822

2463, 3176

222, 237

340, 1835

1857, 2295

2311, 2428

9,256

147,249

49020

Discharge summary

report

Admission Date: [**2187-8-13**] Discharge Date: [**2187-8-16**] Date of Birth: [**2137-2-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Pruritis. Major Surgical or Invasive Procedure: Intubation History of Present Illness: HPI: Mr. [**Known lastname 102892**] is a 50 year old male with ESRD [**12-20**] Alport's disease and two failed renal x-plants on HD who presented to the ED complaining of itching. In discussion with the renal fellow, the patient has been agitated and complaining of pruritis at his dialysis appointments for the last week, and was unable to be dialyzed today secondary to agitation. He left dialysis and came to the ED today. He reported in the ED that he has been non-compliant with phos-lo for the last week. He cannot respond to questions secondary to agitation. . In the ED his vitals were 97.1, 65, BP 213/119, 20, 98% RA. An EKG revealed peaked T waves and a K was 6.2. He was given kayexalate, insulin and D50, however FS fell to 44. He was given 3 more amps of D50 with normalization of his FS. He was highly aggitated in the ED, and received 2 mg ativan without much effect. He subsquently received 2.5 mg IV Haldol, then another 5, in addition to another 1 mg ativan, as he had become progressively more agitated. By the time he had arrived in the MICU he had received 7.5 mg Haldol, 3 mg ativan. He had to be placed in 4 point leather restraints. . He was given hydralazine a total of 45 mg IV without much response, although it was noted that his blood pressure dropped to 170s systolic when calm and sleeping. . On arrival in the MICU he was given 10 mg IV haldol, 2 mg Ativan for extreme agitation. Past Medical History: 1) Alport's syndrome, ESRD s/p 2 failed renal txplants, on HD 2) R testicular mass 3) Dilated CM with recovery of function, etiology likely HTN vs. myocarditis. Last echo [**3-22**]: Conclusions: 1. 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. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF> 55%). Regional left ventricular wall motion is normal. 3. There are simple atheroma in the descending thoracic aorta. 4. Mild (1+) mitral regurgitation is seen. 5. The right upper pulmonary flow velocity was 80 cm/sec, the right lower PV flow velocity was 80 cm/sec , and the left upper PV flow velocity was 60-80 cm/sec. The left lower PV was not seen. 4) CHF 5) HTN 6) SVT s/p ablation [**3-22**] 7) Cataracts/laser surgery 8) Seizures (? metabolic) 9) Fractured knee s/p MVA Social History: Divorced with two children, ages 10 and 13. Lives with his 13 year-old son. Previously working with computers. -Tob: Notes 3 pack-year history but online medial record shows 40 pack-year history. -EtOH: Scotch occasionally as many as [**3-23**] in one sitting but none in last year. -Drugs: +MJ, +cocaine snorting, most recently 2 years ago. No IVDU Family History: Mother: [**Name (NI) 60693**] syndrome, kidney dz, HOH (symptoms at later age) Father: CAD and a CABG at age 60 - he later died of lung cancer (was a smoker). Physical Exam: PE: 204/109, HR 146, RR 24, 98% RA Gen: Muscular african american male, rapidly shifting from extreme agitation and thrashing to somnolence and snoring. Appearing in acute distress at times, almost scared, pleading for help. HEENT: Anicteric sclerae. Abd: NABS. Extr: No c/c/e. Skin: No burrows The remainder of exam could not be performed secondary to agitation. Pertinent Results: [**2187-8-13**] 06:15PM GLUCOSE-88 UREA N-90* CREAT-18.3*# SODIUM-138 POTASSIUM-6.3* CHLORIDE-95* TOTAL CO2-24 ANION GAP-25* [**2187-8-13**] 06:15PM ALT(SGPT)-26 AST(SGOT)-27 LD(LDH)-196 ALK PHOS-112 TOT BILI-0.3 [**2187-8-13**] 06:15PM ALBUMIN-4.2 CALCIUM-10.5* PHOSPHATE-7.5* MAGNESIUM-2.7* [**2187-8-13**] 06:15PM PHENYTOIN-<0.6* [**2187-8-13**] 06:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2187-8-13**] 06:15PM WBC-7.9 RBC-3.72* HGB-11.8* HCT-36.6* MCV-98 MCH-31.8 MCHC-32.4 RDW-18.5* [**2187-8-13**] 06:15PM NEUTS-36.7* LYMPHS-50.1* MONOS-6.3 EOS-6.3* BASOS-0.7 [**2187-8-13**] 06:15PM HYPOCHROM-1+ ANISOCYT-2+ MACROCYT-2+ [**2187-8-13**] 06:15PM PLT COUNT-149* [**2187-8-13**] 06:15PM PT-12.9 PTT-30.3 INR(PT)-1.1 CXR: IMPRESSION: 1. Findings consistent with mild/moderate fluid overload. 2. Mild opacification of right mid lung zone, possibly represents early pneumonia. Recommend repeat imaging following diuresis and clinical correlation. Brief Hospital Course: A/P: 50 year old male with ESRD secondary to Alport's Syndrome, s/p 2 failed transplants, chronically on prednisone, presenting with pruritis over the course of the last week, culminating in acute agitation. 1) Delirium/agitation: The patient initially presented to the ER with a chief complain of pruritis, during his ER admission he was agitated likely due to his intense pruritis, ativan was administered with paradoxical worsening of his agitation additional doses of ativan and then haldol were given, which contributed to his delirius and agitated state. Ultimately, secondary to intratable agitation he was sedated and intubated. Multiple studies were ordered to determine the etiology of his delirium, his toxicology screen was negative for illicit drugs. He also had a history of seizure activity, and the rapid cycling of the agitation and somnolence was suspicious of status epilepticus and an EEG was conducted and is still pending on dischareg. A head ct was unrevealing with no bleed or acute changes. Infectious etiologies were considered, the patient had no clinical signs of infection. He remained afebrile with normal WBC, cultures were negative for growth. A RPR was pending on discharge. The patient was hypoglycemic while in the ED, but agitation persisted after glucose correction. He was extubated and transferred out of the MICU and continued on dialysis and he quickly normalized to his baseline mental state, awake alert and orientated. The etiology of his delerium and agitation was thought to be associated with his end stage renal disease, as improvement was noted with dialysis. . 2) Pruritis: The pruritis may have been secondary to uremia, although BUN was close to baseline. His pruritis was controlled with sarna lotion and benadryl. Infectious etiologies were considered as he did have eosinophil elevation, and the patient was being treated on steroids, a strongyloides Ab was sent out is still pending. He continued with dialysis and his pruritis improved, on discharge he had no complaints of itching. . 3) HTN: Patient was not hypertension during admission. His antihypertensives were initially held, but he became hypertensive during his admission and was restarted on his outpatient regiment of metoprolol and lisinopril with good control of pressures. . 4) Hypoglycemia: Secondary to insulin in ED with impaired renal clearance in ESRD. His sugars quickly were normalized with D50 and remained in good control throughout his admission. . 6) ESRD s/p transplant: He was scheduled for his routine dialysis while inpatient, and also aluminum hydroxide while the patient was NPO, eventually he was started on renagel with increasing dosage when he tolerated PO intake and discharged with renagel. He was also continued on his home regiment of prednisone . 8) FEN: He was initially NPO with normal electrolytes except for potassium and phosphate, he was restarted on a low phosphate diet without difficulty. . 9) Code: Full. Medications on Admission: Epogen 3000 TIW Protonix 40 mg qd Phos-lo qd Sodium bicarbonate 650 mg qd prednisone 5 mg qd Lisinopril 2.5 qd toprol xl 25 qd. Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Toprol XL 25 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* 3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 4. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 5. Protonix 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* Discharge Disposition: Home Discharge Diagnosis: Pruritis End Stage Renal Disease Delerium Alport's Disease Discharge Condition: Good, Stable, Discharge Instructions: You were admitted for your pruritis and for your mental status changes. Because of your increased agitation we were required to intubate you at one point. Your pruritis was likely due to your kidney problems. We performed a Head CT scan, and a work up for infectious etiologies but did not find another source for your change in mental status. It did notably improve after you began dialysis. Please take your medications as instructed You are to follow up with your regular dialysis physician this [**Name9 (PRE) 2974**] for treatment. If you experience increased anxiety, itching, agitation, delerium, please call your PCP or go to the ED Followup Instructions: You are to follow up with your regular dialysis physician this [**Name9 (PRE) 2974**] for treatment. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2187-9-13**] 3:00 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-10-1**] 1:00

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icd9cm

[ [ [] ] ]

[ "96.04", "39.95", "38.95", "96.71" ]

icd9pcs

[ [ [] ] ]

8512, 8518

4709, 7688

323, 336

8621, 8637

3674, 4686

9332, 9733

3114, 3274

7867, 8489

8539, 8600

7714, 7844

8661, 9309

3289, 3655

274, 285

364, 1781

1803, 2730

2746, 3098

65,815

141,497

43985

Discharge summary

report

Admission Date: [**2137-5-31**] Discharge Date: [**2137-6-6**] Date of Birth: [**2061-9-19**] Sex: F Service: MEDICINE Allergies: Neurontin Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: Mrs. [**Known lastname **] is a 75 year old female with a PMH significant for metastatic colon cancer on palliative cetuximab therapy admitted to the MICU for dyspnea and hypoxia. The patient reports that she has had progresive shortness of breath over the past 2 weeks such that she was dyspneic with minimal activity inclduing activities such as showering. She denies any orthopnea, PND, increased LE edema, CP, f/c/s, or productive cough. The patient presented to oncology clinic this morning for scheduled cetuximab therapy and was noted to have a SaO2 87%RA increased to mid-90s on 3L nc. Upon infusion of cetuximab, she developed acute worsening of her dyspnea and was transferred to the [**Hospital1 18**] ED for further evaluation. . In the [**Hospital1 18**] ED, VS 95.2 146 132/87 46 94%NRB. An ECG was notable for afib with RVR, CXR for right-sided pleural effusion and diffuse parenchymal opacities, and a large right-sided pleural effusion, and CTA was negative for PE. The patient was placed on BiPap with subjective improvement and subsequently converted to NSR. Attempts to discontinue BiPap resulted in marked increase in dyspnea and O2 sat 90%. The patient was also noted to have a TnT of 0.4 up from <0.01 on admission, BNP 700, and lactate 4. Cardiology was called in the ED and based on ECG and cardiac biomarkers, elevated TnT was felt to be secondary to demand ischemia but recommended heparin gtt. The patient received ASA 325 mg, vancomycin, heparin gtt, and pip/tazo and was transferred to the MICU for further management. Past Medical History: Colon CA Hypothyroid Hyperlipidemia Iron deficiency anemia Gastritis . Oncologic history: Metastatic colon cancer, status post five cycles of FOLFOX and Avastin on protocol, which was completed in [**2135-4-10**]. Chemotherapy was resumed in [**2135-9-10**] in the setting of rising CEA and CT evidence of disease progression. She completed 13 cycles of oxaliplatin, capecitabine, and Avastin as of [**2136-6-29**]. She had a rise in her CEA and therefore her regimen was switched to FOLFIRI and Avastin on [**2136-7-20**]. Infusional 5-FU was reduced by 50% given her history of myelosuppression, diarrhea. Her second cycle of therapy, bolus 5-FU was reduced by 25% in the setting of mucositis and vaginal irritation. In total, she completed three cycles of this regimen. Chemotherapy was discontinued as of [**2136-10-17**]. She had a rise in her CEA in addition to interval disease progression at the end of [**Month (only) 1096**] and therefore she was started on single [**Doctor Last Name 360**] cetuximab and has received 13 doses. KRAS testing of her original tumor specimen was wild type. Social History: Patient lives with husband. Independent in AIDLS. Former smoker (quit 12 years ago, 1ppd x20 years). Denies EtOH, IV, illicit, or herbal drug use. Family History: Father died of colon cancer @about 77. Sister died of ovarian cancer @57. Mother died of CHF @56. Daughter died of glioma @20. Physical Exam: Gen: On BiPap HEENT: Perrl, eomi, sclerae anicteric. NIV mask in place. CV: Nl S1+S2 Pulm: Rhonchorous throughout bilaterally. Dullness to percussion at right base [**1-11**] way up lung field. Abd: S/NT/ND +bs Ext: No c/c/e Pertinent Results: [**2137-6-1**] 04:32PM PLEURAL WBC-283* Hct,Fl-2* Polys-35* Lymphs-51* Monos-13* Eos-1* [**2137-6-1**] 04:32PM PLEURAL TotProt-5.2 Glucose-116 LD(LDH)-934 [**2137-6-1**] 4:32 pm PLEURAL FLUID GRAM STAIN (Final [**2137-6-1**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2137-6-4**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. CTA ([**5-31**]): No pulmonary embolism. Stable large right-sided pleural effusion with slightly more collapse of the right lower lobe. CTH ([**5-31**]): No acute intracranial path TTE ([**6-4**]): The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (LVEF < 20 %) with some preservation of the basal inferior and inferolateral walls. The right ventricular cavity is moderately 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Severe global left ventricular hypokinesis with relative preservation of the basal inferior and inferolateral walls. Marked tachycardia. Right ventricular dilation and dysfunction. Moderate pulmonary hypertension. Brief Hospital Course: Mrs. [**Known lastname **] is a 75 year old female with metastatic colon cancer admitted from oncology clinic with sub-acute dyspnea. # Respiratory distress: The patient reports that dypsnea has been worsening over the past 2 weeks. On CT chest review, parenchymal disease burden is worse compared to last CT scan performed prior to admission, and right lower lobe is now completely collapsed. Dsypnea less likely to be related to cetuximab therapy given dyspnea and hypoxia prior to chemo infusion. Respiratory decline unlikely to be PE given negative CTA. There was initial concern given tumor burden for malignant pericardial effusion with resulting hypoxia and tachyarrythmia, but CT and TTE did not demonstrate significant pericardial effusion. The patient was placed on BiPaP in the ED and had a persistent BiPaP requirement during her admission for comfort. She had a diagnostic and therapeutic thoracentesis with exudative pleural fluid based on Light's criteria with cytology pending at the time of death. Serial CXR after therapeutic paracentesis was performed were notable for reaccumulation of pleural effusion, and attempts at weaning BiPaP were unsuccessful. After numerous family meetings in discussion with the patient's primary oncologist (Dr. [**Last Name (STitle) **] and PCP (Dr. [**Last Name (STitle) **] and the patient and her family, the patient was made comfort measures only. BiPaP was titrated for comfort and the patient expired shortly thereafter. # Narrow complex tachycardia: The patient presented in the ED with atrial fibrillation that spontaneously converted to NSR. During her hospital course, she intermitently had runs of narrow complex tachycardia with a ventricular rate up to 220 that was minimally responsive to AV nodal blockade with IV metoprolol and diltiazem. The frequency of the patient's SVT increased during her admission such that by the time of her death she had a HR>100 despite po metoprolol. # CV: Increase in TnT during admission likely represented demand ischemia rather than ACS in setting of tachyarrythmia. BNP was also elevated to 700 on admission suggesting element of heart failure that may have been rate-related. She was initially heparinized per discussion with cardiology, and this was held as the patient was transitioned to comfort measures only. # Colon CA: Patient with extensive mets on palliative biologic therapy with cetuximab. The patient's primary oncologist was involved in family discussions as the patient was transitioned to CMO. # Goals of care: As above, multiple family meetings were held during her admission in consultation with the patient's primary oncologist, PCP, [**Name10 (NameIs) **] palliative care and the patient was transitioned to comfort measures only. Medications on Admission: Atenolol 50 mg daily Diazepam 5 mg Q8H prn Lomotil 2 tablets Q4-6H prn for diarrhea HCTZ 25 mg daily Irbesartan 150 mg daily Levothyroxine 200 mcg daily Lorazepam 0.5 mg tablet Q8H prn for anxiety Opium tincture 10 mg/mL 0.3-0.5 mL PO Q6H prn diarrhea Coumadin 1 mg po qhs for venous catheter patency. Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired Completed by:[**2137-6-6**]

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icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

8339, 8348

5180, 7947

284, 299

8407, 8424

3585, 3951

8488, 8533

3193, 3324

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8448, 8465

3339, 3566

237, 246

327, 1884

3987, 5157

1906, 3012

3028, 3177

23,042

121,546

18679

Discharge summary

report

Admission Date: [**2188-8-14**] Discharge Date: [**2188-8-21**] Date of Birth: [**2159-6-26**] Sex: M Service: NEURO MED CHIEF COMPLAINT: Weakness and numbness in the left leg. HISTORY OF PRESENT ILLNESS: The patient is a 29 year old man who was admitted through the emergency room on [**2188-8-14**], after he had a motor vehicle accident while riding on his motorcycle. He was rear-ended on the afternoon before admission and was thrown forward, apparently hitting the windshield of the car in front of him. He did not remember actually hitting the windshield. He remembered stinging in his neck and his feet and was taken to an outside emergency department where a C-spine film was performed that showed no fracture. He went home with a cervical collar, but after falling asleep that night, he was awakened by the sudden onset of a golfball-like sensation in his lower back and sudden weakness and numbness in his left leg that happened very suddenly. He also had weakness in his right leg and numbness of his right thigh which progressed more slowly than the left. He could not feel his bowel movements or the urge to urinate and had incontinence of both urine and feces. PAST MEDICAL HISTORY: Multiple motor vehicle accidents while riding his Motocross bike including fracture of a leg in the past. MEDICATIONS ON ADMISSION: None. ALLERGIES: No known drug allergies. FAMILY HISTORY: There is no history of spinal cord disease and no history of stroke. SOCIAL HISTORY: The patient is a mechanic. He has occasional alcohol use, although he denies driving under the influence. He rides Motocross bikes as a hobby. PHYSICAL EXAMINATION: On presentation temperature was 97.7, blood pressure 147/99, heart rate 107, O2 sat 99 percent in room air. In general, he was a well-developed, well-nourished, young man in a cervical collar, in no apparent distress. HEENT exam revealed no evidence of trauma to the head with moist mucous membranes. Lungs were clear to auscultation bilaterally. Cardiovascular regular rate and rhythm without murmurs, gallops or rubs. Abdomen was soft and slightly distended, but nontender. Extremities showed 2+ pulses and no pedal edema. NEUROLOGIC EXAMINATION: Mental status awake and alert and oriented to person, place, time and situation. Speech was fluent and comprehensible. Naming and repetition were intact. He was able to tell his medical history. Cranial nerves pupils equally round and reactive to light. Extraocular movements intact with no diplopia. Face was symmetric. Tongue and palate were midline. Sternocleidomastoid and trapezius muscles were not tested due to the cervical collar. Motor on admission he had 2/5 weakness on the right lower extremity with hip flexors and knee flexors being more greatly affected. He also had impaired dorsiflexion and plantar flexion of about [**3-12**] to [**4-9**] on the right. On the left he had no muscle contraction upon hip flexion or knee flexion or extension. He was able to wiggle his toes on the left with slight ability to flex and extend graded at 2/5. He had poor rectal tone. Sensory decreased sensation to pin and temperature and light touch on the medial aspect of the thigh on the right. He had decreased sensation to pin, temperature, light touch and joint position in the entire left lower extremity. He appeared to have no joint position sense even up to the level of the knee on the left. He had a sensory level of approximately T11-T12 to pin and light touch. He had saddle anesthesia. Reflexes were brisk in the upper extremities symmetric and bilaterally. There was clonus of the left knee and otherwise reflexes were brisk throughout the lower extremities as well. He had bilateral Babinski signs. LABORATORY DATA: On presentation white count was 16,000, platelets 346,000, hematocrit 41.7. Chemistries were unremarkable. Coagulation studies were normal. An MRI of the spine on [**2188-8-14**], showed mild degenerative changes at the C4-C5 and C3-C4 levels with mild to moderate narrowing of the left C3-C4 and C4-C5 neural foramina. There was no evidence of spinal stenosis or evidence of spinal cord compromise. There was no evidence of herniation or impingement on the conus or the cauda equina. A CT of the cervical spine showed no evidence of fracture in the cervical spine or misalignment. A CT of the abdomen and pelvis showed no evidence of traumatic intra-abdominal injury including normal appearing bladder, liver, gallbladder, pancreas, spleen, adrenal glands and kidneys. MRI and MRA of the head and neck revealed no evidence of stroke and MRA of the cerebral vasculature revealed normal carotid and vertebral arteries as well as a normal circle of [**Location (un) 431**]. T-spine and L-spine films showed no fractures identified in either the thoracic or the lumbar spine. Chest x-ray showed no evidence of pneumothorax or infiltrate. Pelvic plain films no evidence of fracture or dislocation. MR of the cervical spine showed no evidence of vertebral edema or edema in the soft tissues. Mild spondylosis on the left at levels C3-C4 and C4-C5 with mild to moderate foraminal stenosis. There was no spinal canal narrowing. Cauda equina appeared normal. C-spine films C-1 to C-7 vertebrae identified and no evidence of fracture. CT of the head on [**8-17**] done for a headache showed no evidence of intracranial hemorrhage. HOSPITAL COURSE: Lower extremity weakness. There was no fracture seen on the MRI imaging, however, given the symptoms of incontinence and lower extremity weakness, he was admitted to the ICU with the diagnosis of presumed spinal cord infarction potentially due to nucleus pulposus embolus. He was admitted to the neuro ICU and placed on pressors to increase the perfusion pressure to the spinal cord. He was also given a methylprednisolone drip for the first 24 hours to reduce the chance of spinal cord edema caused by contusion. He was also placed on heparin for the possibility of a spinal cord stroke. The patient had a severe amount of pain and was initially controlled with morphine p.r.n. However, this had to be changed to a Dilaudid PCA pump. His neck was cleared for cervical spine fracture and the cervical collar was discontinued. He was continued on Solu-Medrol 125 b.i.d. starting on the third hospital day. On the morning of [**8-17**] the patient had a severe headache, having fallen asleep and not pressing his Dilaudid PCA pump for the three hours that he had fallen asleep. Because it was the worst headache that he had experienced, he received a CAT scan which showed no evidence of acute intracranial hemorrhage and also lumbar puncture to rule out subarachnoid hemorrhage, which it did. Patient was kept on the PCA pump and slowly was able to taper off the analgesics. He was transferred to the neurology floor on the evening of the 13th with the diagnosis of spinal cord contusion. At this time his steroids were discontinued. The patient was seen by the psychiatry service to evaluate whether he had drug seeking behavior, given the high doses required to give him pain relief. There was no evidence found for malingering despite the suspicion that the patient may have gone to a hospital previously for analgesics for a similar clinical presentation. This was never verified, however. Physical therapy saw the patient and the patient also continued to improve in terms of his motor function of the lower extremities. Upon discharge the patient's exam was such that he had 4+/5 strength in both lower extremities and was able to walk a distance of 40 feet without assistance. He appeared to be staggering, but otherwise kept good balance and never fell. Sensory exam was such that he continued apparently to have joint position loss in the lower extremities. However, some elaboration was suspected due to the fact that even by moving his legs on joint position testing, such that his legs touched the bed, patient was still not able to say whether his joints were moving up or down. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with no physical therapy. DISCHARGE DIAGNOSES: 1. Spinal cord contusion. 2. Back injury status post motorcycle accident with no evidence of fracture or intra-abdominal or intra-thoracic trauma. DISCHARGE MEDICATIONS: 1. Dilaudid 6 mg p.o. q.four hours p.r.n. pain for 14 days. 2. Docusate sodium 100 mg p.o. b.i.d. FOLLOWUP: The patient was recommended to obtain a primary care physician at his earliest convenience. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**] Dictated By:[**Name8 (MD) 4064**] MEDQUIST36 D: [**2188-9-4**] 11:10 T: [**2188-9-12**] 16:12 JOB#: [**Job Number 51233**]

[ "V65.2", "723.1", "784.0", "788.30", "787.6", "E812.2", "780.79", "724.2", "782.0" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

1422, 1492

8159, 8309

8332, 8771

1360, 1405

5441, 8052

1678, 2210

156, 196

225, 1203

2235, 5423

1226, 1333

1509, 1655

8077, 8138

11,212

124,038

4692

Discharge summary

report

Admission Date: [**2149-5-27**] Discharge Date: [**2149-6-14**] Date of Birth: [**2073-4-9**] Sex: M Service: MEDICINE Allergies: Bactrim / Ciprofloxacin / Percocet Attending:[**First Name3 (LF) 348**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: -Rigid bronchoscopy x 2 -Flexible bronchonscopy -Intubation x 3 - for procedures and airway protection, not for respiratory failure -IR angiography -IR guided embolization of R bronchial artery. History of Present Illness: 75 year old male with CAD s/p MI and CABG, CHF (EF 20%), and Aflutter, admitted [**2-24**] w/AFib s/p ablation, admitted from [**Hospital **] rehab for hemoptysis. Pt coughed up sputum this am after waking (normal for him) but + blood clots, x 5 today, totaling [**1-20**] cup. Feels congestion in chest and coughing up blood, rather than blood from nasopharynx or emesis. Chest CT today showed chronic PEs, mucoid impaction in right bronchus, and unchanged mediastinal and right hilar adenopathy. No specific tx was given in ED. Pt was admitted for further eval given his comorbidities. . Pt had repeat episode this am, one tsp of bloody clots. . ROS: Recently has been feeling well; denies F/C, CP, palpitations, SOB, orthopnea or PND (but coughs more lying flat), pleuritic CP, or wheezing. No N/V, abd pain, diarrhea, BRBPR, or melena. No recent URIs. Has an IVC filter. + 20 lb weight loss in last 3 months after his recent hospitalization for CHF. No epistaxis, hematuria, other bleeding. Former smoker, but quit 30 yrs ago. Past Medical History: Congestive Heart Failure, ischemic cardiomyopathy (EF 20-30% [**2149-3-6**]) Atrial Fibrillation s/p ablation ([**2-24**]) CAD s/p Anterior wall MI (PCI), CABG x 4 [**5-20**] LIMA to D1, radial to LAD, SVG to PDA S/P placement of biventricular ICD . Hyperlipidemia . Recurrent DVT/PE s/p IVC filter ([**5-20**]) Moderate Pulmonary Hypertension Interstitial fibrosis (? [**2-20**] amiodarone) . Hx Renal cell carcinoma ([**2129**]), s/p left nephrectomy ([**2137**]) Hx Bladder CA Skin cancers - squamous cell (s/p excision) . Previous Hypothyroidism, now hyperthyroidism ([**2149-2-19**]) . S/P Right CEA S/P TIA with no residual symptoms ([**2143**]) . GERD S/P previous Upper GI Bleed . CKD - Cr baseline appears to be 1.2-1.4 . S/P splenectomy post traumatic event s/p total hip replacement: [**1-/2144**] Social History: Patient is widowed and lives with his son and his family. He has a total of four children. Was to be d/c from [**Hospital **] Rehab on [**5-27**], the day of admission to [**Hospital1 18**]. Family History: nc Physical Exam: Admission PE: VS: T 99.4 BP 102/60-114/71 HR 70s RR 22 O2 93-96% RA GEN: Elderly male, pleasant, NAD. no conversational dyspnea. HEENT: EOMI, anicteric, clear OP, MMM. NECK: JVP ~8 cm, no carotid bruits, no LAD CARDIAC: RRR nl S1 S2, III/VI SEM LSB, no S3 or S4 LUNGS: Distant BS throughout, L base rales, no wheezing. ABD: + BS, soft, ND/NT EXT: Trace pitting LE edema to ankles only. Faint DP pulses b/l. L ankle with gauze bandage NEURO: A&O X3, CN II-XII intact, moving all extremities equally Discharge PE: T: 96.5 BP: 126/80 O2 sats: 98% on RA CV: +SEM RUSB, LSB Resp: [**Month (only) **] breath sounds at bases; no crackles or wheezing Abd: Soft NT Pertinent Results: Admission Labs: [**2149-5-27**] 12:20PM WBC-8.5 RBC-3.53* HGB-11.3* HCT-34.2* MCV-97 MCH-32.1* MCHC-33.1 RDW-20.1* [**2149-5-27**] 12:20PM NEUTS-63 BANDS-0 LYMPHS-12* MONOS-20* EOS-3 BASOS-1 ATYPS-0 METAS-1* MYELOS-0 [**2149-5-27**] 12:20PM PLT SMR-NORMAL PLT COUNT-410 [**2149-5-27**] 12:20PM PT-22.1* PTT-28.4 INR(PT)-2.2* [**2149-5-27**] 12:20PM GLUCOSE-97 UREA N-29* CREAT-1.2 SODIUM-138 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13 [**2149-5-27**] 12:20PM DIGOXIN-1.1 . Hematocrit and Cr were stable during this admission. . ECG: V paced at 79 bpm, LAD with RBBB pattern . ECHO: [**2-24**]: The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (ejection fraction 20-30 percent). The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2149-1-28**], no major change is evident. . Chest CT [**5-27**]: 1. Evidence of chronic thromboembolic disease and pulmonary hypertension with pruning and narrowing of distal branches. IVC filter noted on scout image. 2. Right hilar mass which encases a pulmonary artery and appears to slightly compress the right bronchi. Slightly increased attenuation material within the bronchi is seen -- while this may represent mucoid material or thrombus, invasion of a malignant tumor into the bronchus cannot be excluded. 3. Left flank hernia involving a small portion of the descending colon. 4. Right adrenal nodule, which cannot be further characterized on this examination. 5. Prominent ascending aorta with dense calcification. . CXR [**5-27**]: 1. Unchanged appearance of emphysema and chronic lung disease. 2. Slight increase in probable left pleural effusion. 3. Pulmonary artery hypertension. Cardiomegaly. . CXR: [**2149-5-30**]: INDICATION FOR STUDY: Right hilar mass with hemoptysis, status post bronchoscopy, evaluate for any interval change. Comparison made to prior radiographs from [**2149-5-27**]. Cardiac pacing lines in satisfactory positions. Again seen is a right hilar mass. The lung volumes are low, with consolidation now noted in the right lower lobe. These features are superimposed on emphysema and chronic lung disease. The left pleural effusion is again noted and not significantly changed. The retrocardiac space is obscured and consolidation cannot be excluded in this region. IMPRESSION: New right lower lobe and probable left lower lobe consolidation in this patient with a right hilar mass. . [**5-31**]: Biopsy of R lung mass: Lung, right lower lobe, biopsy: Organizing hemorrhage and scant bronchial tissue with squamous metaplasia; no malignancy identified. . [**2149-6-1**]: CXR: IMPRESSION: PA and lateral chest compared to chest films since [**5-27**], most recently [**6-1**] at 11:08 a.m. Progression of small foci of consolidation in the right upper lobe over the past three days, most likely pneumonia. Small right pleural effusion and right basal atelectasis unchanged. Mild interstitial edema and moderate cardiomegaly stable. Right ventricular pacer defibrillator and right atrial and ventricular pacer leads unchanged in their respective positions. . [**2149-6-4**]; CXR: FINDINGS: Pulmonary edema continues. Bilateral pleural effusions are unchanged as well as bibasilar atelectasis. Cardiac and mediastinal contours are stable. The patient is status post CABG. IMPRESSION: Continued pulmonary edema. . [**6-5**]: Right lower lobe, transbronchial biopsy: a. Bronchial mucosa with distorted atypical cells suspicious for large cell carcinoma, see level 1 recut. b. Fibrinous exudate in alveolar spaces. Note: Immunoperoxidase studies for cytokeratin are not contributory . [**6-5**]: IR Procedure: IMPRESSION: No active bleeding was identified doing right pulmonary artery arteriogram and right brachial artery arteriogram.No abnormal arteries identified . [**6-10**]: IR Embolization: FINDINGS: Right fifth intercostal arteriogram demonstrates a patent artery with no evidence of blood supply to the lung. The right sixth intercostal artery origin from the aorta bifurcates early and supplies the right sixth and seventh intercostal spaces. No definite blood supply to the lung from either level. The vessels are patent. Descending thoracic aortogram demonstrates patency of the descending thoracic aorta with mild mural irregularity and calcification consistent with atherosclerosis. A dilated tortuous right bronchial artery is identified. Right bronchial arteriography demonstrates a dilated tortuous patent right bronchial artery with collateral flow to a second more inferior artery. The second more inferior artery does not appear to connect to the aorta on this arteriogram and also was not visualized on the flush aortograms. In addition, there is evidence of bronchial artery to pulmonary artery shunting in the right lower lobe. No supply to the spinal artery was identified. Right bronchial arteriography through the microcatheter was performed at two stations to confirm on going patency and inflow of blood into the bronchial artery, which was present. It also helped to confirm appropriate positioning of the microcatheter. In addition, based on the findings of these diagnostic arteriogram, it was determined that the patient was a suitable candidate for and may benefit from right bronchial artery embolization. IMPRESSION: Dilated tortuous right bronchial artery with supply to lung in the expected region of the known hilar mass. Partial embolization of the region of the mass was performed with 700-900 micrometer embospheres. However, the catheter became occluded. As such, the main bronchial artery was coil embolized with cessation of flow. . [**6-12**]: PET-CT: There is no focally abnormal increase of uptake of FDG within the lungs at distant sites. CT images show multiple paratracheal/precarinal lymph nodes which have FDG avidity similar to the remainder to the mediastinum. Small bilateral pleural effusions, associated with atelectasis, ground-glass opacities, and regions of bronchial calcification/collapse at the right lower lobe with endobronchial opacities are present. The right adrenal gland is somewhat enlarged and rounded, without FDG avidity. The left kidney and spleen are absent. The right kidney has a somewhat irregular contour, possibly secondary to scarring. IVC filter is seen, and extensive vascular calcifications are seen within the great vessels as well as coronary arteries. Air-fluid level in the right maxillary sinus is consistent with sinusitis. Physiologic uptake is seen in the heart, distal right ureter, and bladder. IMPRESSION: 1. Sensitivity of examination for detection of neoplasm is slightly decreased due to the redistribution of FDG to the skeletal muscles. See comment above. 2. No suspicious regions of FDG avidity are seen, neither in the right hilum nor at distant sites. . [**6-12**]: CT Head with Contrast: CONCLUSION: No significant changes since [**2148-12-20**]. Evidence of old infarction with no evidence of metastatic disease. Note that MR with contrast is more sensitive than CT for detecting metastasis . [**6-12**]: CT Chest, Abdomen and Pelvis with Contrast: CT OF THE CHEST WITH IV CONTRAST: There is an apparent right-sided infrahilar mass which is seen compressing the right lower lobe bronchus and arteries and extends into the subcarinal region. There is mucous plugging involving the bronchi to the right lower lobe with partial collapse of the right lower lobe. Mural thrombus is identified within the left lower lobe segmental pulmonary artery which appears slightly decreased from the previous exam, consistent with chronic thromboembolic disease. There are small, bilateral pleural effusions. There are prominent mediastinal lymph nodes with a right paratracheal node measuring 2.6 x 1.5 cm and multiple left hilar nodes, the largest measuring 1.5 x 1.0 cm. The lung windows show increased septal lines with scattered ground-glass opacities suggesting fluid overload. There are scattered pulmonary nodules measuring less than 5 mm, with a pulmonary nodule within the right upper lobe (series 3, image 17) and left lower lobe (series 3, image 34). The patient is status post median sternotomy with a dual lead left-sided pacer. There is cardiomegaly. CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: There is an IVC filter in place. There is no left kidney identified. There are small left chest wall hernia sacs some small bowel extending into them without evidence of obstruction. The right kidney contains multiple areas of cortical irregularity consistent with scarring. The liver and gallbladder are unremarkable. Right adrenal gland nodules are again identified. There is no abnormal lymphadenopathy within the abdomen. CT OF THE PELVIS WITH IV CONTRAST: There is no abnormal lymphadenopathy within the pelvis. There is an apparent penile prosthesis pump within the anterior part of the pelvis. The patient is status post left-sided total hip replacement which slightly degrades the images. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. Degenerative changes are seen within the lumbar spine and hips. IMPRESSION: 1. Apparent soft tissue mass within the right infrahilar region which appears to be extending into the subcarinal region. This mass is obstructing the right inferior lobe bronchus and attenuating the right inferior lobe pulmonary artery. There is mucous plugging and partial collapse of the right lower lobe. 2. Prominent mediastinal and left-sided hilar lymph nodes. 3. Findings consistent with chronic thromboembolic disease as seen previously. 4. Bilateral pleural effusions with septal lines and ground-glass opacities consistent with fluid overload. . MICRO: URINE CULTURE (Final [**2149-6-6**]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ENTEROBACTER AEROGENES. >100,000 ORGANISMS/ML.. IMIPENEM sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER AEROGENES | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S IMIPENEM-------------- S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R PIPERACILLIN---------- 16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 76 yo M with a history of CAD s/p ICD, CHF (EF 20%), AFib, and chronic PEs who presented with hemoptysis. The patient underwent CT scan in the ED, which showed encasement of the right pulmonary artery/bronchus by a lung mass on admission. HOD #2: The patient continued to have hemoptysis on the floor. A PPD was checked and warfarin was discontinued. Pulmonary was consulted and recommended bronchoscopy. On HD #3 decision was made to defer bronchoscopy due to elevated INR. He received 2.5 mg of PO Vitamin K. The patient continued to have small (1 tsp) episodes of hemoptysis on the floor. He maintained his O2 sats in the high 90s. On HD #4, he was taken for bronchoscopy with 2 units FFP pre-procedure (INR was 1.9.) It was rechecked later and found to be 1.4. During the flexible bronchoscopy, he was found to have significant bleeding and his R bronchus intermedius was occluded by a blood clot, which could not be aspirated. IP was emergently consulted and felt that the patient needed a rigid bronchoscopy. He was given 3 more units of FFP and 1U PRBC and he was transferred to the Intensive Care Unit for monitoring, and to await rigid bronchoscopy by Interventional Pulmonology. His vitals at that time were 133/72 HR: 80 RR:12 Sats: 96% on 3L. On HD #5, IP then did a rigid bronch and found a tumor/clot in the basilar RLL and superior segment of RLL. He had a transbronchial needle aspirate, endobronchial biopsy tumor excision with forceps, and tumor destruction with APC (Argon Plasma Coagulation) was done at that time. Upon subsequent extubatation, his hemoptysis resolved and he had blood tinged yellow sputum. HD #7 : Rediscussed code status with son. [**Name (NI) **] stated that his father wished to remain intubatable (already had in an ICD), but not for an extended period of time. HD #[**8-27**]: In the interim, he has been oxygenating well on the floor (92-98% on 2-3L), his hct has been stable to the order of 28-29. His biopsy returned as organizing thrombus. He continued to have hemoptysis on the floor (5-6 episodes of maroon/red sputum) and pulmonary and Rad Onc were consulted. At this point, Rad Onc was consulted and did not feel that he is a candidate for emergent radiation at this time and would prefer staging workup by thoracic oncology before defining a plan; i.e. potential for XRT/chemo if cancer is non metastatic. Then, the Pulmonary/IP team decided to try for further biopsies. They indicated that he could not be replaced on anticoagulation until undergoing XRT to the lung field. On HD#10: Bronchoscopy was reattempted. At the beginning of the bronchoscopy, his SBP dropped to 60 in the setting of being started on propfol and remifentanyl and then his BPs responded to neo which was weaned off neo easily. He underwent the transbronchial needle aspiration and biopsy and argon plasma coagulation procedure; during the procedure, he was noted to have massive hemoptysis. A clot was obtained by APC. Subsequently, he was intubated for airway protection. He was taken to IR - where he had both a R pulmonary artery and R bronchial artery arteriograms, but no clear source of bleeding could be identified for embolization. He was transferred to the PACU. . HD #11: Reextubated in MICU. . HD #[**10-31**]: Monitored in the MICU where he continued to oxygenate well and remained stable. Heme-Onc, Thoracics were also consulted regarding a cohesive management plan. HD #15: Underwent embolization of R bronchial artery supplying superior segment of RLL. HD #17: Underwent staging CT Head, Chest, Abdomen/Pelvis and PET-CT. See Results section for CT scan findings. Briefly, he is likely a stage IIIB NSCLC - if we interpret his limited pathology as correct and given that he has contralateral medistinal LAD. His PET CT suffered from diminished sensitivity because patient ate prior to scan. Hence, he could be upgraded to a Stage IV if his PET scan scheduled as an outpatient shows distant metastasis. . Patient's case was discussed at a multidisciplinary firm conference and it was decided that the patient would undergo XRT at this time for primarily palliation. Because of his multiple comorbidities, he may not have a high enough performance status to receive chemotherapy; this is to be discussed further with patient and his oncologist. The secondary benefit of receiving XRT is that once the course is completed, that will be the point where the patient can restart his anticoagulation for his chronic PEs/DVTs. Prior to discharge to rehab, the patient received 2 cycles of XRT with more cycles to be planned after the weekend. Rad Onc will contact the rehab to arrange for times. His additional problems were managed as follows: # Hemoptysis/lung mass: - as above . #. Normocytic Anemia with elevated RDW in setting of recent pulm bleed. Likely anemia of chronic disease. - Only 1+ schistocytes seen on smear. - B12, folate wnl - low iron, increased ferritin, low transferrin c/w anemia of chronic disease -> hence no benefit of Fe supplementation. Underlying neoplastic processes likely contributing; patient also has other chronic diseases. . #. chronic PEs/DVTs: - s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter. Coumadin held due to bleeding risk. - with finding of lung mass, will not be able to replace on coumadin until patient receives XRT. - see above . # ID: - On [**6-3**] overnight, patient spiked temperature. Blood cultures were negative, but his urine culture grew out Enterobacter which was sensitive to Ceftriaxone. He received a 7 day course of Ceftriaxone in house. . # COPD: - Continued on Advair, spiriva and PRN albuterol - minimize supplemental oxygen; he is comfortable on room air . #. Cardiovascular: Stable during this admission . Rate / Rhythm: Has BiV pacer, ICD - Dig level 1.1 - no events on tele while in house . Ischemia: - Continue atorvastatin, ASA . Pump: - continue carvedilol - Daily weights, I/Os, 1.5L fluid restriction - lasix was held during this admission. He was intermittently given lasix as needed for mild overload. . #. Hyperthyroidism: Patient had a history of hyperthyoridism, but on admission , his TSH 21, T4 0.6, T3 78 - this was consistent with hypothyroidism. We d/c'ed methimazole. This was discussed with Dr [**Last Name (STitle) **] on [**5-30**]. Plan for repeat TFTs in 2 wks. An endo outpt f/u arranged for [**Month (only) **]. Rechecked TFTs on [**6-14**] prior to sending to rehab. . # CRI: at baseline. . # FEN: low sodium/ cardiac diet with fluid restriction < 1200cc/day. - Daily weights, I/Os, given h/o CHF - I/O goal: even to net negative . # L heel ulcer: - daily dressing changes - multipodus splints and vitamin C/Zinc . # ppx: PPI (hx GERD), colace. coumadin held. cont home allopurinol, doxycycline, flomax, trazodone prn, remeron. - not currently on colchicine - was on 0.6mg QD at home. . # Code: Full. Has ICD. medicine team on floor discussed with attng on [**5-28**]. Rediscussed with son on [**6-2**] - his father would like to be intubated for the short term, but not for an extended period of time. Medications on Admission: Warfarin 4-7 mg hs for past week Atorvastatin 80 mg Multivitamin Furosemide 40 mg QD, 20 mg QPM Aspirin EC 81 mg Digoxin 125 mcg QD Carvedilol 6.25 mg [**Hospital1 **] Advair 250/50 [**Hospital1 **] ASA 81 mg QD Colchicine 0.6 mg QD Colace 100 mg [**Hospital1 **] Doxycyline 100 mg [**Hospital1 **] Flomax 0.4 mg HS Pantoprazole 40 mg QD Tiotropium 18 mcg QD Trazodone 25 mg HS Remeron 15 mg HS Tapazole 10 mg po BID Allopurinol 100 mg QD Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-20**] Sprays Nasal QID (4 times a day) as needed. 14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 16. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Insulin Regular Human 100 unit/mL Solution Sig: Per scale units Injection every six (6) hours: glc 150-200=2 units; 201-250=4units; 251-300=6units; 301-350=8 units; 351-400=10 units. 18. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 19. Hydrocortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for eczema on ears and nose. 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Non-small cell lung cancer (suggestive of Large cell) Hemoptysis Anemia Left heel pressure ulcer Secondary: Congestive Heart Failure, ischemic cardiomyopathy (EF 20-30% [**2149-3-6**]) Atrial Fibrillation s/p ablation, on coumadin CAD s/p Anterior wall MI (PCI), CABG x 4 [**5-20**] LIMA to D1, radial to LAD, SVG to PDA Hyperlipidemia Moderate Pulmonary Hypertension Interstitial fibrosis Recurrent DVT/PE s/p IVC filter S/P placement of biventricular ICD Hx Renal cell carcinoma ([**2129**]), s/p left nephrectomy ([**2137**]) Hx Bladder CA Previous Hypothyroidism, now hyperthyroidism ([**2149-2-19**]) S/P Right CEA S/P TIA with no residual symptoms ([**2143**]) GERD S/P previous Upper GI Bleed Skin cancers CKD - Cr baseline appears to be 1.2-1.4 Discharge Condition: Fair, with stable hct and no further hemoptysis Breathing comfortably on room air. Will at times require small amount of O2 with exertion. (Does not need O2 all the time) Discharge Instructions: During this admission, you were diagnosed with a lung cancer. This appears to be the reason for your hemoptysis (coughing up blood.) Because you were bleeding, we have stopped your warfarin. This will not be able to be restarted until you have finished a course of radiation therapy. . For your gout flare, you received a course of steroids in the hospital. We have continued you on allopurinol and colchicine was stopped. This may be restarted as necessary. . We found that you had a urinary tract infection here that was treated with 7 days of Ceftriaxone. . Please call your primary care doctor or Dr.[**Name (NI) 3279**] office if you start to redevelop bloody coughing. If you start to develop any increased shortness of breath or chest pain, or start to cough up a large amount of bloody sputum, please come to the emergency department. . If you become acutely short of breath, please turn onto your right side and come to the emergency department. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . Followup Instructions: You have an appointment for another PET/CT imaging scan of your chest on Wednseday [**6-18**] at noon, [**Hospital Ward Name 23**] building [**Location (un) **]. Dinner the night before and breakfast the morning of should be high protein/fat and no carbohydrates (no bread, potatoes, pasta, etc); please do not eat anything for three hours prior to the test (no food after 9am). . Regarding further Radiation therapy. The Radiation Oncology department at [**Hospital1 18**] will contact you regarding scheduling of further radiation treatments. . You need to follow up with Dr. [**Last Name (STitle) **] regarding care of your thyroid gland. Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3972**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2149-6-26**] 10:00 . You have the follow prescheduled appointment with Dr. [**Last Name (STitle) **], your cardiologist. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2149-9-23**] 2:00 . Please make an appointment to see Dr. [**Last Name (STitle) 11139**] over the next few weeks to decide when to restart your warfarin. Note this cannot be done until after your Radiation treatments are finished. Completed by:[**2149-6-14**]

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Discharge summary

report

Admission Date: [**2198-8-8**] Discharge Date: [**2198-8-16**] Date of Birth: [**2174-12-30**] Sex: M Service: Liver Transplant Surgery Service CHIEF COMPLAINT: Abdominal pain, nausea and vomiting due to Tylenol intoxication. HISTORY OF PRESENT ILLNESS: This is a 23 year old male, who presents with nausea and vomiting of bilious and coffee ground material. The patient reports that five days prior to admission he experienced symptoms compatible with a cold which he self treated by taking Tylenol and Tylenol p.m. In total, he took about 50 Extra strength Tylenol and about 20 Tylenol p.m. and some Excedrin. The patient started developing nausea and malaise and dizziness. He vomited bilious material. On the day prior to admission, he vomited occult black material. When he presented to the [**Hospital1 190**] he was found to be hypotensive and tachycardic. An nasogastric tube was placed which gave a lavage of coffee ground material. At that time he had also developed abdominal pain. PAST MEDICAL HISTORY: 1. The patient reportedly has been hypertensive since the age of 12. He reports that he never really had a work-up of his hypertension. The patient reports that it is not unusual for him to have a systolic blood pressure between 115 and 116. The patient was hospitalized in [**Hospital1 69**] in [**2198-4-14**], with a hypertensive urgency episode. During that time, he was also found to have elevated transaminases. OUTPATIENT MEDICATIONS: 1. Prinivil 10 mg q. day. He reports that he has been compliant with his medication except for a weak period in [**Month (only) 958**] that led to his first hospitalization with the hypertensive urgency episode. SOCIAL HISTORY: The patient grew up in [**State 15946**]. His sister is [**Name8 (MD) **] M.D. in [**State 4565**]. The patient was premed at [**University/College 18328**]but did not follow his studies. He discontinued his studies and took at job at Fidelity Investments. Later, he gave up that job as well. The patient has a history of alcohol abuse during his college years. His extensive drinking was particular worrisome to his friends and eventually he presented to the [**Hospital1 188**] Emergency Department in [**2197-10-15**], stating that he had been drinking heavily and requesting help. At that time, he also reported some suicidal ideation. The patient states that he has significantly cut back on his drinking since that episode. The patient denies other substance abuse including opiates and cocaine. FAMILY HISTORY: The patient denies family history of substance abuse or mental illness. He does state that there is family history of hypertension presenting at an early age which is why he was not particularly concerned about his own hypertension. PHYSICAL EXAMINATION: On admission, temperature 98.4 F.; heart rate 110; blood pressure 90/palpable. Constitutional: The patient was in distress and diaphoretic. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. Subconjunctival ecchymoses bilaterally. Neck supple, no jugular venous distention. Cardiovascular: Tachycardia, regular rate and rhythm. No murmurs, rubs or gallops. Lungs clear to auscultation bilaterally. Abdomen with diffuse tenderness to palpation and guarding. Nondistended. Extremities without edema. Two plus peripheral pulses. Skin with widespread petechiae; no rashes. Neurological with no asterixis. LABORATORY: On admission, white blood cell count 17.4, hemoglobin 16.6, hematocrit 47.5, platelets 164. White blood cell count differential 77 neutrophils, one band, 17 lymphocytes, two monocytes, two eosinophils, zero basophils. Chem-7 with glucose of 77, BUN 40, creatinine 6.7. Sodium 129, potassium 6.3, chloride 82, bicarbonate 17. Liver function tests on admission were ALT of 8670; AST 15,600; CPK was 433, alkaline phosphatase 230. Amylase was 1811. Lipase was 1027, albumin 3.0, calcium 7.3, PT 26.4, PTT 49.0 and INR was 4.6. The patient was negative for HVS antigen and HVS antibody, HVC antibody and HAV antibody. He was also negative for HIV antibody. On admission, his toxicology screen was negative for aspirin and ethanol, benzodiazepines, barbiturates and tricyclics, and the acetaminophen levels were 47.1 with normal levels between 5 and 25. HOSPITAL COURSE: The patient was admitted to the Surgical Intensive Care Unit following hepatic failure, coagulopathy, acute renal failure, and pancreatitis, all secondary to Tylenol toxicity. Hospitalization course by systems as follows. 1. Liver failure: The patient was evaluated by the Hepatology Service and Toxicology Service. He was also evaluated for potential liver transplant if necessary. The patient was treated with Mucomyst intravenously 6.3 grams 20% q. four hours and supportive care in the Surgical Intensive Care Unit. His liver function tests trended down and his INR normalized in five days. Acetaminophen levels dropped from 47.1 on the [**11-8**] to undetectable on the [**11-13**]. 2. Acute Renal Failure: The patient's creatinine remained elevated for the first three days of admission and later trended down to normal levels. The patient's acute renal failure was attributed to Tylenol toxicity but chronic damage from hypertension in addition to the use of an ACE inhibitor could have contributed to that. 3. Pancreatitis: The patient was admitted with elevated amylase and lipase, and even though they ultimately trended down, they remained elevated throughout the course of this hospitalization. During his hospitalization also the patient developed very prominent ecchymoses bilaterally in his abdomen (Grey [**Doctor Last Name **] sign). This was attributed to pancreatitis in combination with his coagulopathy. Also, abdominal pain persisted during most of his hospitalization. CT scan of the abdomen without intravenous contrast on the [**11-11**] demonstrated a swollen appearance of the head of the pancreas and stranding of the fat around the pancreatic head. A repeat CT scan of the abdomen with contrast performed on the [**10-16**] revealed normal perfusion of the pancreas without evidence of necrosis. 4. Hypertension: The patient has a known history of hypertension since the age of ten and a prior hospitalization for a hypertensive emergency. During this hospitalization, the patient presented with hypotension but subsequently exhibited hypertension difficult to control with p.o. or intravenous medications. The patient was treated with gradually increased doses of Metoprolol, Hydralazine and Nitropaste. His blood pressure control during hospitalization was not adequate, possibly because of the patient's inability to tolerate p.o. medication and partially because of his prior history. The patient states that he has never had a work-up for his long standing hypertension; however, review of the old medical records reveals that the patient had been seen by [**Hospital1 69**] physicians and the work-up had been initiated in regards to his hypertension and that he subsequently missed his next appointment. 5. Psychiatric Issues: The patient stated that his Tylenol overdose was not a suicide attempt. The patient was seen by the [**Hospital1 69**] Psychiatric consultation. Please see their notes for further details. The patient stated that after discharge he would go to live with his family in [**State 15946**] for better support. Private discussions with his friends from college revealed that they were strongly concerned about him and about the possibility that his excessive drinking and Tylenol overdose had an underlying cause of a psychiatric disorder and potentially was related to a suicide attempt. The fact that the patient plans to leave [**State 350**] makes follow-up more difficult. The patient and his family have been made aware of this and they state that he will seek medical and psychiatric follow-up in [**State 15946**]; however, given the patient's history of noncompliance with medication, noncompliance with medical follow-up regarding his hypertension and in view of his relocation to a different state, his continued medical and psychiatric follow-up are not guaranteed. CONDITION ON DISCHARGE: Good. DISPOSITION: The patient was discharged to home. DISCHARGE INSTRUCTIONS: 1. The patient was advised to come back within a week for follow-up of his liver function tests and INR as well as his pancreatic enzymes. 2. The patient was also advised to have a follow-up regarding his hypertension and a proper work-up that he had been offered before and failed to come to his appointments. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. MEDQUIST36 D: [**2198-9-15**] 19:02 T: [**2198-9-15**] 19:14 JOB#: [**Job Number 44096**]

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icd9cm

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icd9pcs

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676

Discharge summary

report

Admission Date: [**2169-9-11**] Discharge Date: [**2169-9-13**] Date of Birth: [**2119-6-16**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5084**] Chief Complaint: headaches Major Surgical or Invasive Procedure: [**2169-9-11**]: right temporal craniotomy and resection of lesion History of Present Illness: Pt was seen a week prior to this admission for headaches. work up at that time revealed a right temporal lesion. It was recommended that the patient undergo surgical intervention. He recommended discharge home and to follow up electively. He now presents electively for craniotomy and resection Past Medical History: [] Neurologic - Possible/questionable seizures (lightheaded, fatigue, [**Last Name (un) 5083**] vu, +/- LOC), Left hearing loss [] Psychiatric - Anxiety, depression [] Cardiovascular - Hyperlipidemia Social History: Works as a waiter. +Tobacco, 1ppd x 20 years. No ETOH. No illicit drug use. Family History: Heart valve issue (mother). No seizures. No malignancies. Physical Exam: Mental Status - Awake, alert, oriented x 3. Fluent speech. Naming and repetition intact. No dysarthria. Cranial Nerves - [II] PERRL 3->2 brisk. VF full [III, IV, VI] EOMI, 3-4 beats extreme end gaze nystagmus bilaterally, fatigable. [V] V1-V3 intact to light touch bilat [VII] face symmetric [VIII] Hearing intact to finger rub [IX, X] Palate elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength 5/5 bilaterally. [XII] Tongue midline. Motor: Normal bulk and tone. No pronation, no drift. No tremor or asterixis. Strength is [**5-20**] in all muscle groups Sensation intact to light touch Pertinent Results: [**9-11**] MRI Brain: IMPRESSION: Status post resection of right temporal mass. Residual enhancement is identified. Blood products are seen in the region. No change in degree of edema identified. No hydrocephalus or midline shift. Brief Hospital Course: Pt electively presented and underwent a craniotomy and resection of lesion. Surgery was without complication and he tolerated it well. He was extubated and transferred to the ICU for close neurological monitoring overnight and systolic blood pressure control less then 140. Postoperative MRI demonstrated no hemorrhage. Minimal enhancement remained in the tumor bed. On POD 1 the patient was doing well and was transferred to the floor. He was started on SC heparin for DVT prophylaxis. He remained Neurologically intact. He developed moderate rightsided postop facial and periorbital edema. On POD 2 the patient was mobilizing well. At the time of discharge he was tolerating a regular diet, ambulalating without difficulty, afebrile with stable vital signs. Medications on Admission: 1. Acetaminophen-Caff-Butalbital [**1-16**] TAB PO Q4H:PRN pain, headache RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 2. Dexamethasone 4 mg PO Q6H RX *dexamethasone 4 mg 1 tablet(s) by mouth Q6 hours Disp #*60 Tablet Refills:*0 3. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. LeVETiracetam 1500 mg PO BID 5. Nicotine Patch 14 mg TD DAILY RX *nicotine 14 mg/24 hour 1 patch daily Disp #*30 Each Refills:*0 6. Sertraline 50 mg PO DAILY Discharge Medications: 1. Acetaminophen-Caff-Butalbital [**1-16**] TAB PO Q4H:PRN headache RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg [**1-16**] tablet(s) by mouth every 8 hours as needed for headache Disp #*60 Tablet Refills:*0 2. Bisacodyl 10 mg PO DAILY 3. Dexamethasone 1 mg PO SEE TAPER BELOW [**2087-9-12**]: 3mg Q8 hrs [**Date range (1) **]: 3mg Q12 hrs [**9-17**] and continue: 2mg [**Hospital1 **] and continue this dose until follow up RX *dexamethasone 1 mg See taper tablet(s) by mouth See Taper Disp #*90 Tablet Refills:*1 4. Docusate Sodium 100 mg PO BID 5. Omeprazole 20 mg PO BID continue this medication while you are taking Dexamethasone RX *omeprazole 20 mg 1 capsule(s) by mouth Twice daily Disp #*60 Capsule Refills:*1 6. LeVETiracetam 750 mg PO BID RX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth Twice daily Disp #*60 Tablet Refills:*1 7. Lorazepam 0.5 mg PO HS:PRN anxiety 8. Nicotine Patch 14 mg TD DAILY RX *nicotine 14 mg/24 hour 1 patch Transdermal Daily Disp #*1 Pack Refills:*1 9. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX *oxycodone 5 mg [**1-16**] tablet(s) by mouth every 4 hrs Disp #*60 Tablet Refills:*0 10. Senna 1 TAB PO BID 11. Sertraline 50 mg PO QAM Discharge Disposition: Home Discharge Diagnosis: Right temporal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Craniotomy for Tumor Excision Dr. [**Last Name (STitle) **] ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Dressing may be removed on Day 2 after surgery. ?????? Your wound was closed with staples or non-dissolvable sutures then you must wait until after they are removed to wash your hair. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam) for seizure prevention. Continue to take this medication as , you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. Followup Instructions: ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**10-2**] at 3pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. Your Staples will be removed at this appointment. Completed by:[**2169-9-26**]

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icd9cm

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icd9pcs

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4634, 4640

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165,074

28220

Discharge summary

report

Admission Date: [**2155-6-30**] Discharge Date: [**2155-7-9**] Date of Birth: [**2087-1-9**] Sex: M Service: MEDICINE Allergies: NSAIDS Attending:[**First Name3 (LF) 2291**] Chief Complaint: Mental status changes Major Surgical or Invasive Procedure: Intubation History of Present Illness: Mr. [**Known lastname 68548**] is a 68M with h/o COPD (on 3L home O2), CAD, hepatitis B&C, and an FDG avid RLL mass concerning for malignancy who presented to the ED from Stone [**Hospital **] Rehab on [**6-30**] with mental status changes. Specifically, it was reported that the patient has been becoming more lethargic over 3 days. The patient's HCP [**First Name8 (NamePattern2) 2563**] [**Name (NI) 1661**], [**Telephone/Fax (1) 68549**]) was contact[**Name (NI) **] who given a history that the patient has had an increasing number of falls at his rehab facility recently. She does not know the cause of the falls or if there have been complications. Further, the patient was recently admitted to [**Hospital 882**] Hospital on [**2155-6-14**] with PNA and bacteremia Tx'ed with levaquin and course ended [**2155-6-26**]. During this hospitalization, he was found to have a LLL infiltrate thought to be consistent with pneumonia. He was started on vancomycin and zosyn since he described a history of aspiration and had multiple pulmonary co-morbidities. Blood cultures yielded gram positive cocci in clusters that later grew out coagulase negative staph that speciated as Staph hominus. He was switched to levofloxacin with end date of [**2155-6-26**]. In addition, he had altered mental status on admission, which rapidly improved to his baseline with administration of Narcan in the ER. He continued on a pain regimen. In addition, ECHO showed diastolic heart failure (EF 60 %). . In the ED, the patient was unable to provide a history and was noted to be mumbling and unable to state his own name. Sats initially in the low 80s on RA and improved to 93% on non rebreather. CXR showed large left sided consolidation on CXR. Labs significant for WBC 7.3, Hgb 10 (down 11.8), Cr 4.9 (baseline Cr 0.7). His mental status and oxygenation deteroriated prompting intubation. After intubation, he became hypotensive to 77/40. A CVL was placed in R IJ. He was given 5L of fluids and started on vanc/zosyn/levofloxacin. Neosenephrine was started. He was transferred to the MICU for further management of ? sepsis. He received a total of 5 L NS. . On arrival to the floor, the patient's intial vitals were 98.1 110/54 79. He remained intubated on neosenephrine. He was sedated and unable to provide further history. Past Medical History: Arthritis COPD/emphysema Chronic Pain Hep B HEP C HTN GERD, severe polyneuropathy, swelling of ankles and feet PSH - bilat knee replacements, femur (rod put in), chole, hernia repair, hip repair, left hip repair with screws put in, ulnar and radial fx with rod put in Chronic pain syndrome CAD: reports taking plavix for a plaque in "a heart vessel" that caused a heart attack (not listed on medical hx from Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in clinic) Social History: still smoking [**1-9**] cigarettes/day, >40 pack year history denies alcohol & drugs lives in nursing home (Stonehedge NSC/rehab) Family History: noncontributory Physical Exam: On Admission: Vitals: T: 98.1 110/54 79 General: Intubated and sedated HEENT: Sclera anicteric, MMM, ET tube in place Neck: supple, JVP not elevated, R IJ CL Lungs: Decreased breath sounds b/l with rhonci on left CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present GU: foley in place Ext: warm, well perfused, 1+ edema edema On discharge: VS: T:98.4 BP:140/83 HR:68(60-70s, sinus) RR:17 O2 Sat:96% 3L NC General: Alert and oriented, in NAD, talking in full sentences HEENT: Sclera anicteric, MMM, hoarse low pitched voice Neck: supple, JVP not elevated, R IJ without redness/warmth/erythema Lungs: Decreased BS, scattered wheezes, no ronchi/rales CV: RRR, normal S1 + S2, no m/r/g Abdomen: soft, mildly tender in LLQ, no rebound, non-distended, +BS GU: foley in place Ext: WWP, 1+DP/PT pulses bilaterally Neuro: A+Ox3 Pertinent Results: On Admission: [**2155-6-30**] 11:20AM BLOOD WBC-7.3 RBC-3.39* Hgb-10.0* Hct-28.9* MCV-85 MCH-29.4 MCHC-34.5 RDW-14.1 Plt Ct-174 [**2155-6-30**] 11:20AM BLOOD PT-12.7 PTT-26.5 INR(PT)-1.1 [**2155-6-30**] 11:24AM BLOOD Type-ART pO2-191* pCO2-52* pH-7.32* calTCO2-28 Base XS-0 Comment-GREEN TOP On Discharge: Studies: [**6-30**] CT Chest-1. Multifocal opacities with air bronchograms, including complete consolidation/atelectasis of the left lower lobe. Differential considerations include pneumonic consolidations or extensive atelectasis. 2. Mass in the right lower lobe, compatible with known suspected malignancy. 3. Similar slight left adrenal thickening without discrete nodules. [**6-30**] CT Head. IMPRESSION: No evidence of an acute intracranial process. Scattered periventricular white matter hypodensities, grossly unchanged, which most likely represent sequela of mild chronic small vessel ischemic disease. MR would be significantly more sensitive for detection of intracranial metastases, if clinically indicated. [**7-1**] Echo. The left atrium is normal in size. There is mild 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%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. The mitral valve leaflets are not well seen. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. No vegetation seen but cannot exclude (views are suboptimal). Brief Hospital Course: Mr. [**Known lastname 68548**] is a 68 y/o male with PMH COPD, CAD, hepatitis B&C and questionable lung cancer presents with altered mental status and hypercarbic respiratory failure in the setting of PNA # PNA The patient was recently admitted to [**Hospital 882**] Hospital on [**2155-6-14**] with PNA and bacteremia (Staph hominus). Tx'ed with levaquin and course ended [**2155-6-26**]. On [**2155-6-30**] he presented to this hospital with AMS and lethargy. In the ED, the patient was unable to provide a history and was noted to be mumbling and unable to state his own name. Sats initially in the low 80s on RA and improved to 93% on non rebreather. A CXR revealed a LLL consolidation in addition to known right sided lung mass. His mental status and oxygenation deteroriated prompting intubation. After intubation, he became hypotensive to 77/40. A CVL was placed in R IJ. He was given 5L of fluids and started on vanc/zosyn/levofloxacin. Pressors were started. A CT C/A/P showed the left sided consolidation and a right sided mass measuring 30 x 22 mm. He was transferred to the MICU where he was slowly weaned from pressors. A TTE done showed an EF of 55% and no vegitations although was a suboptimal study. A bronchoscopy was performed and cultures taken which grew MRSA. Antibiotics narrowed to just vancomycin. On [**7-2**], the patient passed an SBT and was extubated w/o complications. A PICC was placed on [**7-5**], with plan for 14 days of antibiotic therapy to end on the night of [**2155-7-13**]. Patient back to baseline and doing well on Vancomycin. # Hypotension The patient was initially normotensive in th ED. Following intubation, his BP fell to the 70s/40s and he required pressors. On transfer to the MICU, his pressors were able to be weaned off slowly. Most likely etiology of hypotension is sedating medications for intubation. Vasodilation from sepsis also a possible explanation. Over his MICU stay, the patient was able to be weaned off of pressors. On transfer to the floor, he was hypertensive and his home anti-hypertensives were gradually added back. He is hemodynamically stable at this point. Labetalol 200mg PO BID converted to metoprolol 75mg PO TID. #Atrial fibrillation On [**7-2**] the patient was noted to be in afib with RVR. He has no history of afib. The event started immediatly following an SBT and the patient was initiated on a heparin drip. By the afternoon of [**7-2**] the patient converted back to sinus while being continued on PO dilt. On [**7-3**] the patient had another episode of afib with RVR likely [**1-8**] agressive diuresis, and again spontaneously converted back to sinus rhythm. On [**7-4**] he had a third episode of atrial fibrillation with RVR, and was symptomatic with shortness of breath, diaphoresis, hypertension and EKG changes significant for ST depressions in anterolateral leads. With rate control, symptoms improved and ST depressions resolved, and patient spontaneously converted. He was titrated to metoprolol 75mg po TID, home dose of amlodipine 5mg po daily. Labetalol 200mg PO BID discontinued. Patient has been in sinus for the past 2-3 days at this point, stable. A discussion of anticoagulation was initiated given patient's CHADS score of [**12-8**]. Patient is amenable to starting but he has plans for bx of RLL mass in the not to distant future. Unable to discuss with PCP directly, so anticoagulation for now held and should be initiated and followed by PCP. [**Name10 (NameIs) 39448**] to RN in office and heard that his care will be transfered from Dr. [**Last Name (STitle) 68550**] to Dr. [**Last Name (STitle) 32296**] sometime in [**Month (only) 216**] of this year and given the transition, thought it best not to start a complicated drug like coumadin while in the hospital. # Acute renal failure The patient presented with a Cr of 4.9 which is well above his baseline of ~0.8. His Cr dropped rapidly with fluid resusitation indicative of a prerenal etiology. Creatinine remained at baseline for the remainder of hospitalization. #Lung mass The patient has an FDG avid RLL lung noducle suspicious for malignancy. He is being followed by rad-onc here as an outpatient. It appears that he is not presently a surgical candidate and that cyberknife is being considered. Biopsy will be done through bronch and EGUS instead of mediastinoscopy as evaluated by Thoracic surgery. Patient has followup with Dr. [**Last Name (STitle) 2168**] at [**Hospital3 **] on [**2155-7-17**] for plans to biopsy mass. Plavix and ASA will need to be held prior to biopsy, and should coumadin be started, will need to be held as well. # CAD Unknown baseline history. Last ECHO at [**Hospital1 112**] showing normal EF and ? diastolic heart failure. His anti-hypertensives were initially held in the setting of shock but have been slowly added on as above as the patient's vascular tone recovered. Patient was continued on aspirin and clopidogrel throughout hospitalization. # COPD Patient with oxygen-dependent COPD. Was on Qvar while on vent, now transitioned back to home medications. At the time of transfer from the MICU, patient was back to home O2 requirement of 3L NC and was stable for the remainder of hospitalization. #. Depression/PTSD No active issues. Temporarily held all psychoactive and sedating medications while patient was intubated. #Transitional issues- - follow-up with pulmonologist regarding RLL mass [**2155-7-17**] (Dr. [**Last Name (STitle) 2168**] at [**Hospital3 5506**]) - follow-up with ENT regarding change in voice (appointment made) #Full code Medications on Admission: - lisinopril 40 mg PO qHS - doxepin 50 mg PO qHS - Enlose 10 g/15 mLO 30 mL PO qOD - [**Doctor Last Name **] slices qHS - lasix 80 mg PO qD - omeprazole 40 mg PO qD - amlodipine 5 mg PO qD - ASA 81 mg PO qD - citalopram 50 mg PO qD - clonazepam 1 mg PO qD - docusate 200 mg PO qD - loratadine 10 mg PO qD - Spiriva 1 cap INH qD - vitamin B12 - plavix 75 mg PO qD - labetalol 200 mg PO BID - advair 250/50 INH [**Hospital1 **] - azelastine nasal spray - bupropion SR 200 mg PO BID - levofloxacin 750 mg PO qD (completed on [**2155-6-26**]) - MS Contin 60 mg PO BID - neurontin 600 mg PO TID - hydromorphone 2 mg PO q 4 hr prn pain Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a day. 6. citalopram 20 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 7. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO BID (2 times a day). 8. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 12. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). 13. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. vancomycin 500 mg Recon Soln Sig: 2.5 Recon Solns Intravenous Q 12H (Every 12 Hours) for 4 days: to end on [**2155-7-13**] PM. 15. doxepin 50 mg Capsule Sig: One (1) Capsule PO at bedtime. 16. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO daily prn as needed for constipation. 17. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 18. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) puff Inhalation once a day. 19. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day. 20. Vitamin B-12 Oral 21. azelastine Nasal Discharge Disposition: Extended Care Facility: [**Hospital **] Rehabilitation & [**Hospital **] Care Center - [**Location 1268**] Discharge Diagnosis: Primary diagnosis: 1. MRSA Pneumonia 2. Paroxysmal Atrial Fibrillation Secondary diagnosis: 1. COPD 2. HTN 3. CAD 4. Hepatitis B 5. Hepatitis C 6. Right Lower Lung Mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Transfers from bed to chair Discharge Instructions: It was a pleasure taking care of you at the [**Hospital1 771**]. You presented with pneumonia and have been treated with antibiotics. You will need to continue antibiotic treatment for an addtional 4 days (last day will be [**2155-7-13**]) and have a PICC line in place for the infusion during this period. . Your hospital stay was also complicated by an irregular heart rhythm called atrial fibrillation. This was treated and some changes have been made to your medications. Your heart rhythm is normal and well-controlled at this point. However, with atrial fibrillation, anticoaguation (thinning of your blood) is indicated and should be discussed with your primary care physician. [**Name10 (NameIs) **] starting this medication, you will need frequent blood labs and you will need to be closely monitored. . The following changes have been made to your medications: --STOP labetalol --START metoprolol 75 mg three times a day --START vancomycin 1250mg IV twice a day Please take your other medication as previously prescribed. Followup Instructions: You have the following appointments: **Please make an appointment to see your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 68551**] ([**Telephone/Fax (1) **]) within the next week. Department: LIVER CENTER When: MONDAY [**2155-7-14**] at 10:50 AM With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Location: [**Hospital3 2005**] Hospital Address: [**Street Address(2) 64224**] [**Location (un) 583**], [**Numeric Identifier 994**] Phone: [**Telephone/Fax (1) 68552**] Appointment: Thursday [**2155-7-17**] 10:45am Department: OTOLARYNGOLOGY (ENT) When: WEDNESDAY [**2155-7-30**] at 10:15 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**] Building: LM [**Hospital Unit Name **] [**Location (un) 895**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE Department: RADIOLOGY When: MONDAY [**2155-7-28**] at 2:45 PM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

14210, 14319

6276, 11868

287, 299

14539, 14539

4283, 4283

15733, 17062

3326, 3343

12549, 14187

14340, 14340

11894, 12526

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3358, 3358

4591, 6253

226, 249

327, 2649

14433, 14518

14359, 14412

4297, 4576

14554, 14651

2671, 3162

3178, 3310

8,105

189,720

16728

Discharge summary

report

Admission Date: [**2117-2-21**] Discharge Date: [**2117-2-23**] Date of Birth: [**2085-10-2**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 12722**] Chief Complaint: alcohol intoxication Major Surgical or Invasive Procedure: none History of Present Illness: 31 y.o Male with pmhx of chronic systolic heart failure with dilated cardiomyopathy related to alcohol abuse, atrial fibrilliation, presenting after the patient's roommate contact[**Name (NI) **] 911 because the patient has been abusing alcohol nonstop for the past week. Patient states that he is a known alcoholic and states that he'll he has had 5 beers today. However according to his roommates the patient has been drinking nonstop for one week and has consumed well over several dozen alcoholic beverages. Otherwise the patient states that he did not take any other substances. The patient states that he took his normal lisinopril, digoxin. Otherwise the patient states that he does not have any chest pain, palpitations, shortness of breath, headache, abdominal pain. . In the ED, initial VS were: 99.6 60 130/92 20 96%. The patient was noted to be intoxicated with a serum alcohol level of 400. He had a heart rate of 170 and was noted to be in atrial fibrilliation with RVR. He recieved 3 Liters of IV fluids and multiple bolus of Diltiazam 5m X once IV and 5m Metoprolol IV X once , followed by oral 25 mg Metoprolol X Once and Diltiazam 30mg X once, with good response and heart around 100. He was agitated in the ED and recieved 10mg IV ativan and 4 point restraints. . On arrival to the MICU, He is obtunded and denies any pain and falls back asleep. . Review of systems: patient does not respond to questions Past Medical History: 1. Dilated cardiomyopathy- 2. atrial fibrilliation 3. History of substance abuse 4. Depression 5. Alcohol withdrawlserizures Social History: Drinking as above. Smokes [**2-9**] pack cigarettes per day since age of 13. History of drug use many years ago including cocaine, ecstacy. No drugs in many years. Family History: Maternal great aunt with DM. No heart disease in family. No hypertension Physical Exam: Vitals: T: 99.1 BP:118/66 P:84 R: 18 O2:100% RA General: Alert, oriented X 3, male, crying HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, Pertinent Results: Admission Labs [**2117-2-21**] 11:36PM URINE HOURS-RANDOM [**2117-2-21**] 11:36PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2117-2-21**] 11:36PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015 [**2117-2-21**] 11:36PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2117-2-21**] 11:36PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 [**2117-2-21**] 11:36PM URINE MUCOUS-MANY [**2117-2-21**] 07:00PM GLUCOSE-122* UREA N-5* CREAT-0.8 SODIUM-144 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-30 ANION GAP-18 [**2117-2-21**] 07:00PM estGFR-Using this [**2117-2-21**] 07:00PM ALT(SGPT)-67* AST(SGOT)-72* LD(LDH)-340* ALK PHOS-82 TOT BILI-0.5 [**2117-2-21**] 07:00PM cTropnT-<0.01 [**2117-2-21**] 07:00PM ALBUMIN-5.0 CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-2.0 [**2117-2-21**] 07:00PM DIGOXIN-0.2* [**2117-2-21**] 07:00PM ASA-NEG ETHANOL-392* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2117-2-21**] 07:00PM WBC-9.2 RBC-5.72 HGB-17.8 HCT-50.0 MCV-88# MCH-31.1 MCHC-35.6* RDW-12.7 [**2117-2-21**] 07:00PM NEUTS-53.7 LYMPHS-39.9 MONOS-4.6 EOS-1.1 BASOS-0.7 [**2117-2-21**] 07:00PM PLT COUNT-279 [**2117-2-21**] 07:00PM PT-30.5* PTT-45.0* INR(PT)-3.0* . EKG Atrial fibrillation with rapid ventricular response. Delayed R wave progression in the anterior precordial leads. Diffuse non-specific ST-T wave changes in the inferior and anterolateral leads. Compared to the previous tracing of [**2112-3-24**] the rhythm is now atrial fibrillation with a rapid response. . CHEST XRAY IMPRESSION: Low lung volumes with no signs of CHF or pneumonia. Brief Hospital Course: PRIMARY REASON FOR ADMISSION . 31 y.o Male with pmhx of chronic systolic heart failure with dilated cardiomyopathy related to alcohol abuse, atrial fibrilliation, presented with alcohol intoxication, atrial fibrilliation with RVR and agressive behavoir. . #Alcohol intoxication- the patient is protecting his airway currently with no evidence of aspiration on CXR. Recieved [**4-11**] Liters of fluid intravenous, and one to one for passive SI and agressive behavoir which resolved in the ICU. He was transferred to the floor on HD1. He was placed on a CIWA scale but did not require any diazepam. The patient was seen by social workers and psychiatry (see below). As above the patient had been sober 1 year prior to this event. Patient reported he motivated to obtain sobriety once again after this recent relapse. He was provided information regarding resource information including information about addiction services at [**Hospital 778**] clinic. Behavior remained appropriate, HR improved and the patient was discharged on HD 2. . # Suicidal ideation- [**Last Name (un) **] intoxicated the patient made statements concerning for self harm such as suicidal statements, such as "my number one goal is to harm myself" while intoxicated. When sober the patient denied any sucidical or homicidal ideation. He was evaluated by psychiatry who did not feel he was a danger to himself or others. Per psychiatry recommendations his Celexa was titrated upward to 30 mg. Psychiatry also recommended replacing home seroquel with trazodone. This was tried however, the trazodone was not effective for the patients insomnia and he was restarted on his home seroquel. . #Atrial Fibrillation- Patient initially had heart rates of 100-120 her restarted home carvedilol which was up titrated to 25mg [**Hospital1 **]. He also required Lopressor IV 5mg twice while in the MICU. On the floor heart rates improved and his was discharged on the increased dose of carvedilol. The patient was continued on [**Hospital1 **]. While in house he was given 5 mg daily. On discharge he was restarted on 6 mg MTWTHF and 7 mg on Sat Sun. INR on discharge was 1.6. INR monitoring will be transitioned to [**Hospital 778**] clinic. The patient was initially started on [**Hospital **] as an outpatient in preparation for cardioversion. He will follow-up with his cardiologist to determine the need to continue this medication. Patient was also continued on his home aspirin. . #Systolic Heart Failure- Likely due to dilated cardiomyopathy related to alcohol abuse. Last EF in [**2114**] improved at 40 %. He was continued on his home Lisinopril and Digoxin. Digoxin level was low at 0.2 likely related to poor medication compliance during his recent alcohol binge. As above he will follow-up with his outpatient cardiologist. . # Transaminitis- AST and ALT were mildly elevated on admission 67, 72 respectively. This was felt to likely reflect effect of alcohol. Transaminases trended downward throughout the admission. Hepatitis panel was positive only for HepB surface antigen suggesting previous immunization. Hepatitis C antibody was negative. . TRANSITIONAL ISSUES - As above INR monitoring will be done at [**Hospital 778**] clinic - Patient will follow-up with his PCP and cardiologist - Patient was full code throughout this admission Medications on Admission: carvedilol 12.5 mg p.o. b.i.d. Celexa 20 mg daily digoxin 0.125 mg a day lisinopril 30 mg a day Seroquel 25mg daily aspirin 325 mg a day warfarin. Discharge Medications: 1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 4. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 6. warfarin 1 mg Tablet Sig: 6-7 Tablets PO once a day: take 6 mg [**Hospital **] to friday, 7 mg saturday and sunday . 7. Aspirin 325 mg daily 8. Outpatient Lab Work Check INR on [**2117-2-25**] fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 21392**] Discharge Disposition: Home Discharge Diagnosis: Alcohol intoxication Dilated Cardiomyopathy Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], It was pleasure participating in your care while you were admitted to [**Hospital1 69**]. As you know you were admitted after drinking a significant amount of alcohol. You were also noted to have an extremely fast heart rates in an abnormal rhythm. Your home carevedilol was increased to help control your heart rate. You were also given information about rehab facilities to help your addiction recovery. We made the following changes to your medications 1. INCREASE carvedilol to 25 mg twice a day 2. INCREASE citalopram to 30 mg daily You should continue to take all other medications as instructed. You will need to have your INR checked at the [**Hospital 778**] clinic on [**2117-2-25**] Followup Instructions: Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. Location: [**Hospital6 5242**] CENTER Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 798**] When: [**Last Name (LF) 766**], [**3-1**], 4:00 PM *Dr. [**Last Name (STitle) **] is a resident who works with Dr. [**Last Name (STitle) **]. Department: CARDIAC SERVICES When: TUESDAY [**2117-3-9**] at 2:45 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BWD

[ "428.0", "425.5", "305.1", "428.22", "311", "V49.87", "303.01", "790.4", "V62.84", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8804, 8810

4541, 7865

327, 333

8918, 8918

2834, 4518

9823, 10664

2138, 2212

8063, 8781

8831, 8897

7891, 8040

9069, 9800

2227, 2815

1749, 1789

266, 289

361, 1730

8933, 9045

1811, 1938

1955, 2122

16,053

106,862

53211

Discharge summary

report

Admission Date: [**2121-1-9**] Discharge Date: [**2121-1-17**] Date of Birth: [**2056-4-16**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 3531**] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: [**1-9**]- Endotracheal intubation, mechanical ventilation, subsequent extubation [**1-11**]- Bronchoscopy History of Present Illness: Mr. [**Known lastname **] is a 63 year-old male smoker with a history of severe COPD on home [**Known lastname 20358**] (4L), dCHF, and DM2 who presents from home with dypnea and respiratory failure. He was recently discharged on [**2120-12-19**] after being admitted for a COPD exacerbation (3 day hospital stay) and was sent to [**Hospital3 105**] rehab. He did well at rehab and arrived home yesterday. Since this morning, per his wife, he began feeling increasingly dyspneic and fatigue and had fevers; he has a chronic productive cough at baseline which was unchanged. He then called EMS after finishing [**Holiday 1451**] dinner with his family. Of note, his daughter has cystic fibrosis and is "coming down with a cold." No pets at home. . He was noted by EMS to be dyspneic and received nebs without improvement. He desatted with a NRB and was intubated en route to [**Hospital1 18**] ED. . In the ED, vital signs were initially: 103.4 rectal 96 109/53 99% on vent settings of cmv 550 x 16, peep 8, fio2 100%. A CXR demonstrated a RLL infiltrate. He was given 2.5L IVF, vanc, ceftriaxone, and levoflox and admitted to the [**Hospital Unit Name 153**]. Past Medical History: 1. Severe COPD: followed by Dr. [**Last Name (STitle) **], on prednisone and home [**Last Name (STitle) 20358**] (4L NC) at baseline, recently he has been having monthly admissions for COPD: [**Last Name (STitle) 1570**]'s [**7-23**]: FEV1 19%, FEV1/FVC 43% 2. Chronic Systolic CHF: TTE [**3-24**] LVEF>55%, although patient denies this 3. Gastritis/GERD 4. h/o SBO 5. Tobacco Abuse: Previous 5PPD, now [**3-19**] cigs/day 6. Diabetes Mellitus type 2 7. Diverticulosis 8. C6-C7 HERNITATION 9. B12 Deficiency- on monthly injections 10. Obesity with possible OSA, but pt refuses sleep study or CPAP 11. Psoriasis 12. Hypertension 13. Glaucoma 14. Recent LLE cellulitis [**2-22**] Social History: Home: Lives with his wife [**Name (NI) 319**] [**Name (NI) **] and his son. His [**Name2 (NI) 8526**] has cystic fibrosis and is currently hospitalized for respiratory infection. His wife has recently started a new job and is under a great deal of stress. Tobacco: previous heavy smoking history of 5 PPD, states he recently quit smoking during [**11-22**] hospital admission EtOH: previous history of heavy EtOH, now rarely drinks Drugs: Denies Family History: Mother - died of lung cancer in 60s Father - died of lung cancer in 60s Sister- died of lung cancer in 50s Physical Exam: VS: 103.4 rectal 96 109/53 99% on AC, fio2 100%, 550 x 16, peep 10 GEN: intubated, cushingoid SKIN: No rashes or skin changes noted HEENT: obese neck, unable to appreciate JVD, No lymphadenopathy in cervical, posterior, or supraclavicular chains noted. CHEST: + b/l rhonchi, no wheezes CARDIAC: Regular rhythm; no murmurs, rubs, or gallops. ABDOMEN: obese, no hepatosplenomegaly EXTREMITIES: no peripheral edema NEUROLOGIC: intubated, arousable, unable to assess strength Pertinent Results: Admission Labs: ABG pH 7.27 pCO2 83 pO2 235 HCO3 40 BaseXS 7 Na:142 K:4.4 Cl:100 Glu:207 Lactate:0.6 PT: 11.8 PTT: 21.1 INR: 1.0 145 93 61 ------------< 223 4.8 39 1.7 freeCa:1.08 Lactate:2.3 pH:7.22 CK: 53 MB: Notdone Trop-T: Pnd Ca: 8.3 Mg: 2.9 P: 2.9 Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative 14.4 >--< 229 34.2 CBC on [**2121-1-8**]: 9.7 > 31 < 76 STUDIES: CXR [**2121-1-9**]: Patchy opacities bilaterally which could be consistent with multifocal pneumonia and/or aspiration. Possible overlying pulmonary edema. Trace right pleural effusion. CXR [**2121-1-14**]: Relatively symmetric ground-glass opacification in the lower lung zones is most likely pulmonary edema. Heart is normal size. The mediastinal veins are distended. Left jugular vein ends in the upper SVC. Lung bases are excluded from the examination. Upper pleural margins show no abnormality, but some pleural effusion could be present. EKG: Artifact is present. Sinus tachycardia. Probably normal tracing. Compared to the previous tracing there is no significant change. Brief Hospital Course: Mr. [**Known lastname **] is a 63 year-old male smoker with a history of severe COPD on home [**Known lastname 20358**] (4L), DM2, and diastolic heart failure who presented to the ICU from home (after a brief stay at rehab following recent hospitalization) with dyspnea and respiratory failure. Due to worsening respiratory effort he was intubated in the field, transported to the emergency department and admitted to the ICU. . 1. Hypoxic/hypercapneic respiratory failure: His respiratory failure was felt to be secondary to pneumonia complicated by COPD exacerbation. Mr. [**Known lastname **] has history of multiple COPD exacerbations and pneumonia episodes in past, for which he has been intubated, and he continues to smoke. He presented to the ICU on [**1-9**], intubated with ABG consistent with chronic respiratory acidosis. He was started on empiric vancomycin and zosyn for hospital-acquired pneumonia (given recent hospitalization and rehab stay) as well as azithromycin for atypical coverage. His antibiotics were eventually switched to Levaquin after a bronchoalveolar lavage culture grew stenotrophomonas maltophilia that was sensitive to Levaquin. He was started on tamiflu empirically, and had a flu swab that later returned negative and his Tamiflu was discontinued. He was extubated on [**2121-1-12**] without complication. He was initially on high dose solumedrol IV which was transitioned to prednisone 60 mg po daily. Per Dr. [**Last Name (STitle) **] (outpatient pulmonologist), he should continue this dose of prednisone until he his seen in clinic. He completed a 9 day course of levaquin for his hospital acquired Stenotrophomonas pneumonia. At time of discharge patient is requiring albuterol nebs q3h and ipratropium nebs q6h to prevent acute exacerbation. Patient would also likely benefit a great deal by BiPAP. He was seen by Respiratory Therapy on the medical floor and started on intermittent BiPAP. Recommend continuing to offer BiPAP for intermittent relief and throughout night. Smoking cessation (reportedly has not smoked since [**11-22**] hospital admission) was congratulated and abstinence encouraged. Patient is scheduled to follow up with Dr. [**Last Name (STitle) **] in clinic on [**2121-1-29**] to address prednisone taper. . 2. Acute Renal insufficiency: Mr. [**Known lastname **] has a baseline Creatinine of 0.7 which was elevated on admission to 1.7. His creatinine trended downward (1.0) during his [**Hospital **] hospital course in response to IV fluid. The underlying etiology for ARF on presentation was felt to be pre-renal in the setting of pneumonia. With later diuresis on the medicine floor for volume overload his creatinine fell to 0.8. suggesting his diastolic dysfunction is a considerable contributor to compromised renal function. . 3. Hypertension: After receiving IV fluids and high dose steroids for his pneumonia and COPD, he became hypertensive. He was restarted on his home amlodipine which was increased to 10mg po daily. He was also restarted on lisinopril 40 mg po daily and lasix 60 mg po daily (discontinued on previous admission in setting of ARF). . 4. Diastolic CHF: Patient appeared volume overloaded on presentation to the medicine floor. Lasix was restarted and patient was diuresed > 3 L. Renal function improved with diuresis. Continue antihypertensive regimen as listed about. Recommend compression stockings and leg elevation to reduce lower extremity edema. . 5. Sinus Tachycardia: Persists throughout admission. Likely secondary to frequent albuterol nebs and respiratory distress. If tolerated attempt to decrease frequency of albuterol nebs to decrease tachycardia and allow greater diastolic filling. . 6. CODE STATUS: Patient stated that he no longer would like to be intubated on [**2121-1-17**]. However, he would not like this to take effect until he has discussed this with his family. He plans to meet with his family on [**2121-1-18**] to notify them of this change. Please verify code status with patient after his family discussion. Medications on Admission: MEDICATIONS AT HOME (per last d/c summary): 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) nebs q2h prn 2. Ipratropium Bromide 0.02 % nebs Q6H (every 6 hours) 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H prn 5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID 6. Pantoprazole 40 mg Tablet PO Q12H 7. Simvastatin 5 mg Tablet PO DAILY (Daily) 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr PO HS 9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ferrous Sulfate 325 mg (65 mg Iron) One (1) Tablet PO DAILY 14. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO daily 15. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON 16. Calcium Carbonate 500 mg Tablet, Chewable (1) Tablet PO TIDAC 17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 1 Tablet [**Hospital1 **] 18. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) prn 19. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) neb Q4H 21. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H 22. Fluticasone-Salmeterol 500-50 mcg/Dose Disk: 1 disc [**Hospital1 **] prn 23. Insulin Lispro 100 unit/mL Solution Sig: sliding scale. 24. Triamcinolone Acetonide 0.1 % Ointment: 1 Appl [**Hospital1 **] prn psoriasis 25. Clobetasol 0.05 % Ointment (1) Appl Topical [**Hospital1 **] prn psoriasis 26. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) prn 27. Prednisone 20 mg PO DAILY (Daily) 28. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 29. Spiriva with HandiHaler 18 mcg Capsule: One (1) Inhalation daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn as needed for Constipation. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TIDAC (3 times a day (before meals)). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO DAILY (Daily). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 14. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-16**] Sprays Nasal QID (4 times a day) as needed for congestion. 16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 17. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for psoriasis. 18. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 19. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q3H (every 3 hours). 21. Insulin See Humalog sliding scale. Check fsbs qachs. Half dose while npo. 22. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day: Hold if SBP < 100. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: COPD Hypertension Diastolic CHF Diabetes Mellitus Discharge Condition: Patient on home [**Location (un) 20358**] requirement of 4L/min NC, ambulation is SEVERELY limited by respiratory distress, patient requires assistance/supervision with all ambulation, tolerates po diet and medications. Discharge Instructions: You presented to the [**Hospital1 18**] Emergency Department by ambulance in respiratory failure. You required intubation during your transport. You were admitted to the ICU and found to have pneumonia and an exacerbation of your severe COPD. You were treated with antibiotics, and steroids and improved. You were extubated and transferred to the medicine floor. There you continued to receive antibiotics, steroids, and frequent breathing treatments. Your lasix was restarted to remove extra fluid and to help your breathing and your leg swelling. You were discharged back to [**Hospital **] Rehabilitation Center where you will continue your diuresis and respiratory therapy. The following changes were made to your medications: 1) INCREASE amlodipine to 10 mg by mouth daily 2) RESTART furosemide (lasix) 60 mg by mouth daily 3) RESTART lisinopril 40 mg by mouth daily Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] on [**1-29**] at 4 pm in the Pulmonary Clinic located at [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) 436**].

[ "285.29", "327.23", "V58.65", "266.2", "696.1", "250.02", "276.2", "995.92", "493.22", "038.9", "278.01", "482.83", "V12.04", "562.10", "275.3", "428.0", "428.33", "V46.2", "276.52", "305.1", "530.81", "V58.67", "785.52", "584.9", "518.81", "722.0", "401.9", "365.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "33.24", "96.6", "96.71" ]

icd9pcs

[ [ [] ] ]

12300, 12371

4496, 8551

287, 395

12465, 12687

3393, 3393

13615, 13828

2775, 2884

10298, 12277

12392, 12444

8577, 10275

12711, 13592

2899, 3374

228, 249

423, 1594

3410, 4473

1616, 2295

2311, 2759

42,649

194,814

38308

Discharge summary

report

Admission Date: [**2193-5-25**] Discharge Date: [**2193-6-6**] Date of Birth: [**2117-12-26**] Sex: F Service: CARDIOTHORACIC Allergies: Vicodin / Detrol Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2193-5-29**] 1. Resection of cardiac tumor on pulmonary valve. 2. Coronary artery bypass grafting x4 with left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch, ramus intermedius, and posterior descending artery. History of Present Illness: Ms. [**Known lastname **] is a very nice 75 year old female with known 3 vessel coronary artery disease who has CABG planned for ([**2193-6-4**]), HTN, and HLD who presents with sudden onset of left sided chest "tingling" and burning which radiated into the left neck while [**Location (un) 1131**] a book. She notes that she suddenly became very weak/tired and then started crying and shaking. Patient doesn't know why she was crying. Because of the symptoms in her chest she called 911 and took two nitros which helped alleviate the pain. No palpitations, diaphoresis, shortnes of breath, lightheadedness, abdominal pain, nausea or vomiting. . Of Note, Patients work up for CAD started in [**Month (only) 956**] when she had chest burning across her chest while hospitalized with a urinary tract infection. After discharge patient went to PCP who scheduled Stress Test which was abnormal. Pt went for Cath at [**Hospital6 **] which showed 3VD. She was then referred to Dr. [**Last Name (STitle) **] at [**Hospital1 18**] for evaluation for CABG - she is scheduled for surgery on [**2193-6-4**]. Past Medical History: - Hypertension - Dyslipidemia - Obesity - Gastroesophogeal Reflux Disease - Polymyalgia Rheumatica (4-5 years prior, off steroids) - Osteoperosis - Rheumatoid Arthritis - Glaucoma - Cervical, Lumbar Disc Disease - BLE neuropathy . Past Surgical History - Hysterectomy, Bladder Resuspension - Appendectomy - Cesarean Section - Colonoscopy - Right cataract surgery Social History: [**Location (un) **], Ma. Married for 49 years. 4 children. Retired at 65, worked as a knitter and [**Location (un) 535**]. No tobacco currently, quit 30 years prior at that time smoked [**1-6**] cigerettes daily (from age 21). No EtOH. Family History: Mother died of MI at age 52. One of 16 children. All living brothers and sisters with history of open heart surgery. Physical Exam: VS - BP 129/59 HR: 60 RR: 15 100% RA Afebrile Gen: Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 10 cm. CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. Pain on palpation of lower extremity (stable for years) Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: CN II-XII intact. Strength upper/lower extremity normal. Sensation intact to light touch upper and lower extremity. Gait deferred. . Pulses: Right: Radial 2+ DP 2+ PT 2+ Left: Radial 2+ DP 2+ PT 2+ Pertinent Results: [**2193-5-27**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis <40%. [**2193-5-29**] Echo: Prebypass: No atrial septal defect is seen by 2D or color Doppler. There is mild regional left ventricular systolic dysfunction with mild hypokinesia of the basal portion of the inferior wall. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. A mass is seen on the pulmonic valve. It measures 5mm and is attached to the septal leaflet of the pulmonic valve. It's appearance is suggestive of a fibroelastoma. There is no pulmonic stenosis or regurgitation associated with it. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2193-5-29**] at 1000am. Post bypass: Patient is AV paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. The mass seen prebypass on the pulmonic valve is no longer present. Trace pulmonic insufficiency present. Mild mitral regurgitation present. Aorta is intact post decannulation. Brief Hospital Course: 75 year old female with known 3 vessel disease scheduled for CABG on [**6-4**], HTN, HLD who presents with chest burning and lateral EKG changes which resolved with ASA/Nitro. The patient was evaluated by the cardiac surgery service. Her chest pain resolved with a few transient episodes of neck tingling (likely her anginal equivalent). She was managed with a beta-blocker (metoprolol tartrate), aspirin, pravastatin and continued on her home ACE-inhibitor. She did receive one dose of SL nitroglycerin on the floor. She underwent echocardiogram which showed a very small "mass" on the pulmonic valve - felt to be either degenerative change, or early myxoma or other benign mass. Following this medical management for several days with additional pre-operative work-up, she was brought to the operating room on [**5-29**] where she underwent resection of mass on pulmonic valve and coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours she was weaned from surgery, awoke neurologically intact and extubated. On post-op day one chest tubes were removed. Diuretics and beta blockers were initiated and she was diuresed towards her pre-op weight. She was transferred to the telemetry floor for further care on post-op day two. Over the next several days she had multiple episodes of atrial fibrillation which was treated with beta blockers and diuretics. On post-op day four epicardial pacing wires were removed and she was started on Coumadin. On post-op day six she had near-syncopal episode and was transferred to the CVICU for closer evaluation. She remained stable with no new episodes and was transferred back to the step-down floor the following day. Coumadin was discontinued but continues on beta blockers and amiodarone as she remained in sinus rhythm for 3 days. She worked with physical therapy during her post-op course for strength and mobility. She appeared to be doing well on post-op day eight and was discharged home with VNA services along with the appropriate medications and follow-up appointments. Of note, she was discharged on Keflex 500mg QID x 10 days for erythema on EVH incision. Medications on Admission: Pravastatin 20mg Daily Omeprazole 20 mg daily Aspirin 81 mg daily Atenolol 25 mg daily Calcium 500 mg daily HCTZ 12.5 mg daily Nifedipine ER 10 mg daily NTG 2.5 mg SR cap prn cholecalciferol ( D3) 1000 units daily Quinapril 40mg Daily Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Please take 2, 200mg tablets x 7 days. Then take 1, 200mg tablet daily until stopped by cardiologist. Disp:*40 Tablet(s)* Refills:*2* 9. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a day for 10 days. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Rescetion of cardiac tumor on pulmonary valve Coronary artery bypass graft x 4 Past medical history: - Hypertension - Dyslipidemia - Obesity - Gastroesophogeal Reflux Disease - Polymyalgia Rheumatica - Osteoarthritis - Glaucoma - History of UTI [**2193-2-4**] - Cervical, Lumbar Disc Disease left eye hemorrhage 15 yrs ago ( followed by ophth) - BLE neuropathy Past Surgical History - Hysterectomy, Bladder Resuspension - Appendectomy - Cesarean Section - Colonoscopy - right cataract surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, mild erythema with ecchymosis, no drainage. Trace 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) **] on [**2193-7-4**] at 1:15PM Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36361**] in [**1-5**] weeks Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 85371**] in [**1-5**] 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:[**2193-6-6**]

[ "725", "427.31", "722.4", "278.00", "411.1", "401.9", "272.4", "285.1", "714.0", "733.00", "212.7", "780.2", "414.01", "722.52", "530.81", "355.8" ]

icd9cm

[ [ [] ] ]

[ "38.93", "35.99", "36.15", "39.61", "36.13" ]

icd9pcs

[ [ [] ] ]

8465, 8524

4725, 6974

294, 573

9060, 9304

3332, 4702

10143, 10715

2355, 2473

7259, 8442

8545, 8624

7000, 7236

9328, 10120

2488, 3313

244, 256

601, 1699

8646, 9039

2101, 2339

21,888

188,672

15261

Discharge summary

report

Admission Date: [**2173-8-17**] Discharge Date: [**2173-8-23**] Date of Birth: [**2131-12-9**] Sex: M Service: [**Hospital1 **] CHIEF COMPLAINT: Mental status change. HISTORY OF PRESENT ILLNESS: This is a 41 year old male with a history of alcohol abuse and recent decreased alcohol intake, who presented on [**8-17**] with a questionable history of a seizure. The last ten days, the patient's wife noted that the patient had only taken in two to ten beers a day, down from his normal of 18 to 24 beers a day. The day prior to admission, she witnessed only one beer. In addition, on the day of admission, the patient's wife heard a thud and found the husband thrashing on the floor. It was unclear whether this was tonic/clonic seizure. This continued for about 15 minutes until EMS arrived and gave intravenous Ativan. In the Emergency Department at an outside hospital, the patient received Haldol and Ativan for agitation and was oriented only to himself and described a loss of vision. He was diaphoretic and had blood pressures of systolic 120 to 130 and a heart rates of 100 to 130. Out there, he had a hematocrit that was measured at 25 and LDH was greater than [**2170**]. He was intubated and sedated for transfer to [**Hospital1 1444**] via Life Flight and a cervical collar was also applied for travel. During that flight, the patient received Fentanyl, Etomidate, Apifloxemide, Vecuronium and Versed as well as Ativan. In the [**Hospital1 69**] Emergency Department, the patient's head CT scan was negative and a chest x-ray was negative for acute cardiopulmonary process and 12 mgs of Ativan were given intravenously. Of note, the patient did say that he had had shakes in the past due to alcohol, but no seizures. Also of note, the patient repeatedly said, "I'm sorry" and seemed to recoil from imaginary things in the room during this episode on the day of admission. There was also a question of a right facial droop. The patient was able to talk during this episode and was quite agitated. PAST MEDICAL HISTORY: 1. History of alcohol abuse. 2. Low back pain. 3. Chronic anxiety. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Naprosyn. 2. Ephedrine. 3. Xanax. 4. Percocet. 5. Viagra. SOCIAL HISTORY: One to two packs per day of tobacco and alcohol 24 beers a day. The patient owns a large business of restaurants and has increased stress in his job recently. FAMILY HISTORY: Coronary artery disease and diabetes mellitus. PHYSICAL EXAMINATION: Upon presentation, temperature 99.4 F.; pulse 106; blood pressure 103/71; respirations 25 and the patient was intubated at 100% FIMV of blood pressure support. In general, the patient was intubated and sedated with an abrasion over his left eye. The pupils were 1 mm bilaterally and not reactive. There were moist mucous membranes and they were pale. On HEENT examination also, there was cervical spine collar. Lungs were coarse throughout. The cardiovascular examination was notable for tachycardia but a regular rhythm, with normal S1 and S2. The abdomen was benign with 3 cm hepatomegaly. Guaiac was negative. Extremities showed no cyanosis, clubbing or edema and two plus dorsalis pedis and posterior tibial pulses. Dermatologic examination revealed no rashes or petechiae. Neurologic examination revealed a person who is agitated, moving all four extremities with brisk deep tendon reflexes throughout. LABORATORY: Upon presentation, white blood cell count was 5.2, hematocrit was 21.8, platelet count was 151. Sodium was 122, potassium 4.1, chloride 89, bicarbonate 23, BUN 28, creatinine 1.1, magnesium of 2.8. Liver function tests were normal as well as cardiac enzymes. A urine toxicology was positive for benzodiazepines and opiates. Serum toxicology was negative. Peripheral smear revealed negative schistocytes, negative intracytoplasmic inclusions and positive polychromasia. A cervical spine x-ray was negative for fracture. Chest x-ray was negative for pneumonia or effusions. A head CT scan again was negative for hemorrhage, masses or ischemic changes. An EKG was done which revealed sinus tachycardia at 105, with a slightly increased PR interval at 0.24 seconds with a normal axis, left atrial abnormality and peaked T waves. There were some diffuse ST elevations, likely J-point elevation in lead I, II, AVL, V3, V4, V5 and V6. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit and was intubated for his decreased mental status. By systems: 1. Neurologic: The patient had agitation, hallucinations and delirium and Neurologic was consulted to help as to the etiology of the mental status change. It was felt that the patient might have been undergoing seizure activity due to alcohol withdrawal or acute alcohol delirium. The patient's sodium was noted to be low and he was treated and later became normonatremic. In addition, a lumbar puncture was done and was clear and colorless revealing only a protein of 31, a glucose of 66, one white cell and zero red cells, with 7% polys, 87% lymphs and 6% monos. The patient was checked for babesiosis on peripheral smear and was found to have babesiosis, and the mental status was attributed to either alcohol withdrawal and babesiosis contributing to it, or just alcohol withdrawal. The mental status started to improve on day three. When it was felt that he could be extubated, he was extubated and tolerated it well. The patient remained moderately sedated but was alert and oriented times three, reporting some pain in both of his arms. On neurological examination, it was noted that he did have a right sided facial droop thought to be possibly Bell's Palsy or a new onset event. However, he continued to be agitated and was kept on Ativan for ethanol withdrawal. On day four of his hospitalization, he was transferred to [**Hospital1 139**] Medicine when it was felt that his mental status had improved and he was able to ambulate and tolerate p.o. 2. Infectious Disease: The patient was treated for babesiosis with Atovaquone and Azithromycin starting on day one of his admission. He was also started on Doxycycline for concern of Lyme but was discontinued when that test returned negative. In addition, he had an HIV test which turned out to be negative during his hospital course. Infectious Disease was consulted and recommended at least a ten day course of Atovaquone and erythromycin. Ehrlichieae was sent out but was still pending as of this dictation. The patient continued to do well on the Atovaquone and the Azithromycin and was told to follow-up with Infectious Disease in Clinic one week post discharge for all final laboratory results. 3. Hematologic: The patient had a drop in hematocrit with decreased haptoglobin and increased LDH, indicating hemolysis from babesiosis. However, it was somewhat puzzling why the patient had such a significant hemolysis without much parasite burden noted to be only 0.1% on the peripheral smear. The patient had a Hematology consultation and they recommended transfusion for red blood cells to support his low hematocrit which had dropped as low as 18 on the day of admission. After three blood transfusions, by the fourth hospital day, the patient's hematocrit was rebounding on its own. 4. Renal: The patient had some slight renal insufficiency with a prerenal component with a BUN and creatinine ratio of greater than 20 and a FEna of less than 1%. The patient did have blood in his urine and myoglobinuria was considered. The patient was continued on intravenous fluid hydration and the creatinine slowly corrected to his baseline. Upon discharge, his creatinine was 0.5 with a BUN of 5.0. A creatinine kinase was checked and was as high as 1797, however, this was a decrease from 3,990 on the day prior to discharge. This attempted to support an episode of rhabdomyolysis status post shaking on the day of admission. 5. Pulmonary: The patient was intubated and sedated for agitation and decreased mental status for airway protection and post-extubation did well and oxygenated well on room air. 6. Cardiovascular: The patient was tachycardic during his hospital course and this was thought to be secondary to anemia, anxiety as well as alcohol withdrawal. The patient was asymptomatic with this tachycardia and upon the day of discharge, his heart rate was approximately 84. 7. Fluids, Electrolytes: The patient's sodium, as I mentioned, had corrected from 122 to 135 over the course of seven hospital days. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Babesiosis. 2. History of alcohol abuse and apparent alcohol withdrawal while on this admission. 3. Transient renal failure secondary to prerenal causes. 4. Low back pain. 5. Anxiety. DISCHARGE MEDICATIONS: 1. Atovaquone 750 mg p.o. twice a day. 2. Azithromycin 600 mg p.o. q. day. 3. Ativan. 4. Ibuprofen. DISCHARGE INSTRUCTIONS: 1. The patient is to follow-up in Infectious Disease Clinic one week post discharge and the patient was to make this appointment on his own. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2400**], M.D. [**MD Number(1) 2401**] Dictated By:[**Name8 (MD) 4064**] MEDQUIST36 D: [**2173-8-25**] 17:12 T: [**2173-8-31**] 14:46 JOB#: [**Job Number 44400**]

[ "088.82", "728.89", "584.9", "305.50", "276.1", "283.9", "291.81", "303.90", "276.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "03.31", "96.71" ]

icd9pcs

[ [ [] ] ]

2455, 2503

8635, 8828

8851, 8956

4411, 8562

8980, 9417

2526, 4393

8578, 8614

168, 191

220, 2048

2070, 2260

2277, 2438

6,524

148,282

51374

Discharge summary

report

Admission Date: [**2146-12-26**] Discharge Date: [**2147-1-17**] Date of Birth: [**2083-4-17**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1283**] Chief Complaint: Increasing Angina Major Surgical or Invasive Procedure: [**2147-1-3**] redo CABG x3/ ASD closure (LIMA to LAD, SVG to DIAG, SVG to OM) History of Present Illness: EVENTS / HISTORY OF PRESENTING ILLNESS: Mr. [**Known lastname **] is a 63 y/o M w/ h/o CAD s/p IMI and CABG x3 (in [**2120**]: SVG to LAD and LCx, SVG to RCA), hypertension, hyperlipidemia, and PAF who p/w increasing anginal symptoms over 2 months. He has been generally pain-free since his original CABG, although did have a brief period with anginal symptoms 7 months after his surgery; this was treated medically. This fall, he began noticing anginal pain occuring with less activity than before, associated with greater DOE. Since that time, the frequency and severity of these symptoms have been increasing with less activity, to the point now that just getting into bed will leave him SOB and walking on level ground gives him anginal pain (substernal, non-radiating, no nausea or diaphoresis, resolving with rest). Given his relatively high risk score (TIMI 3), he was admitted for cardiac catheterization. . His cath revealed severe diffuse 3 vessel disease (see below for details) and he is therefore awaiting revision of his CABG, expected to be [**2147-1-3**]. . Past Medical History: PAST MEDICAL HISTORY: 1. CAD s/p IMI in [**2119**], s/p CABG x3 in [**2120**]: SVG to RCA, SVG to LAD, SVG to LCx 2. Hyperlipidemia 3. Hypertension 4. Paroxysmal atrial fibrillation 5. Chronic Renal Insufficiency, baseline Cr 1.3-1.5 6. R tendon injury s/p surgical repair 7. Gout 8. GERD 9. s/p Cholecystectomy [**2134**] 10. s/p Tonsillectomy . Cardiac Risk Factors: Dyslipidemia, Hypertension . Cardiac History: CABG, in [**2120**] anatomy as follows: SVG to LAD, SVG to OM1, SVG to RCA. . Percutaneous coronary intervention has not been previously performed. . Pacemaker/ICD has not been placed. . Social History: SOCIAL and FAMILY HISTORY: . Social history is significant for the absence of current tobacco use. He consumes [**1-21**] alcoholic beverages per night. Married with 3 children; works in electronics sales. Family History: There is no family history of premature coronary artery disease or sudden death. His father had an MI at age 67 and died at age 84. Mother had an MI in her 80s. Physical Exam: PHYSICAL EXAMINATION: . BP 94/60; HR 48-64 (reg) RR 18; Temp 97.8; O2Sat 94%RA . Gen: well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. HEEN: no xanthalesma, conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: supple, JVP of 4 cm. The carotid waveform was normal. There was no thyromegaly. Chest: no chest wall deformities, scoliosis or kyphosis. Pulm: respirations were not labored and there were no use of accessory muscles. CTAB, normal BS and no adventitial sounds or rubs. Cor: PMI located in the 5th intercostal space, mid clavicular line. no thrills, lifts or palpable S3 or S4. normal S1S2, no rubs, murmurs, clicks or gallops. Abd: abdominal aorta was not enlarged by palpation, no hepatosplenomegaly, NT, soft, ND Ext: no pallor, cyanosis, clubbing or edema. Skin: no stasis dermatitis, ulcers, scars, or xanthomas. Pulses: no abdominal, femoral or carotid bruits. Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ . Brief Hospital Course: EKG on [**2146-12-29**] demonstrated Sinus rhythm with nl axis, prolonged PR, prolonged QTc, prolonged QRS; RBBB, no ST-T changes; with no significant change compared with prior dated [**2146-12-27**]. . 2D-ECHOCARDIOGRAM performed on [**2146-12-27**] demonstrated: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction. Although technical quality was limited, there appears to be severe hypokinesis of the anterior wall. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve 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: Regional left ventricular systolic dysfunction (EF 40%)consistent with coronary artery disease. Mild mitral regurgitation. Borderline elevated pulmonary artery pressures. . CARDIAC CATH performed on [**2146-12-27**] demonstrated: 1. Selective coronary angiography of this right dominant system demonstrated severe diffuse three vessel CAD. The LMCA had 20% luminal stenosis. The LAD was occluded from mid-vessel forward after giving several large diagonal branches. The RCA was occluded proximally. The LCX had 70% proximal stenosis and the OM1 had 90% stenosis. 2. Selective arterial conduit angiography revealed the SVGs to OM and to RCA were occluded at origin. The SVG to LAD had an ulcerated lesion causing 90% stenosis 3. Limited resting hemodynamic assessment revealed normal systemic BP (105/52 mmHg) and mildly elevated left heart filling pressure (LVEDP 15 mmHg) 4. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Severe diffuse three vessel coronary artery disease with occlusion of two SVGs and severe ulcerated lesion at the SVG supplying the LAD with occluded distal LAD. 2. Mild diastolic ventricular dysfunction. 3. Consult cardiac surgery. . OTHER TESTING: - CXR: No evidence of acute cardiopulmonary process or significant change from prior. - Carotid U/S: Minimal plaque with bilateral less than 40% carotid stenosis. . Admitted [**12-27**] and cath and studies done with results above. Surgery delayed for plavix washout after he was given 600 mg [**12-27**]. Underwent redo cabg x3 and ASD closure on [**1-3**] with Dr. [**Last Name (STitle) 1290**]. Transferred to the CSRU in stable condition on phenylephrine and propofol drips. Extubated on the morning of POD #1. Reverted back to his chronic Afib on POD #2 and amiodarone started, and then changed to norpace for improved rate control.Heparin also started and vasoactive drips weaned. Continuing hypoxemia ultimately resulted in bronchoscopy on [**1-10**] which revealed bronchitis.Diuresis continued and coumadin started on [**1-11**].Remained in the CSRU for aggressive pulm. toilet and transferred to the floor on POD #12. Respiratory status continued to improve however he continued to require 2L of oxygen to remain above 90% saturated, so home oxygen therapy was planned, and he was ready for discharge on POD #14. Medications on Admission: CURRENT MEDICATIONS AT HOME: Norpace 200 mg po tid Cartia XT 240 mg daily Diovan 160 mg daily Dyazide 37.5/25 mg daily Atenolol 12.5 mg daily Aspirin 325 mg daily Ranitidine 150 mg [**Hospital1 **] Allopurinol 100 mg [**Hospital1 **] MVI Vitamin C 250 mg daily B-50 Nasonex 2 sprays NU [**Hospital1 **] Astelin 2 sprays NU daily Fish Oil 1700 mg [**Hospital1 **] . MEDICATIONS ON TRANSFER: Fluticasone Propionate Nasal 1 SPRY NU [**Hospital1 **] Heparin IV Sliding Scale Acetaminophen 650 mg PO Q4H:PRN fever, pain Multivitamins 1 CAP PO DAILY Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO QID:PRN indigestion Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Allopurinol 100 mg PO BID Oxycodone-Acetaminophen [**12-20**] TAB PO Q4-6H:PRN Aspirin 325 mg PO DAILY Oxazepam 10-20 mg PO Q8H:PRN anxiety, insomnia Ascorbic Acid 250 mg PO DAILY Potassium Chloride PO Sliding Scale Astelin *NF* 137 mcg NU qd Ranitidine 150 mg PO BID Atenolol 12.5 mg PO DAILY Simethicone 40-80 mg PO QID:PRN abdominal discomfort Atropine Sulfate 0.5 mg IV X1:PRN symptomatic bradycardia & hypotension Triamterene-Hydrochlorothiazide 1 CAP PO DAILY Disopyramide Phosphate 200 mg PO Q8H Valsartan 160 mg PO DAILY Fish Oil (Omega 3) 1000 mg PO BID Zolpidem Tartrate 5-10 mg PO HS:PRN . Discharge Medications: 1. Oxygen 2L/min continuous For portability pulse dose system 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(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. Disopyramide 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*180 Capsule(s)* Refills:*0* 5. 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* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1 weeks. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 11. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day: Check INR [**1-19**] with results to Dr. [**Last Name (STitle) **]. Disp:*90 Tablet(s)* Refills:*0* 12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-20**] Puffs Inhalation Q4H (every 4 hours). Disp:*QS 1 month* Refills:*0* 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*QS 1 month* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: redo cabg x3/ASD closure elev. lipids borderline HTN cabg x3 [**1-/2121**] P Afib CRI gout right elbow surgery GERD tonsillectomy cholecystectomy Discharge Condition: stable Discharge Instructions: no lotions, creams, or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 101, redness, or drainage Followup Instructions: IP follow in [**3-24**] weeks call for appt Dr. [**Last Name (STitle) **] in [**1-21**] weeks Dr. [**Last Name (STitle) 14069**] in [**12-20**] weeks Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**] Completed by:[**2147-1-17**]

[ "466.0", "427.31", "401.9", "414.01", "530.81", "E888.9", "799.02", "411.1", "585.9", "272.4", "745.5", "512.1", "412", "414.02", "458.9", "274.0" ]

icd9cm

[ [ [] ] ]

[ "36.12", "93.90", "88.57", "39.61", "33.24", "99.07", "36.15", "35.71", "99.04", "37.22", "88.72", "88.56" ]

icd9pcs

[ [ [] ] ]

9861, 9912

3643, 5491

307, 387

10102, 10111

10333, 10588

2358, 2521

8198, 9838

9933, 10081

6911, 6919

5508, 6885

10135, 10310

6940, 7276

2536, 2536

2558, 3620

249, 269

415, 1492

7301, 8175

1536, 2118

2134, 2145

22,423

142,408

19918

Discharge summary

report

Admission Date: [**2198-5-4**] Discharge Date: [**2198-5-10**] Date of Birth: [**2127-8-8**] Sex: M Service: MEDICINE Allergies: Lipitor / Ciprofloxacin / Trimethoprim / Bactrim / Atenolol / Crestor / Zetia / Vicodin / Cephalexin / Amlodipine / Quinapril / Spironolactone Attending:[**First Name3 (LF) 1515**] Chief Complaint: left leg pain Major Surgical or Invasive Procedure: Dual chamber pacemaker placement Cardiac catheterization with bare metal stent to OM1 Left superficial Femoral Artery- posterior tibial bypass History of Present Illness: This 70-year-old gentleman with history of abdominal aortic aneurysm who presents with noninvasive arterial studies had suggested popliteal artery disease on the left. The patient underwent an arteriogram on [**2198-4-24**] that demonstrated left profunda femoris artery and superficial femoral artery with diffuse disease but patent. The left below-knee popliteal artery was occluded all the way to the tibial bifurcation at which point it reconstituted and gave rise to patent posterior tibial artery and peroneal. The post tibial artery was patent all the way to the ankle as was the peroneal which gave rise to smaller anterior and posterior collateral branches. Given these findings, it was recommended that the patient have a bypass around his occlusion in the below-knee popliteal artery on the left and it was discussed with him that the most appropriate way to perform this would be with arm vein from his right upper extremity. Past Medical History: Allergies:Cipro, Trimeth/Sulfa, Atenolol, Crestor, Zetia, Vicodin, hydrchlorthiazide, Cephalexin, Amlodipine, Spironolactone, QuinaprilPMH:CAD, HTN, hypercholesterolemia, h/o smoking (150 pk yrs), gout, kidney stones, GERD PSH: CABG x3'[**92**], Left CEA ([**1-8**]), L testicular surgery '[**96**], umbilical hernia repair [**4-11**] Social History: Social history: h/o 15 pk y smoking quit 20 y.ago, live with wife Family History: non-contributory Physical Exam: General Appearance: Well nourished, No acute distress, Overweight / Obese Eyes / Conjunctiva: PERRL, No(t) Sclera edema Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3, No(t) S4 Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : bases, Wheezes : expiratory) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent Musculoskeletal: No(t) Muscle wasting Skin: Warm, No(t) Rash: , No(t) Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Movement: Not assessed, Sedated, Tone: Not assessed Pertinent Results: ADMISSION LABS: [**2198-5-5**] 03:30AM BLOOD WBC-10.9 RBC-4.91# Hgb-13.5* Hct-40.9 MCV-83 MCH-27.5 MCHC-33.1 RDW-15.9* Plt Ct-195 [**2198-5-4**] 11:04AM BLOOD PT-14.0* PTT-61.8* INR(PT)-1.2* [**2198-5-4**] 11:04AM BLOOD Glucose-120* UreaN-17 Creat-1.5* Na-139 K-4.2 Cl-106 HCO3-25 AnGap-12 [**2198-5-4**] 11:04AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.5 [**2198-5-5**] 02:12PM BLOOD Triglyc-154* HDL-44 CHOL/HD-6.2 LDLcalc-197* [**2198-5-5**] 03:30AM BLOOD ALT-20 AST-126* CK(CPK)-1192* AlkPhos-103 TotBili-0.9 . CARDIAC ENZYMES: [**2198-5-4**] 11:04AM BLOOD CK-MB-3 cTropnT-<0.01 [**2198-5-5**] 03:30AM BLOOD CK-MB-219* MB Indx-18.4* cTropnT-0.82* [**2198-5-6**] 03:43AM BLOOD CK-MB-246* MB Indx-19.4* [**2198-5-6**] 05:40PM BLOOD CK-MB-62* MB Indx-11.6* [**2198-5-5**] 03:30AM BLOOD CK(CPK)-1192* [**2198-5-6**] 03:43AM BLOOD CK(CPK)-1266* [**2198-5-6**] 05:40PM BLOOD CK(CPK)-534* . Cardiac catheterization: [**2198-5-5**] - Coronary Angiography - right dominant LMCA: subtotally occluded LAD: proximally occluded; distal vessel fills via LIMA LCX: diffuse proximal/mid disease; SVG to major OM seen to be occluded RCA: not injected; known severely diffusely diseased SVG-OM: proximally occluded with acute appearance of thrombus LIMA-LAD: normal SVG-RPDA: mild disease . SVG-OM - dilated and stented with overlapping 4.5x28 and 5.0x18 Ultra stents with no residual, normal flow. . ECHOCARDIOGRAM: [**2198-5-5**] The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with infero-lateral akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2198-1-6**], there is new regional LV systolic dysfunction. . Brief Hospital Course: Mr. [**Known lastname 53751**] is a 70 yo man with CAD s/p CABG in [**2192**], diastolic CHF, severe PVD who was admitted to [**Hospital1 18**] for his elective fem-[**Doctor Last Name **] bypass. He was taken to the OR and he tolerated his procedure well. He recovered in the PACU without acute events and was transferred back to the vascular floor in stable condition. However, in the early morning on POD 1 the patient developed nausea/vomiting, and eventually chest pain and hypoxia and was found to have a post-operative STEMI & CHF. . # Posterior STEMI/CAD: The patient developed ACS from acute occlusion of SVG graft. Two Ultra bare metal stents place in SVG-OM. ECHO with EF 40-45%, with new inferior/lateral akinesis, no significant valve disease. The patient developed stuttering CP since cath with no evidence of new ischemia, Imdur increased from home dose. CPK peaked at 2754 and trended down. Aspirin was increased from 162mg daily to 325mg daily and he was started on Plavix. Omeprazole was changed to ranitidine daily for GERD [**2-5**] interaction with Plavix. Pt should have cardiac rehab as recommended by his outpatient cardiologist. . # Acute on chronic Systolic Congestive heart Failure: Currently seems euvolemic with no O2 requirement, able to lie flat. EF [**Month (only) **] to 40-45%. Pt has acute renal failure with ACE and [**Last Name (un) **] per pt's wife, was on Hydralazine TID at home which was restarted prior to discharge. Furosemide at home dose was restarted at discharge. . # Hypertension - Pt was largely normotensive. His BP were well controlled on metoprolol and Imdur. . # Sick Sinus syndrome: The patient developed prolonged (5 sec) symptomatic pauses s/p MI. EP was consulted and they recommended that the patient get a pacemaker. He received a Metronic Dual chamber pacemaker on [**2198-5-9**] without complication. Metoprolol was restarted at his previous dose after pacer. The patient was advised on routine post pacer activity restrictions. . # PVD s/p bypass - [**2198-5-4**] L SFA-PT (R cephalic) Groin intact with no ecchymosis. Right arm and left leg sutures with no evidence of infections, drainage or pain. Pt will see Vascular surgery in the next 2 weeks. Per surgery, no dressing is necessary and walking is encouraged. . # Hypercholesterolemia - [**Year/Month/Day **] panel showed LDL 197, TG 152. Pt has allergies to all statin with myalgias, weakness being primary side effect. Pt also has been on Wellchol and Niaspan but has not tol these medicines. Pt was referred to [**Year/Month/Day 2200**] clinic here. He is currently tolerating Simvastatin 80 mg and has agreed to continue this at home for now but will d/c if his previous myalgia symptoms return. Dr. [**Last Name (STitle) **] was updated regarding this situation. . # Acute on Chronic Kidney Disease - Patient had a mild elevated in his creatinin to 1.7 s/p cath but quickly improved to baseline of Cr 1.5. . # Obstructive Sleep Apnea - has home CPAP machine with him and using at night. . # Delerium: The patient initially had some post-op delerium on arrival CCU. His mental status cleared slowly during his hospitalization. At discharge, pt is A/O x3 but has difficulty word finding and short term memory is mildly impaired. Sedating meds and anti-cholinergics were held. Expect slow improvement over the next 1-2 months. . # Code - Full Code Medications on Admission: Isosorbide monontirate 30mg [**Hospital1 **], Omeprazole 20mg [**Hospital1 **], Allopurinol 100mg daily, Aspirin 81mg 2 tablets daily, Magnesium Oxide 400mg [**Hospital1 **], Metoprolol succinate 50mg ?????? tablet [**Hospital1 **], Hydralazine 10mg TID, Furosemide 20mg [**Hospital1 **], Potassium 20meq daily, Study medication ? from Dr. [**Last Name (STitle) **] for Tra2P TIMI 50 Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain. 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual ONCE MR2 (Once and may repeat 2 times) as needed for chest pain: Please call 911 if you continue to have chest pain after 3 nitroglycerin tablets. . 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2* 8. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 2 days. Disp:*16 Capsule(s)* Refills:*0* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO three times a day. 11. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO once a day. 14. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Diversified VNA and hospice Discharge Diagnosis: Posterior ST Elevation Myocardial Infarction Sick sinus Syndrome Coronary Artery Disease Peripheral Vascular Disease Discharge Condition: stable. Discharge Instructions: You had vascular surgery to help the circulation in your left leg. After that surgery you had a heart attack and a cardiac catheterization where a bare metal stent was placed in one of your heart arteries. You had some fluid in your lungs that responded well to fluid medicines. While your heart rhythm was being monitored, it was found there were skipped beats so a pacemaker was inserted. Activity restrictions: You cannot lift your left arm over your head or carry more than 5 pounds for 6 weeks. Keep the pacer dressing dry and clean. No showers or baths for one week until after you are seen in the device clinic. You need to take antibiotics for a few days to prevent infection at the pacer site. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet . New medicines: 1. Clindamycin: antibiotic to be used for 2 days to prevent infections at the pacer site. 2. Ranitidine 150 mg twice daily: to take instead of omeprazole 3. STOP taking omeprazole 4. Clopodigrel: to keep the stent from clotting off, do not miss any doses or discontinue this medicine unless Dr. [**Last Name (STitle) **] tells you to. . VASCULAR SURGERY D/C INSTRUCTIONS 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 [**2-6**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Primary Care: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 20587**] Date/Time: Please make an appt to be seen in 1 month. . Vascular Surgery: Dr. [**Last Name (STitle) 1391**] Phone: ([**Telephone/Fax (1) 4852**] Date/time: [**5-18**] at 10:10am at [**Hospital3 **] . Cardiology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 16827**] Date/time: Monday [**5-14**] at 3:20pm. . [**Hospital **] Clinic: Dr. [**Last Name (STitle) 2201**] Date/time: [**6-22**] at 1:00pm. [**Hospital Ward Name 23**] Clinical Center [**Location (un) 436**], [**Hospital Ward Name 516**], [**Hospital1 18**], [**Location (un) **], [**Location (un) 86**] Provider: [**Name10 (NameIs) **] NUTRITIONIST Phone:[**Telephone/Fax (1) 2207**] Date/Time:[**2198-6-22**] 2:00 . DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2198-5-17**] 11:30 [**Hospital Ward Name 23**] Clinical center, [**Location (un) 436**]. Completed by:[**2198-5-12**]

[ "996.72", "410.61", "274.9", "585.9", "403.90", "427.81", "530.81", "584.9", "272.0", "327.23", "414.01", "997.1", "E878.2", "428.0", "428.43", "440.21", "442.3" ]

icd9cm

[ [ [] ] ]

[ "00.46", "88.52", "39.29", "00.40", "00.66", "37.83", "99.20", "36.06", "88.55", "37.72", "37.22" ]

icd9pcs

[ [ [] ] ]

10619, 10677

5234, 8614

415, 560

10838, 10848

2814, 2814

14915, 15946

1987, 2005

9048, 10596

10698, 10817

8640, 9025

10872, 14482

14508, 14892

2020, 2795

3337, 5211

362, 377

588, 1527

2830, 3320

1549, 1887

1919, 1971

60,778

182,747

42245+58508

Discharge summary

report+addendum

Admission Date: [**2154-4-23**] Discharge Date: [**2154-5-10**] Date of Birth: [**2099-4-1**] Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3645**] Chief Complaint: back pain Major Surgical or Invasive Procedure: L4-5 laminectomy and posterior spinal fusion History of Present Illness: 55F with persistent lower back pain. She has significant stenosis at L3-4 and L4-5 with degenerative listhesis at L4-5. The risks and benefits of a posterior L4 laminectomy with a posterior spinal fusion at L4-5 were discussed with her in detail. After informed choice, she was to proceed with surgical intervention. Past Medical History: hep c liver cirrohosis, esophageal varices, HTN, s/p chole, s/p hysterectomy, s/p appy Social History: NC Family History: NC Physical Exam: AVSS Well appearing, NAD, comfortable BUE: SILT C5-T1 dermatomal distributions BUE: [**6-1**] [**Doctor First Name **]/Tri/Bic/WE/WF/FF/IO BUE: tone normal, negative [**Doctor Last Name 937**], 2+ symmetric DTR bic/bra/tri All fingers WWP, brisk capillary refill, 2+ distal pulses BLE: decreased sensation in L5 distr. Otherwise SILT L1-S1 dermatomal distributions BLE: [**6-1**] IP/Qu/HS/TA/GS/[**Last Name (un) 938**]/FHL/Per BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle All toes WWP, brisk capillary refill, 2+ distal pulses Pertinent Results: [**2154-4-23**] 06:57PM PT-15.8* PTT-36.5 INR(PT)-1.5* [**2154-4-23**] 06:09PM GLUCOSE-121* UREA N-12 CREAT-0.6 SODIUM-141 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13 [**2154-4-23**] 06:09PM CALCIUM-8.0* PHOSPHATE-4.9* MAGNESIUM-1.7 [**2154-4-23**] 06:09PM WBC-9.1 RBC-3.60* HGB-9.7* HCT-31.4* MCV-87 MCH-26.9* MCHC-30.8* RDW-18.5* [**2154-4-23**] 06:09PM PLT COUNT-227 [**2154-4-23**] 12:00PM UREA N-11 CREAT-0.7 SODIUM-139 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12 [**2154-4-23**] 12:00PM estGFR-Using this [**2154-4-23**] 12:00PM ALBUMIN-3.4* [**2154-4-24**] 05:30AM BLOOD WBC-7.4 RBC-3.01* Hgb-8.2* Hct-26.8* MCV-89 MCH-27.1 MCHC-30.5* RDW-18.2* Plt Ct-186 [**2154-4-24**] 05:30AM BLOOD Glucose-94 UreaN-12 Creat-0.6 Na-140 K-3.9 Cl-107 HCO3-29 AnGap-8 [**2154-4-25**] 05:34AM BLOOD WBC-10.1 RBC-2.93* Hgb-7.8* Hct-26.3* MCV-90 MCH-26.7* MCHC-29.8* RDW-18.1* Plt Ct-181 [**2154-4-25**] 02:57PM BLOOD Hct-23.1* [**2154-4-25**] 06:11PM BLOOD Hct-28.3* [**2154-4-25**] 11:29PM BLOOD Hct-31.0* [**2154-4-25**] 05:34AM BLOOD Glucose-99 UreaN-9 Creat-0.6 Na-140 K-3.7 Cl-108 HCO3-26 AnGap-10 [**2154-4-26**] 05:24AM BLOOD WBC-11.6* RBC-3.40* Hgb-9.4* Hct-30.1* MCV-89 MCH-27.8 MCHC-31.4 RDW-18.0* Plt Ct-179 [**2154-4-26**] 01:15PM BLOOD Hct-31.0* [**2154-4-26**] 05:24AM BLOOD Glucose-106* UreaN-8 Creat-0.4 Na-137 K-3.8 Cl-105 HCO3-26 AnGap-10 Brief Hospital Course: Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. An IJ central line was placed in OR given poor IV access. Line discontinued day of discharge without incident. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Pain was not immediately well controlled. Pain consult was obtained. She was switched from oxycodone to dilaudid with good effect. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#3. Patient was transfused with 3 units of PRBC for blood loss anemia. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: Nadolol 20 mg PO DAILY, Amlodipine 2.5 mg PO/NG DAILY, Sertraline 100 mg PO/NG DAILY, Hydrochlorothiazide 25 mg PO/NG DAILY, Spironolactone 50 mg PO/NG DAILY, Gabapentin 600 mg PO/NG Q8H, Lactulose 45 mL PO/NG DAILY:PRN constipation Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while on narcotics. Disp:*60 Capsule(s)* Refills:*2* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO DAILY (Daily) as needed for constipation. 5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 6. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for spasms. Disp:*60 Tablet(s)* Refills:*0* 13. Dilaudid 2 mg Tablet Sig: 1-3 Tablets PO every 4-6 hours as needed for pain: no driving. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Guardian [**Name (NI) **] - [**Name (NI) 1474**] Discharge Diagnosis: lumbar spondylosis and listhesis Discharge Condition: good Discharge Instructions: You have undergone the following operation: Lumbar Decompression With Fusion Immediately after the operation: ?????? Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. ?????? Rehabilitation/ Physical Therapy: ◦ 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. ◦ Limit any kind of lifting. ?????? Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. ?????? Brace: You may have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. ?????? Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. ?????? You should resume taking your normal home medications. ?????? You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. ?????? Follow up: ◦ Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. ◦ At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. ◦ We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: OOB without restriction, no brace Treatments Frequency: dress wound only if draining. staples out 2 weeks from surgery at follow up visit. Followup Instructions: Provider: [**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 8603**] Date/Time:[**2154-5-10**] 11:30 Name: [**Known lastname 5405**],[**Known firstname **] Unit No: [**Numeric Identifier 14415**] Admission Date: [**2154-4-23**] Discharge Date: [**2154-5-10**] Date of Birth: [**2099-4-1**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 11437**] Chief Complaint: Laminectomy/spinal fusision Major Surgical or Invasive Procedure: L4-5 laminectomy and posterior spinal fusion Intubation Bronchoscopy History of Present Illness: 55 year-old woman with persistent lower back pain. She has significant stenosis at L3-4 and L4-5 with degenerative listhesis at L4-5. The risks and benefits of a posterior L4 laminectomy with a posterior spinal fusion at L4-5 were discussed with her in detail. After informed choice, she was to proceed with surgical intervention. Past Medical History: - Hepatitis C liver cirrhosis - Esophageal varices - Hypertension - S/p cholecystectomy - S/p hysterectomy - S/p appendectomy Physical Exam: At admission: AVSS Well appearing, NAD, comfortable BUE: SILT C5-T1 dermatomal distributions BUE: [**6-1**] [**Doctor First Name **]/Tri/Bic/WE/WF/FF/IO BUE: tone normal, negative [**Doctor Last Name 14416**], 2+ symmetric DTR bic/bra/tri All fingers WWP, brisk capillary refill, 2+ distal pulses BLE: decreased sensation in L5 distr. Otherwise SILT L1-S1 dermatomal distributions BLE: [**6-1**] IP/Qu/HS/TA/GS/[**Last Name (un) **]/FHL/Per BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle All toes WWP, brisk capillary refill, 2+ distal pulses At discharge: VS: T 99.2, BP 102/50, HR 57, RR 18, O2 95% on 1 liter O2 GENERAL: NAD, breathing comfortably CV: RRR CHEST: Good breath sounds throughout, mild crackles at the bases, no rhonchi or wheezing ABDOMEN: soft, nontender, nondistended NEURO: Alert, oriented x3, attentive PSYCH: Calm, appropriate Pertinent Results: ECHO [**4-30**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. CT CHEST [**5-3**]: AIRWAYS AND LUNGS: The tip of endotracheal tube extends to the carina, almost encroaching into the right main bronchus. Consider retracting the endotracheal tube by 3.5 cm for better seating. Bilateral, extensive ground-glass and reticular opacities are present with some geographically spared areas. In addition, foci of predominantly dependent consolidation are present, mostly in the left lower lobe. Bilateral pleural effusions are minimal. MEDIASTINUM: Few borderline sized lymph nodes measuring up to 11 mm are present in the lower paratracheal, precarinal, and subcarinal regions. No pathologically enlarged supraclavicular or axillary lymph nodes. The main pulmonary artery before bifurcation measures up to 34 mm, suggestive of mild pulmonary artery hypertension. Atherosclerotic calcification involving coronary arteries is severe, distributed along the left anterior descending and circumflex coronary arteries. Low density cardiac contents suggest anemia. The heart is normal size and there is no pericardial abnormality. Left-sided PICC line ends at the level of cavoatrial junction. ABDOMEN: This study is not designed for assessment of subdiaphragmatic pathologies; however, limited views revealed surface irregularity and heterogeneity of the liver, multiple perigastric and perisplenic collateral vessels and mild ascites distributed in the perihepatic region which consistent with cirrhosis and portal hypertension (known cirrhosis per clinical history). Both adrenal glands are normal. BONES: There is no bone lesion concerning for malignancy or infection. IMPRESSION: 1. Bilateral, diffuse, ground-glass and reticular opacities, and dependent foci of consolidation. On concurrently review with prior chest radiograph series through [**4-28**] to [**2154-5-3**], this most likely represents ARDS. Concurrent infection is also possible Differential diagnosis is broad and includes hydrostatic edema and diffuse pulmonary hemorrhage. 2. Tip of the endotracheal tube ends extends to carina, almost encroaching into the right main bronchus. Consider retracting the endotracheal tube by 3.5 cm for better seating. 3. Borderline sized mediastinal lymph nodes. Given the changes in lungs, these are likely reactive. 4. Cirrhosis with portal hypertension. RUQ U/S [**2154-5-5**]: 1. Absent gallbladder. 2. Reversal of directionality (hepatofugal) of portal and splenic veins with xtensive splenorenal shunting in the setting of a cirrhotic liver. 3. Small amount of ascites in the right upper and bilateral lower quadrants. Brief Hospital Course: Patient was admitted to the [**Hospital1 8**] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. An IJ central line was placed in OR given poor IV access. Line discontinued day of discharge without incident. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Pain was not immediately well controlled. Pain consult was obtained. She was switched from oxycodone to dilaudid with good effect. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#3. Patient was transfused with 3 units of PRBC for blood loss anemia. Physical therapy was consulted for mobilization OOB to ambulate. On day of anticipated discharge on [**4-27**], pt was noted to have low grade fevers and hypoxia. A chest XRAY at that point was concerning for pneumonia with pulmonary edema, and she was noted to have a Hafina alvei UTI. She was started empirically on HCAP coverage with vanc/cefepime/azithromycin with the cefepime also covering the UTI per medicine recommendations. She remained on the orthopedic floor but had persistent issues with hypoxia and volume overload. On [**5-1**] she became more short of breath with hypoxia at rest. The medicine consult service recommended further diuresis (received a totoal of 90mg IV lasix over he course of the morning) without good urine output or symptomatic improvement. She was subsequently transferred to the MICU on [**5-1**] for further management. MICU COURSE: # Respiratory Failure: Combination of HCAP and pulmonary edema. Etiology of pulmonary edema not entirely clear, but could be related to her underlying cirrhosis. Echo showed some mild pulmonary hypertension but no other major abnormalities. Chest CT also appeared consistent with ARDS picture. She was started on a lasix gtt on the day of transfer to the MICU with good urine output. However her O2 sats remained low in the 80s. She was started on BiPAP for ventilatory support but her work of breathing persisted and given her diffuse infiltrates on imaging she was intubated on [**5-4**]. She also underwent bedside bronchoscopy in the ICU which was without any obvious abnormality and her BAL was negative. Given her aggressive diuresis on the lasix ggt, she also developed problems with hypotension requiring levophed support and the lasix gtt was stopped on [**5-4**]. She subsequently developed ATN presumed secondary to her hypotensive episodes with Cr peaking at 3.2. Due to the ATN lasix ggt was restarted on [**5-6**] with good diuresis and BPs remained stable. On [**5-8**] she was extubated successfully and lasix ggt was stopped. She was then called back out to the floor on [**5-9**]. She completed an 8 day course of vanc/cefepime for HCAP and 5 day course of azithromycin. The patient remained on the floor without complication. Weaned off O2 and did well. # Renal Failure: Pt with Cr peaking at 3.1. Urine was spun and seemed consistent with ATN in setting of her hypotensive episodes. Urine output improved with diuresis and Cr trended down to 2.6 on discharge # Hypernatremia: To 150. Thoght to be due to overdiuresis and poor PO intake. She was encouraged to take PO after extuabation and this improved. # Hafina alvei UTI: Completed course of cefepime. # Anxiety: On sertraline # Abdominal pain: Unclear etiology but appears to have been going on for a while. U/S showed no source for pain. It remained stable during admission. # EtOH/HCV Cirrhosis: PCP reportedly following cirrhosis which is [**2-28**] ETOH. Had been referred to [**Hospital1 8**] hepatology but has yet to see them. She said her last drink was 2 yrs ago but now reports last drinking on [**4-2**]. Never had EtOH withdrawal seizures or DTs. Has never had a liver biopsy but has had a RUQ U/S, though PCP has no record of this. Pt with some asterixis on exam in MICU. She was maintained on lactulose/rifaximin, and restarted on her home nadolol after BPs stabilized. She will need close liver follow up # Chronic LBP s/p L4-L5 laminectomy with posterior spinal fusion. pain control was with fentanyl during intubation and she was transitioned to PO oxycodone after extubation Transitional issues: - Will need hepatology follow up Medications on Admission: Nadolol 20 mg PO DAILY Amlodipine 2.5 mg PO/NG DAILY Sertraline 100 mg PO/NG DAILY Hydrochlorothiazide 25 mg PO/NG DAILY Spironolactone 50 mg PO/NG DAILY Gabapentin 600 mg PO/NG Q8H Lactulose 45 mL PO/NG DAILY:PRN constipation Discharge Medications: 1. lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO 3 tbsp daily. 2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 3. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. nadolol 20 mg Tablet Sig: Thirty (30) Tablet PO DAILY (Daily). 9. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. 10. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 11. simethicone 125 mg Tablet Sig: One (1) Tablet PO After meals. 12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: [**1-28**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. oxycodone 5 mg Capsule Sig: [**1-28**] Capsules PO every six (6) hours as needed for pain for 7 days. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Guardian [**Name (NI) **] - [**Name (NI) 328**] Discharge Diagnosis: Lumbar spondylosis and listhesis Hopsital-Acquired Pneumonia Acute Respiratory Distress Syndrome Urinary Tract Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 8**]! You were admitted for a spinal surgery which was performed without complication. Your hospital course was complicated by a pneumonia and fluid in your lungs for which you were treated in the intensive care unit. You are now greatly improved and are ready for discharge to a rehabilitaton facility to continue your care. See below for changes made to your home medication regimen: 1) Please STOP Sertraline until instructed otehrwise by your outpatient doctor. This was stopped due to changes on your electrocardiogram. 2) Please START Oxycodone 5-10mg every 6 hours as needed for pain See below for instructions regarding follow-up care: Followup Instructions: Orthopedics: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14417**], [**MD Number(3) 4254**]: [**Telephone/Fax (1) 14418**] Please call to set up an appointment after discharge. Department: Liver Center Building: [**Hospital1 536**] Address: [**Location (un) **]., [**Location (un) 42**], MA Phone: ([**Telephone/Fax (1) 10887**] Notes: The Liver Center is working on a follow up appointment for you in [**10-12**] days after your hospital discharge. You will be notified of the appointment date and time. If you have not heard from the Liver Center in 2 business days please call the office number listed above. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11438**] MD [**MD Number(2) 11439**] Completed by:[**2154-5-10**]

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29821

Discharge summary

report

Admission Date: [**2174-3-24**] Discharge Date: [**2174-4-22**] Date of Birth: [**2105-6-17**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: MVR coil embolization lumbar artery CCY Trach & open G-J tube History of Present Illness: 68 yo man admitted to [**Hospital3 1280**] MC [**3-17**] w/pulm edema and Afib. Started on antibiotics for presumed pneumonia/sepsis. Intubated and started on pressors. A subsequent TEE showed severe MR with a [**Month/Day (4) **] posterior leaflet. He was transferred to [**Hospital1 18**] for cardiac cath and surgical evaluation. Past Medical History: Atrial fibrillation Prostate CA Social History: Lives with wife denies tobacco or ETOH use Family History: noncontributory Physical Exam: Preop VS 99.5 HR 120-140 BP103/79 RR28-vented Gen Intubated/sedated Pulm anterior sounds present bilat CV irreg-irreg/tachycardiac Abdm soft, no BS Ext cool Discharge VS 98.6 HR85SR BP93/44 RR20 O2sat 98% 35%TM Gen NAD Neuro nonfocal Pulm diminished at bases CV RRR, no murmur Abdm soft NT/+BS. G-J tube CDI Ext warm, no edema Pertinent Results: [**2174-3-24**] 10:49PM TYPE-ART PO2-422* PCO2-59* PH-7.20* TOTAL CO2-24 BASE XS--5 [**2174-3-24**] 10:33PM GLUCOSE-157* LACTATE-2.5* [**2174-3-24**] 09:48PM PLEURAL TOT PROT-1.1 GLUCOSE-141 LD(LDH)-105 [**2174-3-24**] 09:48PM PLEURAL WBC-155* RBC-3725* POLYS-38* LYMPHS-29* MONOS-28* MESOTHELI-3* OTHER-2* [**2174-3-24**] 08:46PM GLUCOSE-159* UREA N-24* CREAT-0.9 SODIUM-145 POTASSIUM-4.7 CHLORIDE-113* TOTAL CO2-23 ANION GAP-14 [**2174-3-24**] 08:46PM ALT(SGPT)-81* AST(SGOT)-55* ALK PHOS-44 AMYLASE-86 TOT BILI-0.6 [**2174-3-24**] 08:46PM LIPASE-76* [**2174-3-24**] 08:46PM WBC-22.5* RBC-3.87* HGB-12.3* HCT-37.2* MCV-96 MCH-31.9 MCHC-33.2 RDW-16.5* [**2174-3-24**] 08:46PM PT-18.9* PTT-37.0* INR(PT)-1.8* [**2174-4-22**] 02:05AM BLOOD WBC-19.6* RBC-3.01* Hgb-9.1* Hct-28.0* MCV-93 MCH-30.2 MCHC-32.5 RDW-16.9* Plt Ct-648* [**2174-4-21**] 02:51AM BLOOD WBC-21.6* RBC-2.95* Hgb-9.2* Hct-27.4* MCV-93 MCH-31.1 MCHC-33.5 RDW-16.7* Plt Ct-617* [**2174-4-20**] 03:28AM BLOOD PT-15.0* PTT-28.2 INR(PT)-1.4* [**2174-4-22**] 02:05AM BLOOD Glucose-116* UreaN-29* Creat-0.7 Na-137 K-4.1 Cl-102 HCO3-29 AnGap-10 [**2174-4-20**] 03:28AM BLOOD ALT-144* AST-78* AlkPhos-90 Amylase-173* TotBili-1.1 DirBili-0.5* IndBili-0.6 [**2174-4-20**] 03:28AM BLOOD Lipase-394* [**2174-4-19**] 03:27AM BLOOD Lipase-443* CHEST (PORTABLE AP) Reason: assess for infiltrates/effusions [**Hospital 93**] MEDICAL CONDITION: 68 year old man s/p recent MVR with high WBC, FTW and pleural effusion. REASON FOR THIS EXAMINATION: assess for infiltrates/effusions PORTABLE SEMIERECT CHEST. COMPARISON: [**2174-4-18**]. INDICATION: Elevated white blood cell count. A tracheostomy tube and central venous catheter remain in place. Cardiac and mediastinal contours are within normal limits. Focal consolidation in the right upper lobe is unchanged allowing for differences in patient positioning, but has improved compared to an older study of [**2174-4-5**]. Additional multifocal areas of consolidation in the left upper and both lower lobes show interval improvement compared to the recent radiograph with residual opacity most prominent in the left lower lobe. Small left pleural effusion has also slightly improved. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] RADIOLOGY Final Report VIDEO OROPHARYNGEAL SWALLOW [**2174-4-20**] 1:45 PM VIDEO OROPHARYNGEAL SWALLOW Reason: r/o aspiration [**Hospital 93**] MEDICAL CONDITION: 68 year old man with s/p mvr REASON FOR THIS EXAMINATION: r/o aspiration INDICATION: Please rule out aspiration. Video fluoroscopic images were obtained with assistance speech pathologist. Barium of various consistencies was given to the patient. No aspiration or penetration was seen. Delayed emptying of valleculae and piriform sinuses was seen most likely secondary to patient's weakness. Please look at the speech pathologist's report in CCC for complete assessment and recommendation. IMPRESSION: 1. No aspiration or perforation is seen. 2. Slight retention of barium within the valleculae and piriform sinuses most likely secondary to patient's weakness. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Cardiology Report ECHO Study Date of [**2174-3-30**] PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for MVR Status: Inpatient Date/Time: [**2174-3-30**] at 15:19 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW1-: Test Location: Anesthesia West OR cardiac Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**] MEASUREMENTS: Left Atrium - Long Axis Dimension: *6.3 cm (nl <= 4.0 cm) Left Ventricle - Inferolateral Thickness: 0.7 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: *6.0 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%) Aorta - Ascending: 3.4 cm (nl <= 3.4 cm) INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mild spontaneous echo contrast in the body of the RA. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Moderately dilated LV cavity. Normal regional LV systolic function. Overall normal LVEF (>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Moderate global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Focal calcifications in ascending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Partial mitral leaflet [**Last Name (Prefixes) **]. Mild mitral annular calcification. No MS. [**Name13 (STitle) 650**] (4+) MR. Eccentric MR jet. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. Suboptimal image quality. The rhythm appears to be atrial fibrillation. Results were personally reviewed with the MD caring for the patient. Conclusions: PRE CPB The left atrium is markedly dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. Mild spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler, though can not completely rule out a small PFO. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] There is moderate global right ventricular free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. An intraaortic balloon is seen (IABP). It's tip is about 4 cm below the distal arch. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. There is partial posterior mitral leaflet [**Name13 (STitle) **]. Severe (4+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. There is a trivial/physiologic pericardial effusion. POST CPB The patient is receiving epinephrine and norepinephrine by infusion. RV systolic function is somewhat improved - now mildly globally hypokinetic. LV systolic function is normal. There is a bioprosthesis in the mitral position. It is well seated and both leaflets demonstrate normal excursion. The maximum gradient across the MV was 7 mm Hg with a mean gradient of 5. There is trace valvular MR. The thoracic aorta appears intact. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD on [**2174-3-30**] 16:15. [**Location (un) **] PHYSICIAN Brief Hospital Course: Cardiac cath on [**3-24**] showed clean coronaries. Echocardiogram on [**3-25**] confirmed 4+ MR [**First Name (Titles) **] [**Last Name (Titles) **] leaflet. He was seen by pulmonology for ? of pna and remained on vanco/cefepime and flagyl. Bilateral chest tubes were placed for 5 liters with dramatic improvement in his ventilation which was able to be weaned to 40% Fio2. A PA catheter was placed and a balloon pump was inserted for afterload reduction. He was seen by infectious diseases for ? of endocarditis given that he had a back abscess drainded in [**Month (only) 404**]. He was treated for presumed endocarditis with continued vanco, ceftriaxone. TEE on [**3-25**] showed no vegetation or abscess. His sedation was stopped and He was started on tube feeds. He was seen by neurology for unresponsiveness, and was thought to have toxic-metabolic encephalopathy along with slow recovery from sedation. Head CT was negative. His mental status improved slowly. He was taken to the operating room on [**3-30**] where he underwent an MVR(#33 porcine). His IABP was removed. He was transferred back to the SICU in critical but stable condition. He was switched to zosyn for VAP. He was followed by cardiology for atrial fibrillation, and remained on IV amiodarone, and was started on heparin and coumadin. He was extubated on POD #2. On [**4-6**] he complained of LLQ pain, CT scan showed retroperitoneal bleed. He was seen by vascular surgery, who performed a coil embolization of lumbar artery via right CFA. The procedure was performed by Dr. [**Last Name (STitle) **]. He was again seen by vascular for decreased perfusion to his right foot. He was placed on pletal with improvement. On [**4-9**] he was reintubted for increased work of breathing. A dobhoff tube was placed and he was started on tube feeds again. He was seen by thoracic surgery for consideration of tracheostomy and PEG placement. His white count continued to rise, and he complained of RUQ pain, and had evidence of acute cholecystitis on ultrasound. On [**4-12**] he returned to the OR where he underwent open cholecystectomy, G-J tube and tracheostomy. Passy Muir valve was placed [**4-14**]. Speech swallow evaluation suggested PO diet of thin liquids and soft solids. His tube feeds were changed to cycle at night to supplement, and his trach downsized to #6 on [**4-22**]. Antibiotics were dc'd, and his white count continued to improve. s/p Tracheostomy/CCY/open G-J tube placement [**4-12**] Medications on Admission: coumadin, inderal, Magnesium oxide, MVI, lipitor Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol [**Month/Year (2) **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 3. Tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Cilostazol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO bid (). 5. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) ml PO BID (2 times a day). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily): 400mg QD thru [**4-29**] then 200mg QD. 10. Metoprolol Tartrate 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: s/p MVR(#33 porcine)[**3-30**]. s/p retroperitoneal bleed/coil embolization of lumbar artery bleed. s/p Tracheostomy/CCY/open G-J tube placement [**4-12**] Discharge Condition: stable Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds [**Last Name (NamePattern4) 2138**]p Instructions: Dr [**Last Name (Prefixes) **] in 4 weeks PCP 1-2 weeks after discharge from rehab Cardiologist 1-2 weeks after discharge from rehab Vascular Surgeon (Dr. [**Last Name (STitle) **] in one month Completed by:[**2174-4-22**]

[ "185", "272.0", "575.0", "429.5", "427.31", "428.0", "486", "518.81", "568.81", "785.51", "424.0", "349.82" ]

icd9cm

[ [ [] ] ]

[ "96.6", "34.04", "33.22", "35.23", "31.1", "51.22", "88.72", "39.61", "88.56", "99.07", "89.64", "34.91", "99.04", "96.72", "46.39", "37.61", "37.22", "39.79" ]

icd9pcs

[ [ [] ] ]

13215, 13289

9497, 11978

341, 405

13489, 13498

1286, 2661

900, 917

12077, 13192

3767, 3796

13310, 13468

12004, 12054

13522, 13676

13727, 13952

4736, 9474

932, 1267

282, 303

3825, 4710

433, 767

789, 823

839, 884

2,905

194,546

11962

Discharge summary

report

Admission Date: [**2141-4-26**] Discharge Date: [**2141-5-1**] Date of Birth: [**2064-10-30**] Sex: M Service: MEDICINE Allergies: Keflex Attending:[**First Name3 (LF) 2485**] Chief Complaint: Transfer for Trach and PEG Major Surgical or Invasive Procedure: 1. Tracheostomy 2. PEG 3. A-line History of Present Illness: 70 y/o male with PMHx significant for recent MCA stroke, CHF (LVEF 15%) who was initially at [**Hospital1 18**] in [**2141-1-12**] for MCA stroke. Patient during that admission developed MRSA PNA and sent to [**Hospital **] rehab for completion of antibiotics. At [**Hospital1 **] got nosocomial PNA initially treated with vanc/zosyn as well as developed CHF exacerbation. He was intubated and then extubated for 72 hours and then needed to be re-intubated for hypoxic respiratory failure. He was extubated again and then reintubated after failing bipap for 24-48 hours. He was noted to have a persistant WBC count and underwent CXR which showed increased R pleural effusion. A thoracentesis was done which drained 600cc of exudative fluid that was cloudy (LDH 1200 and glucose 5). A chest tube was placed which drained approximately 2L and grew E. Coli from his sputum and chest tube drainage. At that time he was switched from zosyn to aztreonam based on sensitivities. His WBC count decreased and his clinical condition improved so he underwent another trail of extubation on [**4-24**]. He started to decompensate 24 hours later felt to be in heart failure so given Bipap and maxamized cardiac meds. He continue to fail and was re-intubated on [**4-26**] felt to be because patient too weak and unable to clear secreations. After discussion with patient's sister decision made to have patient undergo trach and PEG so transferred to [**Hospital1 18**]. Past Medical History: - Hypertension - hypercholesterolemia - disc bulge L4-5 w/o herniation - hx of osteomyelitis T12-11 [**2136**] - screening carotid study '[**37**]: bilateral mild to moderate carotid stenosis - s/p laminectomy thoracic spine - Cardiomyopathy with LVEF 10-15% - Ischemic MCA CVA - Paroxymal Afib - History of GI bleed - Aspiration PNA (patient failed speech and swallow in past) - CRI with baseline Cre 1.8-2.2 . Social History: From [**Hospital **] rehab. No history of tobacco, history of heavy alcohol use (2 pint/day) but has been less recently. Retired biochemist. Family History: Non contributory Physical Exam: PE: T 97.0 BP 119/65 HR 89 AC 450x14 PEEP 5 Fio2 100% O2Sat 100% 7.51/48/404 Gen: Large male, sedated left eye droop Heent: Intubated, OG tube in place Chest: CT tube sounds, diffuse ronchi; R chest tube in place Cardiac: RRR S1/S2 no murmurs appreciated Abdomen: obese, soft, active bowel sounds Ext: +2 edema in LE and UE b/l; heel ulcer, Pertinent Results: [**4-27**] chest ct: IMPRESSION: 1. Improvement of right lower lobe pneumonia with persistent moderate right hydropneumothorax. 2. Enlarged small left pleural effusion and atelectasis. 3. Stable cardiomegaly. 4. Anasarca. . [**4-29**] cxr: Comparison made to prior study of [**2141-4-28**], at 11:04 a.m. Persistent loculated right pneumothorax is unchanged. The location of the two chest tubes are unchanged, one with its side port projecting over the right lower lung fields, and the second with its sidehole projecting over the right upper to mid lung field. The extreme left costophrenic angle has been excluded from the study. Left basilar atelectasis is unchanged. Atelectasis at the right lung base is unchanged. . IMPRESSION: Loculated hydropneumothorax on the right is unchanged. . CXR [**4-30**]: FINDINGS: Markedly stable examination demonstrating a loculated hydropneumothorax at the right lung base with an indwelling apically directed chest tube. Again seen is massive cardiomegaly. The left costophrenic angle has been excluded on this radiograph and demonstrates a small effusion. Tracheostomy in stable position. IMPRESSION: Markedly stable examination. . Labs: On admission: [**2141-4-26**] 07:42PM PT-17.1* PTT-31.0 INR(PT)-1.6* [**2141-4-26**] 07:42PM PLT SMR-VERY HIGH PLT COUNT-708*# [**2141-4-26**] 07:42PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-2+ TARGET-1+ SCHISTOCY-OCCASIONAL [**2141-4-26**] 07:42PM NEUTS-78* BANDS-0 LYMPHS-9* MONOS-12* EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-3* [**2141-4-26**] 07:42PM WBC-13.0* RBC-3.48* HGB-9.5* HCT-30.0* MCV-86 MCH-27.2 MCHC-31.6 RDW-21.0* [**2141-4-26**] 07:42PM CALCIUM-9.4 PHOSPHATE-3.9 MAGNESIUM-2.4 [**2141-4-26**] 07:42PM estGFR-Using this [**2141-4-26**] 07:42PM GLUCOSE-83 UREA N-71* CREAT-1.8* SODIUM-144 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-36* ANION GAP-12 [**2141-4-26**] 07:58PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [**2141-4-26**] 07:58PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2141-4-26**] 07:58PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2141-4-26**] 09:56PM freeCa-1.23 [**2141-4-26**] 09:56PM TYPE-ART PO2-404* PCO2-48* PH-7.51* TOTAL CO2-40* BASE XS-13 . On discharge: [**2141-5-1**] 03:29AM BLOOD WBC-15.1* RBC-3.37* Hgb-9.2* Hct-28.9* MCV-86 MCH-27.2 MCHC-31.8 RDW-21.5* Plt Ct-640* [**2141-5-1**] 03:29AM BLOOD Neuts-79.9* Lymphs-13.5* Monos-5.8 Eos-0.6 Baso-0.2 [**2141-5-1**] 03:29AM BLOOD Plt Ct-640* [**2141-5-1**] 03:29AM BLOOD Glucose-152* UreaN-55* Creat-1.6* Na-142 K-3.8 Cl-101 HCO3-32 AnGap-13 [**2141-5-1**] 03:29AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0 [**2141-4-29**] 06:50PM BLOOD Type-ART Temp-36.6 Rates-/22 pO2-136* pCO2-51* pH-7.44 calTCO2-36* Base XS-9 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-TRACH MASK . Micro: [**4-26**]: [**2141-4-26**] 8:26 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2141-4-28**]** GRAM STAIN (Final [**2141-4-26**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2141-4-28**]): MODERATE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). SPARSE GROWTH. . bld cx [**4-27**] pending . [**4-26**] C Diff negative . bld cx [**4-26**] pending . urine [**4-26**] negative Brief Hospital Course: 76 y/o male with PMHx significant for MCA stroke who presents from [**Hospital1 **] with R pleural effusion s/p chest tube placement who has failed multiple extubation transferred here for trach and PEG. . ## Respiratory Failure: Patient with exudative plerual effusion that was growing E. coli. Recent CXR raises question of necrotizing pna and possible PTX. The patient has a chest tube in place and had a ct to further assess. Based on CT patient with hydropneumothorax. He had a new chest tube placed, and with 2 tubes now will possibly help reexpand the lung. Given initial concern for abscess clindamycin used, but stopped on [**4-29**], and only aztreonam used. would cont aztreonam at least for 4-6 weeks days, until [**5-28**] or longer per IP. Pt weaned off vent on [**4-29**] to trach mask. Chest tubes to be kept in place and managed for empyema; length and suction management per IP. He is s/p trach and PEG on [**4-28**]. Cont IH/nebs as needed. Chest tubes can be d/c'd once each one has <100 cc of output per 24 hours. Also, tomorrow tpa could be applied to each chest tube to see if this increases output. . ## CHF: Patient did not appear to be in failure at admission. He has a known LVEF of 15%. BB, imdur, hydralizine, and digoxin were continued. Lasix used prn to keep volume even to -500cc. Cr slightly elevated on d/c (1.^) so withheld adding ACEI; please recheck at rehab and consider adding ACEI and stopping hydralizine if this returns to his baseline. . ## C. diff colitis: Patient with large quantity of loose stool. Reported C. diff colitis at [**Hospital1 **], although C diff negative here. Will cont PO flagyl until one week after last abx dose. Can use 500 mg PO tid via PEG. . ## H/O ischemic stroke: Per recent d/c summary patient was to get repeat CT head and if no evidence of intracranial bleed then start anticoagualtion; however patient also with history of GI bleed with significant Hct drop so holding anticoagulation and ASA. resumed ASA on d/c. . ## Paraxomal Afib: Most likely cause of patient's stroke. Patient currently in sinus. Cont BB. . ## CRI: The pt's Cr has been stable while in house. . ## Multiple ulcers: wound care saw patient who reccomende dmultipodus boots, aquacel, and nutrition. . ## PPx: heparin SC, PPI, tylenol prn . ## FEN: trach/PEG, RISS. TF's started- probalance at goal on discharge . ## Code: full Medications on Admission: Hydralazine 50mg q8 Lasix IV 40mg q12 Isosorbide dinitrate 30mg q8 Tylenol 1000mg q6 Fentanyl gtt Versed gtt Metoprolol 75mg q8 Aztreonam 1gm IV q8 Digoxin 0.125mg qod Protonix 40mg q24 Flagyl 250mg q6 Atrovent/albuterol INH MVI Ascorbic Acid Heparin SC Darbepoetin alpha 100mcg q7d RISS Ferrous sulfate 325mg daily Discharge Medications: 1. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 3. Ascorbic Acid 90 mg/mL Drops [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 4. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000) units Injection TID (3 times a day). 6. Ferrous Sulfate 300 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO DAILY (Daily). 7. Isosorbide Dinitrate 10 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a day). 8. Senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed. 9. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mls PO BID (2 times a day). 10. Hydralazine 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8 hours). 11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1) neb Inhalation PRN (as needed). 12. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb Inhalation PRN (as needed). 13. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day). 14. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML Intravenous DAILY (Daily) as needed. 16. Aztreonam [**2133**] mg IV Q8H 17. Flagyl 500 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO three times a day: to continue until one week after last dose of abx. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: 1. respiratory failure 2. congestive heart failure 3. c. difficil colitis 4. Paroxysmal AF Discharge Condition: stable Discharge Instructions: Please call 911 or retunr to hosptial is there is respiratory distress, nausea/vomiting, fevers/chills, chest pain/pressure or any bleeding. 1. Cont antibiotics for 4-6 weeks 2. Monitor renal fucntion and concsider ACEI 3. F/uw ith IP as needed for chest tube management Followup Instructions: admission. .

[ "518.83", "403.90", "585.9", "V12.59", "707.03", "427.31", "433.30", "425.4", "272.0", "008.45", "707.07", "428.0" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.71", "96.6", "43.11", "34.04", "33.22" ]

icd9pcs

[ [ [] ] ]

10857, 10928

6277, 8651

294, 328

11063, 11072

2821, 4001

11392, 11408

2426, 2444

9018, 10834

10949, 11042

8677, 8995

11096, 11369

2459, 2802

5154, 6254

228, 256

356, 1814

4016, 5139

1836, 2250

2266, 2410

22,266

149,488

48402

Discharge summary

report

Admission Date: [**2107-1-15**] Discharge Date: [**2106-1-23**] Service: REASON FOR ADMISSION: Gastrointestinal bleed. HISTORY OF PRESENT ILLNESS: Patient is an 82-year-old male with a history of myasthenia [**Last Name (un) 2902**] and history of atrial fibrillation on Coumadin who presented with a chief complaint of melena as well as bright red blood per rectum and hematemesis. The patient was in his usual state of health until a few days prior to admission when he had a few episodes of nausea and vomiting. Since that time, the patient had not been able to eat much. Three days prior to admission, patient reported he noted black stools which continued until the morning of admission at which time patient began having bright red stools and blood in the toilet bowl. At this point, the patient presented to the Emergency Department where he complained of lightheadedness. While in the Emergency Department, the patient was noted to have a hematocrit of 19 and was given 1 unit of packed red blood cells. The patient had a nasogastric lavage that showed scant blood, which lavaged clear. No active bleeding or coffee-grounds were noted. The patient was transferred to the Medical Intensive Care Unit for volume resuscitation and close monitoring. PAST MEDICAL HISTORY: 1. Myasthenia [**Last Name (un) 2902**]. 2. History of atrial fibrillation. 3. History of coronary artery disease status post stenting in [**2103**] and an ETT in [**4-20**] that has noted a normal ejection fraction. 4. History of hyperlipidemia. 5. History of negative colonoscopy six years ago. 6. History of hypertension. 7. History of gallstones. 8. History of diverticulosis. 9. Status post appendectomy. 10. Status post TURP. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg p.o. q. day. 2. Coumadin 6 mg p.o. q. day. 3. Lasix 40 mg p.o. once a day. 4. Lopressor 6.25 mg twice a day. 5. Pyridostigmine 60 mg three times a day. 6. Aldactone 25 mg q.o.d. and 12.5 mg q.o.d. 7. Pravachol 20 mg p.o. q. day. 8. Ultram 50 mg p.r.n. 9. Folate 400 mg p.o. q. day. ALLERGIES: Curare derivatives. SOCIAL HISTORY: He is a retired pharmacist. No history of tobacco use, occasional glass of wine at night. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Patient's vital signs on admission were 98.8, blood pressure of 117/43, heart rate between 90-120 in atrial fibrillation, the patient was sating 100% on room air. Generally, he was in no apparent distress. HEENT was notable for moist mucous membranes. Neck was supple without lymphadenopathy. Chest was clear to auscultation bilaterally. Cardiovascular was irregularly irregular, no murmurs were appreciated. Abdomen was mildly distended with diffuse tenderness to palpation, no rebound and no guarding. The patient had 1+ pedal edema bilaterally and neurologically patient was alert and oriented times three. LABORATORIES: Patient had a white count of 10 on admission with 79 neutrophils, 2 bands, hematocrit of 19.6, platelets of 230, INR was 3.3. Patient's chemistries were all within normal limits as was his LFTs. Urinalysis was unremarkable. Patient had a CK of 244 and troponin of 0.4 on admission. Chest x-ray showed no infiltrates, no congestive heart failure. Electrocardiogram was notable for left axis deviation and atrial fibrillation. No ST-T wave changes from previously. In short, this is an 82-year-old male admitted with a GI bleed. HOSPITAL COURSE: 1. GI: Patient was evaluated by both GI Service and by Surgery. Patient had an endoscopic workup which showed no source of bleeding. EGD with ulcers, however, did raise the question of Barrett's esophagus. The patient had a negative enteroscopy, although there was some question of vascular lesions in the esophagus. There was no evidence that the throat had recently bled, and the patient also had a negative colonoscopy, which showed nonbleeding polyps and nonbleeding hemorrhoids. The patient underwent transfusion of 8 units of packed red blood cells before his hematocrit stabilized at around 30.0 and also received 2 units of fresh-frozen plasma until his INR was within normal limits. The patient's Coumadin was held throughout the rest of the course of his hospital stay. Patient underwent barium upper GI study which showed no evidence of any lesions throughout his upper GI tract; thus no cause of bleeding was elucidated during this [**Hospital 228**] hospital stay. He was subsequently referred to [**Hospital3 **] for pill enteroscopy to determine a potential cause of this patient's bleed. The patient was also found to be H. pylori positive, and was treated with ampicillin and clarithromycin, 2 units of packed red blood cells, hematocrit remained stable. 2. Infectious Disease: Patient developed a cough productive of yellow sputum. Upon further questioning, it was discovered that his wife was [**Name2 (NI) **] with pneumonia at home. Thus, the patient was started on levofloxacin for which he would complete a 10 day course. The patient had no positive blood cultures or urine cultures within his hospitalization. 3. Heme: As noted above, the patient was transfused a total of 8 units of packed red blood cells throughout the course of his hospitalization. His hematocrit remains stable in the 28-32 range for the rest of his hospitalization. Patient's Coumadin was discontinued indefinitely. The patient will readdress this issue as an outpatient after a source of his bleeding has been determined. 4. Cardiovascular: Patient had no evidence of active ischemia while in hospital. He was ruled out for myocardial infarction on admission. The patient was continued on a statin, however, his aspirin was held given his bleeding. Patient remained clinically euvolemic with no evidence of failure while hospitalized, and the patient remained rate controlled on his usual dose of metoprolol while hospitalized. 5. Neurological: The patient was continued on Prostigmin for myasthenia [**Last Name (un) 2902**] during his hospital stay. CONDITION ON DISCHARGE: The patient was discharged in good condition on [**2107-1-23**]. FINAL DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed. 2. Hypertension. 3. Coronary artery disease. 4. Atrial fibrillation. 5. Myasthenia [**Last Name (un) 2902**]. 6. Pneumonia. 7. Helicobacter pylori. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg po q day x5 days. 2. Clarithromycin 500 mg po bid x4 days. 3. Amoxicillin 1 gram po q12h for four days. 4. Protonix 40 mg po q day. 5. Prostigmin 15 mg tid. 6. Metoprolol 12.5 mg po bid. 7. Lasix 40 mg po q day. 8. Aldactone 12.5 mg po q day. 9. Pravachol 20 mg po q day. 10. Ultram 50 mg po tid. 11. Vitamin E. 12. Folate. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. Dictated By:[**Name8 (MD) 8330**] MEDQUIST36 D: [**2107-4-22**] 17:37 T: [**2107-4-25**] 11:42 JOB#: [**Job Number 101924**]

[ "455.0", "211.3", "358.0", "E934.2", "285.9", "041.86", "427.31", "790.92", "578.9" ]

icd9cm

[ [ [] ] ]

[ "45.23", "45.13" ]

icd9pcs

[ [ [] ] ]

2233, 2251

6355, 6935

1765, 2107

3457, 6038

2274, 3440

6156, 6332

159, 1275

1297, 1739

2124, 2216

6063, 6129

31,407

169,513

33089

Discharge summary

report

Admission Date: [**2106-2-7**] Discharge Date: [**2106-2-11**] Service: NEUROSURGERY Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2724**] Chief Complaint: fall from standing - neck pain Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **]F s/p fall at noon today. Fell backwards on head, unsure of why she fell. Denies LOC. Originally presented to [**Hospital **] hospital where head CT was negative and c-spine CT showed a fracture of C2 through the dens with bilateral involvement of the transverse processes. Past Medical History: PMH: "Liver" ca - pt did not want treatment HTN CAD Back pain DNR PSH: none Social History: no EtOH, non smoker Family History: not obtained Physical Exam: PE 97.2 92 147/59 20 96% RA AAOx3 NAD RRR CTAB Soft NT/ND no edema or peripheral injury, extrem warm CII-CXII intact, motor 5+ Upper and lower extrem B/L, pat reflexes intact, no clonus sensation upper and lower extremities bilaterally Pertinent Results: Labs: U/A neg Trop-T: <0.01 133 99 34 118 AGap=16 4.3 26 1.6 CK: 160 MB: 4 Ca: 11.0 Mg: 2.8 P: 3.8 ALT: AP: Tbili: Alb: AST: LDH: 1136 Dbili: TProt: [**Doctor First Name **]: Lip: 36 8.1>33.5<276 PT: 13.2 PTT: 27.6 INR: 1.1 Rads: CT Head - no bleed CT C-spine - C2 fracture through dens with extensive damage to the right transverse process and injury to the left transverse process CXR/Pelvis - no trauma MRA neck -25% stenosis of the right internal carotid artery as well as narrowing of the right common carotid. No evidence of vertebral artery dissection. Brief Hospital Course: Pt was admitted to neurosurgery service to ICU for close neurologic monitoring. Her neuro exam remained intact. On HD#2 she was transferred to the floor. She remained in hard collar. Her diet and activity were advanced. Her CT c-spine showed comminuted fracture of the C2 body and lateral masses bilaterally extending to the neural foramen on the left involving the posterior elements on the right and a pars fracture on the left with permeative destruction of the right lateral mass, consistent with a pathologic fracture. There is an adjacent soft tissue mass. There are lung nodules which are likely malignant. She was evaluated by PT/OT and they recommended rehab/[**Hospital1 **] for increased risk of fall due to decreased balance and pain. She is discharged eating a regular diet, bowel and bladder function intact, and pain controlled with oral pain medications prn. Medications on Admission: Diazide, Gabapentin, naproxen, tylenol, zantac Discharge Medications: 1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 10. Medications Please restart home medications as prescribed before your fall and as necessary to control blood pressure and volume status. Discharge Disposition: Extended Care Facility: [**Hospital **] Nursing and Rehab Center Discharge Diagnosis: C2 pathologic fracture Discharge Condition: Neurologically stable Discharge Instructions: ?????? you are required to wear a cervical collar until follow up and likely indefinitely. ?????? Do not smoke ?????? Limit your use of stairs to 2-3 times per day ?????? You may shower briefly without the collar / back brace unless instructed otherwise ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN [**4-11**] WEEKS. YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT

[ "585.9", "197.0", "199.1", "403.90", "733.13" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3602, 3669

1655, 2535

276, 282

3736, 3760

1045, 1632

4798, 4978

760, 774

2632, 3579

3690, 3715

2561, 2609

3784, 4775

789, 1026

206, 238

310, 607

629, 707

723, 744

72,314

137,817

39912

Discharge summary

report

Admission Date: [**2102-6-29**] Discharge Date: [**2102-7-6**] Date of Birth: [**2028-12-30**] Sex: F Service: MEDICINE Allergies: Prozac Attending:[**First Name3 (LF) 783**] Chief Complaint: Abdominal pain, right renal hemorrhage, AoCRF Major Surgical or Invasive Procedure: None History of Present Illness: 73 year old woman with PMHx hypertension, lupus, type 2 diabetes (insulin dependent), OSA, gout, depression who presents with abdominal pain since Monday afternoon. The patient states she was in her usual state of health and driving to [**Location (un) 5028**] to her son's house for [**Hospital1 107**] day festivities when she stopped to get flowers and developed acute dull RLQ pain. She describes the pain as "lumpy" sore pain that made her intermittently diaphoretic. The patient was able to drive to her son's house but stayed on the couch most of the time there. She felt briefly light headed, like she was going to pass out, with poorer mentation. She was, however, able to take in corn and meat dishes without change in her pain. The patient had someone drive her home and stayed home Monday-Wednesday as the pain was persistent. The patient felt slightly better yesterday but worse today and so she saw her PCP at [**Name9 (PRE) 2274**] - [**Location (un) **]. The patient has not taken anything for pain, but found resting helped the discomfort. The patient endorses subjective fevers, decreased appetite, skin pallor, worsened pain in the RLQ with deep breathing. Denies nausea/vomiting, diarrhea, constipation, chest pain, BRBPR, hematemesis. Also denies flank pain, recent trauma to her back, hematuria, dysuria, changes in urine output. . On arrival to [**Hospital1 18**] ED, initial vitals were: T98.0, HR68, BP132/54, RR18, 100% on 2L nasal cannula. Labs were drawn and the patient was noted to have acute renal failure with creatinine 3.3 (baseline 1.5-1.6) and drop in hematocrit to 26.6 (baseline 32-36), also mild leukocytosis to 12.2 with left shift. Urinalysis with only RBC<1, negative for blood - also negative for UTI. CT abdomen and pelvis was performed which showed a 11 X 12 X 9cm swirling high density right renal hemorrhage/rupture. Urology was consulted and recommended non-surgical management for now. Renal was also consulted and will follow the patient in-house. The patient was type and crossed for two units of pRBC, two large bore IVs placed. She received two liters IVF. VS on transfer: T97.8, HR73, BP125/58, RR20, 95% on RA. . On arrival to the MICU, patient walked comfortably from stretcher to bed. Children at bedside. Has on-going dull RLQ pain. . ROS: Denies chills, headache, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. . Past Medical History: * Chronic kidney disease * Discoid lupus erythematosus (skin, joint involvement) * Type 2 diabetes mellitus, on insulin * Hypertension * OSA on CPAP * Gout * Morbid obesity * Depression * Osteoarthritis * Colonic adenomas Social History: Denies tobacco (quit in [**2051**]), alcohol, illicit drugs. Lives in [**Location 686**] with aunt ([**Age over 90 **] years old) and is her primary caregiver. Supportive children in the area. Family History: End stage renal disease in both parents. Father also had two MIs. Aunt and cousin died of end stage renal disease. Paternal grandmother had glomerulonephritis. Aunts with breast cancer. Physical Exam: Admission Physical Exam: VS: Temp: 97.3 BP: 144/59 HR: 74 RR: 17 O2sat 96% on RA GEN: Pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, dry mucus membranes, op without lesions, no jvd RESP: CTA b/l with good air movement throughout, no wheezing, rhonchi, rales CV: RR, S1 and S2 wnl, no murmurs/gallops/rubs ABD: Non-distended, obese, +bowel sounds, soft, no masses, TTP in RLQ/RUQ EXT: No cyanosis/ecchymosis/edema. Sclerotic and hypopigmented skin across bilateral knuckles NEURO: AAOx3. CN II-XII intact. Strength and sensation grossly intact Discharge Physical Exam: VS: Temp: 97.4 BP: 122/64 HR: 74 RR: 20 O2sat 94%RA Gen: Comfortable, NAD HEENT: PEERL, EOMI, anicteric, op without lesions RESP: clear, good air movement throughout, minimal crackles bilaterally CV: RR, S1 and S2 wnl, no m/r/g ABD: Non-distended, obese, +BS, soft, no masses, TTP in RLQ/RUQ EXT: No cyanosis/edema. Sclerotic and hypopigmented skin across bilateral knuckles. Neuro: A&Ox3. CN II-XII intact. Strength and sensation grossly intact. Pertinent Results: Admission Labs: [**2102-6-29**] 11:24PM GLUCOSE-87 UREA N-45* CREAT-2.9* SODIUM-139 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-16 [**2102-6-29**] 11:24PM CALCIUM-10.1 PHOSPHATE-4.0 MAGNESIUM-2.2 [**2102-6-29**] 11:24PM WBC-13.3* RBC-2.99* HGB-8.7* HCT-25.8* MCV-86 MCH-29.0 MCHC-33.7 RDW-16.9* [**2102-6-29**] 11:24PM PLT COUNT-266 [**2102-6-29**] 11:24PM PT-12.7 PTT-24.7 INR(PT)-1.1 [**2102-6-29**] 02:44PM LACTATE-0.8 [**2102-6-29**] 02:30PM LIPASE-14 [**2102-6-29**] 02:30PM ALT(SGPT)-17 AST(SGOT)-19 ALK PHOS-68 TOT BILI-0.5 [**2102-6-29**] 02:30PM WBC-12.2* RBC-3.10* HGB-8.8* HCT-26.6* MCV-86 MCH-28.2 MCHC-32.9 RDW-16.5* [**2102-6-29**] 02:30PM NEUTS-75.7* LYMPHS-16.8* MONOS-4.5 EOS-2.7 BASOS-0.4 [**2102-6-29**] 02:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2102-6-29**] 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2102-6-29**] 02:30PM URINE RBC-<1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-0 [**2102-6-29**] 02:30PM URINE MUCOUS-RARE . CT abdomen/pelvis without contrast [**6-29**]: 11 x 12 x 9 cm swirling high density in the right kidney consistent with renal hemorrhage/rupture. High density cysts in the left kidney should be evaluated with ultrasound or MRI for characterization. . CXR on [**6-30**]: FINDINGS: No previous images. The cardiac silhouette is within normal limits and there is tortuosity of the aorta. No vascular congestion or pleural effusion. There is increased opacification at the right base medially with silhouetting of a portion of the hemidiaphragm posteriorly, consistent with a lower lung pneumonia. . CXR on [**7-4**]: FINDINGS: As compared to the previous radiograph, the pre-existing right basal opacity, suspected to represent pneumonia, has not changed. Also constant is a small atelectasis at the left lung base. Unchanged borderline size of the cardiac silhouette without overt pulmonary edema. Moderate tortuosity of the thoracic aorta. . Renal US [**7-4**]: IMPRESSION: Slightly decreased size of right renal perinephric hematoma. Multiple simple cysts within the left kidney. . Discharge labs: [**2102-7-6**] 06:05AM BLOOD WBC-13.1* RBC-2.94* Hgb-8.3* Hct-25.3* MCV-86 MCH-28.2 MCHC-32.8 RDW-16.5* Plt Ct-403 [**2102-7-6**] 06:05AM BLOOD Glucose-105* UreaN-46* Creat-2.5* Na-134 K-4.3 Cl-99 HCO3-22 AnGap-17 Brief Hospital Course: 73 year old woman with PMHx hypertension, lupus, type 2 diabetes (insulin dependent), OSA, gout, depression who presented with RLQ abdominal pain and was found to have large renal hemorrhage and acute on chronic renal failure. . # Right renal hemorrhage from ruptured cyst: Fairly large on CT abdomen/pelvis, associated with leukocytosis and RLQ abdominal pain. Patient has hx of bilateral complex renal cysts of unknown etiology since [**5-8**]. Fhx of ESRD, so these may be related to APKD. Etiology of hemorrhage unclear as the patient has not had any trauma to the area, procedures/interventions (lithotripsy), not on blood thinners. Likely it was spontaneous. Her hematocrit remained stable while in the hospital and she did not require blood transfusions. She was medically managed on the floor after observation in the MICU, and followed by both nephrology and urology. She received IV pain medication for her right flank pain and was transitioned to PO pain medication at discharge with minimal pain. She will follow up with her outpatient urologist; it is recommended to perform an MR urography to reevaluate cysts in [**4-2**] weeks. . # Acute on chronic renal failure: Patient's Cr prior to admission was 1.7 secondary to diabetic nephropathy. Out pt work up as been otherwise not revealing. On admission, Cr had increased to 3.5. Etiologies included prerenal failure (urine lytes were consistent with this etiology as FeBUN ~30% and her creatinine responded initially to IVF decreasing from 3.5-2.7, however it had stabilized at 2.7 & patient was euvolemic), acute interstitial nephritis (urine eosinophils negative), postrenal obstruction (CT was not consistent with hydronephrosis), or renal failure from compression/obstruction by the cyst. Due to her acute renal failure, her allopurinol, furosemide, losartan, and lantus were held initially and Cr improved to 2.2. The patient received furosemide on [**7-3**] due to her SOB and crackles on lung exam, however it was stopped due to her euvolemia and increased creatinine (3.1) on [**7-5**]. The patient's creatinine improved to 2.5 on day of discharge. Lasix and losartan were held at discharge. . #Shortness of Breath: Patient experienced shortness of breath on room air the morning of [**2102-7-3**]. Her ambulatory oxygen was 89-90% on RA. She normally receives furosemide at home and it had been held in the setting of her acute renal failure. She had bilateral crackles on exam. Her SOB was thought to be secondary to fluid overload. Other things considered included PNA (although patient did not have any symptoms and exam is not consistent) or PE (although patient had been ambulating and utilizing boots for ppx). She didn't have pleuritic chest pain nor sputum production. EKG was normal; CXR revealed persistent right basal opacity representing PNA from [**6-30**], with some possible pulmonary edema. The patient was afebrile, hence antibiotics for pneumonia were held off as it was recognized that the opacity could have also been due to her body habitus. Her home furosemide was restarted and on the following day the patient had audible expiratory wheezes and wheezes throughout her lung examination with worsening respiratory distress. The patient has a distant history of asthma; due to her change in exam, her SOB was likely due to airway inflammation from an unknown trigger rather than fluid overload at that point. She was started on albuterol and ipratropium nebulizers, with marked improvement. Her furosemide was stopped as patient's creatinine was trending upwards and the patient was euvolemic on exam. She was discharged on prn albuterol inhaler on room air. . #Leukocytosis: Patient was admitted with a mild leukocytosis with a left shift, with no signs of infection. Her urinalysis was negative and she remained afebrile in house. Her chest xray did reveal a right lower lobe opacity that could be suggestive of pneumonia, but she did not have fever, SOB, nor cough. The opacity may have been due to her body habitus and poor inspiration. Blood cultures were obtained on admission and were negative. Leukocytosis is likely secondary to stress from renal failure. . # Discoid lupus erythematosus: Diagnosed ~15 years ago. Patient has been on steroids in the past, and hasn't been on any in months. Mainly presents with skin and joint involvement. . # Type 2 diabetes mellitus: The patient is controlled with insulin at home. Her home lantus was initially held due to renal failure and poor PO intake. She was started back on [**1-29**] dose when her diet was advanced; sugars were stable throughout the admission. . # Hypertension: The patient continued her home dose of amlodipine, however, given her renal failure, her losartan and furosemide were held, and not restarted on discharge. . # Gout: Her allopurinol was held due to her renal failure, but it was restarted at discharge at 100mg qd. . # Obstructive sleep apnea: On CPAP at home, which the patient's family brought in. . # Depression: Stable, continued citalopram. . # Osteoarthritis: Stable, written for tylenol prn. Medications on Admission: * Allopurinol 200mg daily * Losartan 100mg daily * Amlodipine 10mg daily * Citalopram 20mg daily * Furosemide 40mg daily * Lantus 44 units qHS * Vitamin D3 [**2091**] units daily . Allergies: Penicillin, prozac, (prednisone causes hyperglycemia) Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Five (5) Tablet PO DAILY (Daily). 3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 6. insulin glargine 100 unit/mL Cartridge Sig: Twenty Two (22) Units Subcutaneous at bedtime: Please utilize 22 units at bedtime until you are eating a regular diet or you notice that your blood sugars are elevated. 7. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain: do not take if driving, drinking alcohol, or if sleepy. Disp:*10 Tablet(s)* Refills:*0* 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: Right renal cystic hemorrhage Secondary Diagnosis: Acute on Chronic Renal Failure Diabetes mellitus type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a bleed in your right kidney. We believe that the bleed was due to rupture from one of your kidney cysts. You remained stable throughout the hospitalization with improvement in your pain and you were discharged home. You will need to follow up with your urologist regarding the kidney bleed in the next few weeks and get a imaging test of your pelvis to assess your cysts. Your kidneys were not working at their usual level when you were admitted. We think this may have been from the bleed you had in your right kidney. Your kidneys were working better at the time of your discharge. We would like you to follow up with a nephrologist to further evaluate your kidney function and ensure that it continues to improve. (see below) You also had new shortness of breath associated with wheezing, it appeared to be asthma related. You were treated with medications and improved. You were started on an inhaler. The following changes were made to your medications: -START albuterol inhaler as needed -CHANGE Allopurinol to 100 mg each day (one tablet daily) -STOP losartan until you see your PCP [**Name10 (NameIs) 8983**] lasix until you see your PCP [**Name10 (NameIs) **] your [**Name9 (PRE) **] to 22 units until you are eating a regular diet and your blood sugar increases -START taking oxycodone as needed for pain -START taking docusate and senna to prevent constipation while taking the oxycodone Followup Instructions: Please follow up with the following appointments: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2261**] Appointment: Monday [**7-10**] at 10:50AM Name: [**Last Name (LF) **], [**First Name3 (LF) **] Specialty: Nephrology Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2296**] Appointment: Wednesday [**7-12**] at 2PM Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Specialty: Urology Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2284**] Appointment: Thursday [**8-17**] at 12:15PM [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2102-7-10**]

[ "403.90", "V58.67", "585.9", "311", "493.90", "272.0", "715.90", "584.9", "695.4", "274.9", "753.10", "583.81", "250.40", "278.01", "593.81", "327.23", "285.1" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

13485, 13542

6975, 12050

312, 318

13713, 13713

4564, 4564

15314, 16370

3314, 3502

12347, 13462

13563, 13563

12076, 12324

13865, 15291

6737, 6952

3542, 4072

227, 274

346, 2841

13634, 13692

4580, 6721

13582, 13613

13728, 13841

2863, 3087

3103, 3298

4097, 4545

18,859

128,242

22979

Discharge summary

report

Admission Date: [**2195-11-18**] Discharge Date: [**2195-11-21**] Date of Birth: [**2139-5-22**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2090**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: 56yo man with PMH significant for multiple sclerosis, unclear type, and MI s/p stenting presents with an episode of total body weakness and associated slurred speech. He reports that at 10pm last night he had the sudden onset of loss of feeling and use of all 4 extremities while he was sitting watching medicine. He reports he has had simlilar episodes before but never as severe. He had bowel incontinence and was unable to get up to get help. He also reports have slurred speech at the time. His ex-sister in-law came to check on him and called an ambulance. He was seen at [**Hospital3 417**] hospital where a head CT was reportedly "normal". Currently reports being back to his baseline since 3am. Denies f/c/CP/SOB/abdominal pain. In the ED, inital vitals were 98.0 70 91/54 16 100% RA. At the time of admission to our ED, the patient reported that he was back at his baseline. Neuro reported "On examination, he has a R RAPD, L red desaturation, BLE>BUE, L>R hypertonia, L sided weakness, and decreased sensation in the left lower leg. It is unknown how much of this is baseline or if any is new. He is also a fairly unreliable historian, which makes it difficult to further assess and localize his deficits. By history alone, weakness of all extremities usually localizes to the c-spine, esp with fecal incontinence, but the slurred speech indicates a location in the brain. He describes listing to the right, so perhaps he had mostly right sided weakness with the old left sided weakness. It is also possible that he became hypotensive and had reexpression of prior bilateral deficits. Head CT shows many periventricular white matter lesions." While in the ED, he became hypotensive to the SBP 70's despite 3L NS. Tox screen was negative. He did not receive pressors or central venous access. Urine out put was 500cc while in the ED. He was admitted to the ICU for closer monitoring. Past Medical History: -- Multiple Sclerosis -diagnosed reportedly in [**2189**] by MRI, secondary to symptoms of dysequilibrium and falls. He feels he has not had any episodes but has been slowly progressing. He started using a cane at the time of diagnosis, then within a year progressed to a walker, and for the last year has been requiring a wheelchair for long distances. Took avonex x 1 yr and had episodes of difficulty moving just after taking the medication, somewhat like the current complaint. He started copaxone 1 yr later -- s/p MI/2 stents [**2189**] -- Hyperlipidemia Social History: Lives alone but his [**Last Name (un) **] lives in [**Location 59316**] down the hallway; uses walker to get around his apartment and electric wheelchair if he goes out. Quit smoking and ETOH in [**2189**] when he was diagnosed with MS. Pt last saw his outpatient neurologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57792**] in [**Hospital1 1474**] 1 yr ago due to insurance coverage problems. Family History: cardiac disease in multiple family members Physical Exam: Vitals - afebrile, HR 53, BP 96/60, RR 12, O2 100% 2L General - awake, alert, lying in bed comfortably HEENT - PERRL, EOMI, oropharynx dry Neck - supple, no bruits CV - RRR Lungs - CTA B/L Abdomen - soft, non-tender, non-distended Ext - tip of right index finger amputated Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date except says [**2195**]. Attentive, says [**Doctor Last Name 1841**] backwards though slowly. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. [**Location (un) **] intact. Registers [**1-24**], recalls [**11-26**] +1 with cue at 20 minutes. No right-left confusion. No evidence of apraxia or neglect. Cranial Nerves: Fundoscopic examination reveals sharp disc margins temporally, no pallor. Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Left eye red desaturation, right eye RAPD. Visual fields are full to confrontation. Extraocular movements intact bilaterally with bilateral end-gaze nystagmus. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline, movements intact. Motor: Decreased bulk throughout. Hypertonic throughout, LLE>RLE>LUE>RUE. No observed myoclonus, asterixis, or tremor. Left arm drifts down with fingers drifting in. [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE R 5 5- 5 5 4 5- 4 - 5 4 5 4- L 5 5 5 5 5 5 5 5 5 4+ 5 4+ cannot bend LLE at all, even when with gravity Sensation: No extinction to DSS. Decreased light touch in left lower leg, decreased pinprick in left lower leg and increased to pinprick in left foot, decreased vibration and minimally decreased position sense in left big toe. Reflexes: 2 and symmetric throughout BUE; 2+ R patella, 3+ L patella, 2 in b/l achilles. Toes upgoing bilaterally with clonus elicited on L with plantar stim. Coordination: finger-to-nose intact, fine finger movements slowed bilaterally. Gait: could not assess in ED due to absence of walker - will assess on the floor Pertinent Results: GLUCOSE-113* UREA N-13 CREAT-1.0 SODIUM-143 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-31 ANION GAP-11 CK(CPK)-95 ALT(SGPT)-36 AST(SGOT)-27 CK(CPK)-94 ALK PHOS-67 TOT BILI-0.8 LIPASE-16 CK-MB-3 cTropnT-<0.01 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG WBC-10.2 RBC-4.45*# HGB-13.7*# HCT-38.2*# MCV-86 MCH-30.7 MCHC-35.8* RDW-13.7 NEUTS-82.8* LYMPHS-14.3* MONOS-2.4 EOS-0.2 BASOS-0.3 PLT COUNT-280 PT-14.7* PTT-23.4 INR(PT)-1.3* [**2195-11-18**] CXR - No pneumonia or CHF. [**2195-11-18**] Urine culture negative CARDIAC ECHO [**11-20**]: The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the distal septum and anterior walls. The remaining segments contract normally (LVEF = 55 %). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2192-12-5**], regional left ventricular systolic function is improved. [**11-18**] MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST FINDINGS: Diffuse periventricular FLAIR and T2 hyperintensities are consistent with chronic multiple sclerosis. Several subcentimeter foci that are bright on diffusion-weighted imaging are not clearly identified on ADC map and therefore no correlative information is available. These areas may represent more acute plaque formation, although they are difficult to characterize without correlative information. There are no foci of abnormal enhancement. The intracranial vertebral and internal carotid arteries and their major branches appear normal without evidence of stenosis, occlusion, or aneurysm. IMPRESSION: Extensive chronic multiple sclerosis, without evidence of enhancing plaques. Vascular structures are unremarkable. MR [**Name13 (STitle) **] SCAN WITH CONTRAST FINDINGS: Multiple small foci of increased signal intensity on STIR and T2 weighted imaging in the spinal cord are most prominent near C2-3, C3-4, between C5-7 and in the medulla. At C3-4, an anterior osteophyte that touches the anterior cord. A tiny midline disc protrusion at this level also touches the cord. At C4-5, an uncovertebral osteophyte slightly flattens the anterior cord. At C5-6, a large osteophyte causes severe bilateral neural foraminal narrowing. At C6-7, images are limited by motion but are grossly unremarkable. There is no enhancing lesion in the cord. IMPRESSION: 1) Multiple foci of STIR and T2 hyperintensity are consistent chronic multiple sclerosis. There are no enhancing cord lesions. 2) Degenerative changes as noted above. Brief Hospital Course: 56 yo M with h/o multiple sclerosis now with total body weakness # [**Name13 (STitle) **] - The patient responded to IVF boluses. There was no evidence of infection. It was felt he was hypovolemic at the time of admission. # Weakness - Etiologies includes MS flare, toxic/metabolic, [**Name13 (STitle) **], TIA. -- no abnl detected on telemetry, cardiac enzymes negative, cardiac Echo improved from previous -- no new demyelinating plaques on MRI +/- brain and c-spine, but does have old plaques in medulla whihc could account for some [**Name13 (STitle) **] dysfunction -- PT evaluated him and thought he was safe for D/C home # Multiple Sclerosis - continue copaxone and oxybutinin # Hyperlipidemia - continue statin # CAD - holding atenolol given [**Name13 (STitle) **]; continue ASA Medications on Admission: Atenolol 25mg daily ASA 325mg daily Copaxone Injection 20mg SC daily Oxybutinin 15mg daily Simvastatin 40mg Discharge Medications: 1. Glatiramer 20 mg Kit Sig: One (1) Kit Subcutaneous daily (). 2. Oxybutynin Chloride 15 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO daily (). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: MS [**First Name (Titles) **] [**Last Name (Titles) **] [**Last Name (Titles) **] Instability Dehydration Discharge Condition: Stable at baseline. He has an UMN pattern of weakness in the LLE and normal strength otherwise. Discharge Instructions: Please call your doctor or return to the ED if you have any new weakness, numbness, trouble speaking, trouble seeing, lightheadedness, dizziness, or other new neurologic problems. Please take your medications as directed. We stopped your metoprolol as this can drop your blood pressure, but it is very important that you discuss this with your PCP given your history of heart attack. Otherwise, take all of your medications as you were doing. You need to drink 64 ounces of fluid daily to maintain your blood pressure in a good range. Followup Instructions: Pls call to discuss your tilt table testing. Provider: [**Name10 (NameIs) **] TESTING Phone:[**Telephone/Fax (1) 8139**] Date/Time:[**2195-12-16**] 11:00. Please call your PCP to schedule an appointment for the next week from now. We would like you to be seen at the neurology clinic here at least once for an opinion. Please call [**Telephone/Fax (1) 5434**] to schedule an appointment with Dr. [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] in the [**Hospital **] Clinic at her next available appointment. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**] Completed by:[**2195-12-3**]

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Discharge summary

report

Admission Date: [**2132-11-30**] Discharge Date: [**2132-12-9**] Date of Birth: [**2050-4-1**] Sex: M Service: MEDICINE Allergies: Penicillins / Tetracycline / Sulfa (Sulfonamides) / Meperidine Attending:[**Doctor First Name 1402**] Chief Complaint: ICD firing Major Surgical or Invasive Procedure: VT ablation History of Present Illness: The patient is an 82 year old with known nonischemic cardiomyopathy (LVEF 10-15%), s/p BiV ICD, CAF s/p AVN ablation, VT s/p ablation who presents with recurrent VT and ICD firings. In [**2127**], the patient had a BiV ICD placed, with an EF of 15%, prolonged, QRS, and NYHA class 3. The patient represented on [**2132-2-17**] with VT storm and ICD firing about 8 times. The patient was loaded with amioderone. He then underwent EPS and VT ablation. On study, the patient was found to have three VTs with RBBB morphology with varying late precordial transition and at least three VTs with LBBB morphology were seen. An unstable induced VT with LBBB morphology with superior axis and dominant precordial R waves were induced, which required defibrillation. After the last set of ablation lesions, no inducible VT was seen with single extrastimulus testing. Endocardial mapping demonstrated basal posterolateral and apical scar. The patient was discharged on amioderone from that hospitalization. . The patient was intially maintained on amioderone 200mg daily. Without reoccurance, that dose was intially decreased to 100mg. A subsequent ICD interrogation during the summer of [**2131**] showed two recurrent episodes of VT requiring ICD shocks, and the amioderone dose was returned to 200mg. He has remained symptom free, without further ICD firings, palpitations, chest pain, or pre-syncope. . Over the last 3 weeks, the patient has noted increasing symtpoms of heart failure, with dysnpnea at rest and lower extremity swelling. His lasix dose was uptitrated from 40mg to 80mg [**Hospital1 **], with notable improvement of symptoms, and loss of 5-6lbs of water weight. 6 days prior to presentation, the patient's ICD fired. He was instructed by his cardiologist to go the ED if it reoccurred more than 1x per day. The patients ICD fired again on thursday and friday, and on follow up with his cardiologist, his amioderone was increased to 200mg [**Hospital1 **]. His device fired again on saturday morning. . On the day of presentation, the patient awoke from sleep at 5am and felt light headed. He reports trying to feel his radial artery, but couldn't feel a strong pulse. He felt a shock, and went back to bed. He awoke again at 630 am, with a similar dizzyness, and his device fired for a second time. This happened again at 7am. The patient went to [**Hospital6 **], where he was bolused with amioderone, and started on a gtt. He again went into stable VT, and again his device fired. He was transfered to [**Hospital1 18**] for further care. . In the ED, the patient remained comfortable and chest pain free. He had another reoccurance of VT, with HR of 150. His blood pressure dropped to 78 systolic. His ICD did not fire. He was given atomadate and DCCV. He was bolused with lidocaine, and started on a lidocaine gtt. His blood pressures improved to 105/70, and V-paced rhythm 85. The patient is being admitted to the CCU for further care. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis. He had bloody stools three months prior, with a negative GI work up. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS:: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: [**2-16**] with normal coronary arteries -PACING/ICD: BiV/ICD in [**2127**] 3. OTHER PAST MEDICAL HISTORY: . Cardiomyopathy with EF 15% s/p ICD Glaucoma Macular degeneration, Chronic Kidney Disease ( Cr~1.5) Atrial fibrillation Gastric polyps Cataracts Macular degeneration L hip osteoarthritis Social History: Reports no EtOH, no tobacco, no drugs. pediatrician Family History: No FHx of MI, otherwise non-contributory Physical Exam: VS: T=96.4 BP=136/64 HR= 85 O2 sat= 99% on 2L GENERAL: Affable male in NAD. Oriented x3. Mood, affect appropriate. Flush in the face. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of [**4-15**] cm. CARDIAC: PMI laterally displaced. RR with occasional PVCs, normal S1, with paradoxially split S2. No m/r. No thrills, lifts. ? + S3 in LLDP LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 1+ posterior ankle edema, trace pre-tibeal edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Laboratory values: . [**2132-11-30**] 12:55PM BLOOD WBC-6.4 RBC-4.00* Hgb-13.0*# Hct-38.2*# MCV-96 MCH-32.5* MCHC-34.0 RDW-17.1* Plt Ct-188 [**2132-11-30**] 12:55PM BLOOD PT-22.7* PTT-25.9 INR(PT)-2.2* . [**2132-11-30**] 12:55PM BLOOD Glucose-107* UreaN-70* Creat-2.6*# Na-143 K-3.6 Cl-102 HCO3-30 AnGap-15 [**2132-12-1**] 04:15PM BLOOD Glucose-80 UreaN-60* Creat-2.3* Na-145 K-3.7 Cl-108 HCO3-23 AnGap-18 . [**2132-12-9**] 05:30AM BLOOD WBC-5.2 RBC-3.32* Hgb-10.7* Hct-31.5* MCV-95 MCH-32.3* MCHC-34.0 RDW-16.5* Plt Ct-160 [**2132-12-9**] 05:30AM BLOOD PT-23.7* INR(PT)-2.3* [**2132-12-9**] 05:30AM BLOOD Glucose-92 UreaN-82* Creat-2.7* Na-141 K-4.0 Cl-105 HCO3-25 AnGap-15 [**2132-12-9**] 05:30AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.3 . [**2132-11-30**] 12:55PM BLOOD cTropnT-0.08* [**2132-11-30**] 12:55PM BLOOD CK(CPK)-61 [**2132-11-30**] 12:55PM BLOOD Calcium-9.6 Phos-3.5 Mg-2.3 [**2132-11-30**] 12:55PM BLOOD TSH-10* [**2132-12-1**] 06:44AM BLOOD T3-68* Free T4-0.95 . [**2132-11-30**] 12:55PM BLOOD Digoxin-2.9* . [**2132-12-1**] 04:43AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2132-12-1**] 04:43AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2132-12-1**] 04:43AM URINE Hours-RANDOM UreaN-605 Creat-54 Na-39 [**2132-12-1**] 04:43AM URINE Osmolal-396 . Imaging/Studies: CXR [**11-28**] - No overt pulmonary edema or change in position of the dual pacemaker leads. . ECHO [**12-3**]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %) with global hypokinesis and akinesis to dyskinesis of th inferior and infero-lateral walls. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . EKG [**12-1**]: Ventricular paced rhythm. Compared to the previous tracing of [**2132-2-21**] ventricular premature depolarizations are no longer evident. Brief Hospital Course: 82 y/o male w/ a hx of non-ischemic CM (EF 15%) s/p CRT/D, CAF s/p AV ablation, VT s/p ablation, p/w VT w/ multiple ICD firings. # CORONARIES: The patient has no history of CAD with clean coronaries on cath [**2-16**]. . # PUMP: The patient with known non-ischemic cardiomyopathy with an EF of 15%, and reported recent heart failure exacerbation, with described improvement of symptoms from increased diuresis. Creatinine inceased from 1.5 baseline to 2.6, which may be the product of over diuresis. Diuresis was initially held, however when pt underwent procedure for attempted VT ablation he received IVFs and was felt afterwards to be volume overloaded. He was diuresed over the next two days as blood pressure allowed with moderate responsive in uop to Lasix 60mg IV. His home [**Last Name (un) **] was held in the setting of acute renal failure. B-blocker was continued, but digoxin level was held as his level was supratherapeutic. Compression stockings were applied. On [**12-5**], the patient was started on a milrinone drip to improve cardiac output and in particular blood flow to the kidneys. He was maintained on po torsemide 40mg po bid. His milrinone was discontinued on [**12-7**]. His spironolactone was also discontinued in the setting of marginally low blood pressure. His valsartan was also discontinued, in the setting of low blood pressure and acute renal failure. His carvedilol was switched to metoprolol because metoprolol was thought to be better at reducing ectopy. Your digoxin was discontinued. . # RHYTHM: Patient with history of VT, s/p ablation. Patient had been treated with increasing diuresis for HF exacerbation. Has been on amiodarone. Over last week, has had increasing frequency of ICD firings with VT storm over last 24 hrs, with unstable VT in the ED requiring DCCV with exernal pads. In AF with V-paced rhythm on arrival to the ICU and maintained on an amiodarone + lidocaine drip initially. He was brought to the EP [**Month/Year (2) **] for VT ablation at basal, posterolateral LV. VT was temporarily terminated, but patient did have some subsequent VPBs. He was started on po amiodarone and mexiletine with good effect. He then underwent generator change for his pacemaker on [**12-2**] without complications. His Coumadin was held for several days due to a supratherapeutic INR and was restarted on [**12-6**]. He completed a 7 day course of levofloxacin for prophylaxis given penicillin and sulfa allergy. He was scheduled to follow-up with his cardiologist, Dr. [**Last Name (STitle) 45945**] for device check and follow-up. The patient was discharged on mexilitine, amiodarone, and metoprolol. You should have your INR checked every other day, and coumadin dosed accordingly, with goal INR between [**1-13**]. . # ARF: On admission, the patient's creatinine up from presumed baseline 1.5 (last [**2-16**]) to 2.6 in the setting of diuresis for HF. All medications were renally dosed, and [**Last Name (un) **] was held. Diuresis was initially held, but resumed in the setting of volume overload. He had moderate response to diuresis with both Lasix and torsemide throughout. Once started on milrinone, his uop increased and creatinine remained stable at 2.6. His lasix was discontinued and he was continued on torsemide.His valsartan was not continued at discharge. You should have your labs drawn on [**12-15**], prior to your appointment with Dr. [**First Name (STitle) 14966**]. . # Hypertriglyceridemia: Continued fibrate. . # Glaucoma: Continued Latanoprost and Brimonidine gtts Medications on Admission: 1. Gemfibrozil 600 mg Tablet PO BID 2. Furosemide 80 mg PO BID 3. Metoprolol Succinate 50 mg PO DAILY 4. Valsartan 40 mg PO DAILY 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 8. Digoxin 125 mcg PO DAILY 9. Warfarin 2.5 mg daily QOD without dose on qTues Discharge Medications: 1. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for VT. Disp:*90 Capsule(s)* Refills:*2* 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAYS (MO,TU,WE,TH,FR,SA). 10. Outpatient [**Hospital1 **] Work Na, K, Cl, CO2, BUN, Creatinine, Mg, PO4, Ca, AST, ALT, Alkaline Phosphatase, PTT, PT INR. Please draw [**12-15**]. Please send results to Dr.[**Name (NI) 56956**] office Fax# [**Telephone/Fax (1) 56957**] 11. Outpatient [**Name (NI) **] Work PTT, PT, INR measure qod. Goal INR is between [**1-13**]. Titrate coumadin accordingly. Discharge Disposition: Extended Care Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Primary: Ventricular tachycardia, acute kidney failure, Chronic systolic Congestive Heart Failure Secondary: Dyslipidemia, Hypertension, Cardiomyopathy, Chronic Kidney Disease, Atrial fibrillation Discharge Condition: Hemodynamically stable, afebrile. Discharge Instructions: You were admitted to [**Hospital1 18**] with multiple activations of your ICD (cardioversion device) and low blood pressures. You underwent a procedure called VT ablation to help remove a focus of your arrhythmia. However, you continued to have arrhytmia (VT, ventricular fibrillation) in the laboratory. Because of this, you were continued on Amiodarone and started on Mexiletine. You also underwent a generator change for your ICD. You hospital stay was complicated by acute renal failure, which stabilized at time of discharge. Your Valsartan and spironolactone were discontinued secondary to low blood pressure and acute on chronic kidney disease. Please discuss with your cardiologist whether you should restart your valsartan and spironolactone. You carvedilol was discontinued and replaced with metoprolol because metoprolol is more effective in minimizing ventricular ectopy. Please continue taking metoprolol. Your Lasix was discontinued and replaced with torsemide for more effective diuresis. Please continue taking torsemide. You were discharged home in good condition. Should you experience any palpitations, heart flutter, chest pain, dizziness, faintness, recurrent shocks, shortness of breath, or any other symptom concerning to you, please call your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23651**] or go to the nearest emergency room. Followup Instructions: You have a follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14966**] on [**2132-12-15**] [**Telephone/Fax (1) 14967**] at 12:45pm . You have a previously scheduled appointment with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 14967**] on [**12-22**] at 3pm ().

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icd9cm

[ [ [] ] ]

[ "37.34", "37.26", "00.54" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2179-11-22**] Discharge Date: [**2179-12-3**] Date of Birth: [**2116-4-21**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1267**] Chief Complaint: Shortness of breath, pleuritic chest pain, nausea, and chills. Major Surgical or Invasive Procedure: Right Sided Cardiac Cath with Pericardiocentesis: [**2179-11-22**] pericardiectomy [**11-25**] History of Present Illness: Patient is a 63 year old female with a past medical history of Hypercholesterolemia who presented to [**Hospital1 18**] ED with worsening shortness of breath and chest pains lasting for the past week. Chest pain is described as a tightness around her neck and shoulders bilaterally. For the past week, she had also been having shortness of breath and pleuritic chest pain with inspiration relieved with an upright position. She has had a non productive cough for the past few days. She denies any fevers. She has noted chills, nausea and vomiting today. She denies any peripheral edema, or abdominal distension. She saw her PCP in [**State 5111**] who performed a CT scan of the chest. Initial diagnosed with pneumonia, she was given Rocephin, Avelox, and Decadron short acting and a depot formulation. Upon presentation to the Emergency Department, she was hypotensive with a systolic blood pressure in the 70s and tachycardic to the 110s. She recieved 2L IVF bolus with good response. She was taken to Cath Lab for a right heart cath and pericardicentesis. She was transfered to the CCU for further monitoring in a fair condition. Past Medical History: Dyslipidemia arthritis s/p TAH/BSO Social History: Patient is a nonsmoker. Occasionally uses alcohol with no history of alcohol abuse. She works as a nurse [**First Name (Titles) **] [**Last Name (Titles) 5111**]. Has lost her son to pneumococcal pneumonia recently and feels under stress. Family History: No family history of CAD, Stroke, rheumatologic disorders, or pericardial disease. Physical Exam: Vital Signs: Afebrile, BP 134/75, HR 101, RR 20, O2 97% on 2L, CVP 20 General Exam: WDWN female in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with right IJ in place. No noted lymphadeopathy. Cardiovascular: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. S3. Prominent rub throughout precordium. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mild crackles at base/posterior. Abdomen: Ssoft, NTND, No HSM or tenderness. No abdominial bruits. Extremeties: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2179-12-3**] 07:35AM BLOOD WBC-11.5* RBC-3.23* Hgb-9.8* Hct-29.3* MCV-91 MCH-30.2 MCHC-33.3 RDW-13.6 Plt Ct-753* [**2179-12-3**] 07:35AM BLOOD Plt Ct-753* [**2179-11-22**] 10:33AM BLOOD WBC-10.2 RBC-3.75* Hgb-11.6* Hct-34.9* MCV-93 MCH-31.0 MCHC-33.3 RDW-13.3 Plt Ct-364 [**2179-11-22**] 12:11PM BLOOD PT-12.4 PTT-22.4 INR(PT)-1.1 [**2179-11-22**] 10:33AM BLOOD Glucose-160* UreaN-17 Creat-0.7 Na-142 K-4.3 Cl-106 HCO3-21* AnGap-19 [**2179-11-24**] 06:01AM BLOOD ALT-148* AST-32 LD(LDH)-149 AlkPhos-102 TotBili-0.5 [**2179-12-1**] 06:00AM BLOOD Vanco-18.7 CHEST (PA & LAT) [**2179-12-2**] 7:48 PM [**Hospital 93**] MEDICAL CONDITION: 63 year old woman s/p pericardectomy REASON FOR THIS EXAMINATION: evaluate for effusions PICC in mid SVC. Relatively unchanged left small and decreased small right pleural effusions. Similar appearance of pulmonary vascularity. [**Numeric Identifier **] PICC W/O PORT [**2179-12-1**] 7:30 AM Reason: for iv antibiotics PROCEDURE NAME: PICC line placement. INDICATION: IV access needed for antibiotics. TECHNIQUE: Using sterile technique and local anesthesia, the right brachial vein was punctured under direct ultrasound guidance using a micropuncture set. Hard copies of ultrasound images were obtained before and immediately after establishing intravenous access. A peel-away sheath was then placed over a guidewire and a double-lumen PICC line measuring 44 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French double-lumen PICC line placement via the right brachial venous approach. Final internal length is 44 cm, with the tip positioned in SVC. The line is ready to use. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 8021**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75921**] (Complete) Done [**2179-11-25**] at 8:46:20 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 1112**] W. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2116-4-21**] Age (years): 63 F Hgt (in): 65 BP (mm Hg): 156/78 Wgt (lb): 120 HR (bpm): 98 BSA (m2): 1.59 m2 Indication: Intraoperative TEE for pericardial resection ICD-9 Codes: 786.05, 423.9, 424.0 Test Information Date/Time: [**2179-11-25**] at 08:46 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW4-: Machine: Siemens Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Aorta - Ascending: 2.8 cm <= 3.4 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Borderline normal RV systolic function. Abnormal septal motion c/w pericardial constriction. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. PERICARDIUM: Small to moderate pericardial effusion. The pericardium may be thickened. Constriction is present. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Bilateral pleural effusions. 1. No atrial septal defect is seen by 2D or color Doppler. 2.There is mild regional left ventricular systolic dysfunction with mild hypokinesia of the lateral and inferolateral wall. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). 3.Right ventricular systolic function is borderline normal. There is abnormal septal motion suggestive of pericardial constriction. 4. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7.There is a small to moderate sized pericardial effusion. The pericardium may be thickened. Pericardial constriction is present. 8. Post pericardial resection there is reduction in the pericardial effusion. Brief Hospital Course: Patient was transferred to the CCU after her pericardiocentesis in a fair condition. She was seen and evaluated by the CCU team upon her arrival. Since the procedure, she had an improvement in her dyspnea and pleuritic pain. She was no longer nauseated and her chest pain was improved with doses of IV morphine. She was placed on supplemental O2 via nasal canula. Wound site was hemostatic with no bleeding. Patient was evaluated for possible causes of pericardial effusion including infectious causes (Viral EBV, Adenovirus, HIV, TB, Streptococcus, CMV, [**Doctor Last Name **], ect), malignancy, or rheumatologic causes. Her pericardial drain was dc'd on [**11-23**]. She continued on vanco and zosyn. She was seen by cardiac surgery for potential pericardiectomy secondary to contriction. She was taken to the operating room on [**11-25**] where she underwent a pericardiectomy. She was transferred to the ICU in critical but stable condition. She was extubated later that day. She was transferred to the floor on POD #2. She did well postoperatively. She was followed closely by infectious diseases who recommended that she complete a 2 week course of vanco and levo, and await finalization of her OR cultures. Rheumatology felt that the effusion was not due to an immune process/RA. A PICC line was placed on [**11-30**]. ID recommended that she complete a 2 week course of vanco and levo which she will receive in [**State 5111**]. The results of a weekly CBC, chemistry and vanco trough will be sent to her PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 805**]. She will also follow up with CT surgery at [**Location (un) **] Medical Center in [**Location (un) 1661**]. Medications on Admission: Zetia 10mg PO Daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Ezetimibe 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. PICC line PICC line per protocal for heparin and NS flushes 6. Outpatient Lab Work Weekly vanco trough, chem 7 and CBC with results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**] Phone ([**Telephone/Fax (1) 75922**], FAX *** 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks: started [**11-30**], completed [**12-13**]. Disp:*14 Tablet(s)* Refills:*0* 8. 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* 9. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750) Recon Soln Intravenous Q 24H (Every 24 Hours) for 2 weeks: started [**11-26**] ends [**12-10**]. Disp:*[**Numeric Identifier **] Recon Soln(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**State 5111**] VNA Discharge Diagnosis: Pericardial effusion with tamponade ^chol, Arthritis, s/p TAH/SBO 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. [**First Name (STitle) 805**] 1-2 weeks Dr. [**Last Name (STitle) 28181**] 2 weeks Please make an appointment with CT surgery at [**Location (un) **] Medical Center [**Telephone/Fax (1) 75923**] in [**3-28**] weeks. We have faxed them a copy of your operative report and discharge summary. Completed by:[**2179-12-3**]

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4615

Discharge summary

report

Admission Date: [**2171-2-1**] Discharge Date: [**2171-3-18**] Date of Birth: [**2111-5-11**] Sex: M Service: MEDICINE Allergies: vancomycin / daptomycin Attending:[**First Name3 (LF) 3963**] Chief Complaint: cough, dyspnea, O2 requirement, tranaminitis Major Surgical or Invasive Procedure: liver biopsy History of Present Illness: Mr. [**Known firstname **] [**Known lastname 4580**] is a 59 year old male with monoclonal gammopathy, severe oral lichen planus, recent GIST tumor s/p surgical resection [**2170-12-27**], possible neuromuscular disorder who presents with cough and fever X 3 days. . His symptoms began three days ago beginning with one day of low grade fever to 100.4, cough, and fatigue. He was noted to have increased O2 requirement and transaminitis and was referred to the ED. Patient has had no abdominal or GI symptoms. . Of note patient has had a long and complicated medical history beginning in [**2169-8-20**] when he suddenly lost his sense of taste after treatement of social anxiety with proproanolol. It was the start of a progressive course of oral lichen planus. Due to loss of taste, he last 20 lbs. He developed respiratory problems including a number of sinus infections in the summer of [**2170**] requiring treatmetn with antibitotics. Workup by his PCP [**Name Initial (PRE) 7837**] "abnormal immunoglobulin levles, further evaluated with bone marrow biopsy revealing MGUS. He began to develop rashes, and worsening of his oral lichen planus with mouth, pain and thrush. He had biopsies of his tongue confirming diagnosis lichen planus. Biopsy of plaques on the dorum of his knuckles were suggestive of Gottren's papules, making diagnosis concerning for dermatomyositis. Given patient had not had weakness consistent with this, it was suggested that he had a diagnosis of sine dermatomyositis. Later with subsequent biopsy, this diagnosis was challenged with systemic lichen planus. Furthermore, as dermatomyositis was raised, patient underwent an exhausive workup for malignancy including colonsocopy and endoscopy. A gastric mass was discovered, found to be a benign GIST tumor. Throughout these hospitalization, patient became malnourished as workup for his symptoms continued. He developed several pneumonia . During his most recent hospitalization for low grade temperature, cough, and hypoxia, he was found to have a possible aspiration and/or bronchiectasis/bronchiolitis with resultant transpulmonary shunt. Sputum cultures grew MSSA and pan-sensitive Pseudomonas. He was treated with a 10day course of cipro and cefazolin. At time of discharge he was satting in the low 90s on room air with ambulatory sats in the mid-90s on room air. A cause of his weakness has not been discovered. Neurology has recommended a voltage gated calcium channel antibiody [**Hospital1 **] nicotinic receptor binding antibody which must be ordered as outpatient. Weakness was also thought to be the cuase of his aspiration risk and NIF of -40. It was unclear whether this was a neuromuscular process or rheumatologic condition. Decision was made to initiate treatment with steroids. Patient's breathing improved (NIF improved to -80). He was discharged on a prolonged steroid course. . Of note, skin biopsy recently showed overlap between lichen planus and connective tissue disorder (lichen planus with immune deposition). Serologic tests include: negative [**Doctor First Name **], ANCA, anti-synthetase antibodies and normal CK. Inflammatory markers were markedly elevated. Sine dermatomyositis was suggested, but seems less likely based on his clinical course. . In the ED, initial vital signs were 98.7 102 101/60 22. He triggered for hypoxia 84% on RA. CXR from earlier in the day was clear. He was not given antibiotics. He was admitted for management of hypoxia. He was given 1L NS. Vital sings on tranfer were: 112/75, 101, 90% 4L nc. . On the floor, patient has no new complaints. Looking forward to returning home. Past Medical History: Bronchiolitis, Bronchiectasis Monoclonal gammopathy with balanced 2;21 translocation and 10% plasma cells in [**2170-4-20**] Clinical judgement of "amyopathic dermatomyositis" 4.2 cm gastric stromal tumor s/p endo-lap resection [**2170-12-27**] Biopsy proven Lichen planus with oral and peripheral lesions Shingles 5 years ago s/p hernia repair at age 16 ?Autoimmune hepatitis ([**1-/2171**]) Social History: Is a self-employed TV engineering consultant who builds TV studios. Remote tobacco - quit [**2144**]. Rare alcohol (a few glasses of wine per week prior to getting sick, none with his altered taste sensation). No illicits. Married for 20+ years and lives with wife who travels around the world doing preformance art. No children. + cat (indoor only). No other pets. Summers at family home in [**State 1727**] on the ocean. No known exposures/bites including ticks. Family History: Mother died of MI in her 70s. Father had emphysema and angina and died at 78. Had one older brother who died of [**Name (NI) 8751**] in college. Physical Exam: On admission: Vitals: 95.9 98/64 97 20 90% on 3L General: Alert, oriented, emaciated gentleman appearing older than stated age, no acute distress HEENT: Sclera anicteric, MMM, oropharynx with healing mucosal ulcerations. Neck: supple, JVP not elevated, no LAD, muscle atrophy noted. Lungs: Fair airmovement, with audible expiratory wheezes, forced expiratory wheeze elicits cough. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro:CN2/12 intact. Strenth [**4-25**] throguhout, overall weak to my assessment, lower extremity worse than upper. Gait narrow and steady, mentally clear and responds to questions appropriately. On dishcarge: Patient expired. Temperature 96.2, no heart or breath sounds on ascultation. Pertinent Results: [**2171-2-1**] 10:45AM BLOOD WBC-3.4* RBC-4.27* Hgb-12.8* Hct-36.9* MCV-86 MCH-30.0 MCHC-34.8 RDW-16.2* Plt Ct-204 [**2171-2-1**] 10:45AM BLOOD Neuts-72.4* Lymphs-16.6* Monos-10.3 Eos-0.4 Baso-0.3 [**2171-2-1**] 04:10PM BLOOD PT-11.4 PTT-30.7 INR(PT)-1.1 [**2171-2-1**] 04:10PM BLOOD Glucose-136* UreaN-18 Creat-0.5 Na-132* K-3.6 Cl-97 HCO3-24 AnGap-15 [**2171-2-1**] 10:45AM BLOOD ALT-602* AST-259* AlkPhos-185* TotBili-0.6 [**2171-2-1**] 04:10PM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0 [**2171-2-1**] 10:45AM BLOOD calTIBC-216* VitB12-1676* Folate-15.7 Ferritn-2285* TRF-166* [**2171-2-2**] 06:45AM BLOOD TSH-2.0 [**2171-2-2**] 06:45AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2171-2-2**] 11:26AM BLOOD AMA-NEGATIVE [**2171-2-2**] 06:45AM BLOOD Smooth-NEGATIVE [**2171-2-2**] 06:45AM BLOOD [**Doctor First Name **]-NEGATIVE [**2171-2-2**] 06:45AM BLOOD IgG-971 IgM-18* [**2171-2-2**] 06:45AM BLOOD tTG-IgA-3 [**2171-2-1**] 04:37PM BLOOD Lactate-2.5* [**2171-2-5**] 03:29PM BLOOD CERULOPLASMIN- 34 [**2171-2-5**] 03:29PM BLOOD ALPHA-1-ANTITRYPSIN- 244 [**2171-2-2**] 06:45AM BLOOD VARICELLA ZOSTER ANTIBODY, IGM- neg [**2171-2-2**] 06:45AM BLOOD HERPES SIMPLEX (HSV) 2, IGG- neg [**2171-2-2**] 06:45AM BLOOD HERPES SIMPLEX (HSV) 1, IGG- neg [**2171-2-2**] 06:45AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM- neg CXR: PA and lateral chest compared to [**1-10**] through [**1-16**], extent of peribronchial thickening and impaction of extensive bibasilar bronchiectasis may have increased slightly since the most recent prior lateral chest radiograph, [**1-10**]. There is really no change in the appearance of the frontal views as recently as [**1-16**]. Generalized hyperinflation is due to emphysema. Heart size is normal. There is no pulmonary edema, consolidation. A tiny right pleural effusion may be new, but probably not clinically significant. Findings would therefore be attributed to decompensation of emphysema and bronchiectasis. RUQ U/S: 1. Normal hepatic Doppler examination. 2. Sludge and likely polyps within the gallbladder. No pericholecystic fluid or wall thickening. CT Abd: 1. Bibasilar bronchiectasis with mucoid plugging of several bronchi. 2. Normal morphologic-looking liver with a single hamartoma in segment III of the liver. 3. Bilateral renal cysts. 4. Replaced right hepatic artery arising from the superior mesenteric artery. Liver Bx: Liver, needle core biopsy: 1.Marked peri-centrivenular, mild portal and periportal inflammation consisting of lymphocytes, plasma cells, neutrophils and macrophages with apoptotic hepatocytes and peri-centrivenular hepatocyte drop out (confirmed by reticulin stain). 2.Associated foci of central endothelialitis with peri-centrivenular hemorrhagic necrosis identified. 3.No significant steatosis seen. 4.Trichrome stain highlights central vein damage; no definitive increase in fibrosis identified. 5.Iron stain shows mild iron within predominantly peri-centrivenular hepatocytes. 6.[**Country 7018**] red stains are negative for amyloid, with satisfactory control. Note: The features are those of a marked active hepatitis with a predominantly centrivenular pattern of injury. The differential includes an immune-mediated drug effect and autoimmune hepatitis; viral hepatitis is less likely. Further correlation with clinical and serologic findings is needed. Given the patient's history of monoclonal gammopathy and the presence of rare binucleate plasma cells, the case will be further reviewed by hematopathology and their findings issued separately in an addendum. . Video Swallow: Penetration, but no gross aspiration, with thin and nectar thick liquids, similar to prior study. . Thyroid US [**2171-2-27**]: 11 mm spongy nodule in the left thyroid without worrisome features. , EKG [**2171-3-4**]: Sinus tachycardia with increase in rate as compared with previoui tracing of [**2171-2-23**]. Variation in precordial lead placement. Except for rate, the tracing remains normal without diagnostic interim change. . CTA [**2171-3-4**]: 1. No evidence for PE. 2. Improved nodular opacities in the right lower lobe consistent with resolving infection. 3. Unchanged bronchiectasis with bronchial wall thickening and mucous plugging in the lower lobes. . CXR [**2171-3-6**]: Heart size and mediastinum are unremarkable. Right lower lobe and left lower lobe bronchiectasis with bronchial wall thickening and endobronchial impaction overall appear unchanged since the prior examination with no evidence of interval progression of the infectious process. Note is made that the left costophrenic angle was not included in the field of view. There is no appreciable pleural effusion or pneumothorax. The Dobbhoff tube tip is in the stomach. Substantial hyperinflation is redemonstrated. . CXR [**2171-3-11**]: IMPRESSION: 1. Dobbhoff feeding tube is seen coursing below the diaphragm with the tip not completely identified but positioned within the stomach proximally. It does not appear to be significantly changed. Bilateral lower lobe bronchiectasis is stable. No focal airspace consolidation is seen to suggest an acute pneumonia. No pleural effusions or pneumothoraces. Overall, cardiac and mediastinal contours are unchanged. Lungs remain hyperinflated. . CXR [**2171-3-13**]: Bronchial wall thickening or peribronchial infiltration in the lower lungs where most pronounced bronchiectasis is have worsened since [**3-11**] consistent either with a flare of bronchiectasis or development of peribronchial pneumonia. Heart size is normal. There is no pleural effusion, no pneumothorax. Feeding tube ends in the upper stomach. CXR [**2171-3-14**]: As compared to the previous radiograph, there is no relevant change. Moderate-to-severe overinflation with known areas of bronchiectasis and perifocal parenchymal opacities. The opacities are unchanged in distribution and severity. Normal size of the cardiac silhouette. Normal hilar and mediastinal structures. No newly appeared focal parenchymal changes. . CXR [**2171-3-17**]: 1) Small left effusion with underlying collapse and/or consolidation. In the appropriate clinical setting, the differential would include a pneumonic infiltrate. Findings discussed with the covering house officer on the afternoon of the exam. Brief Hospital Course: BRIEF HOSPITAL COURSE This is a 59 year old gentleman with systemic disease of unclear etiology now with fever, cough, hypoxia, and transaminitis who eventually decompensated on [**2171-3-16**] with respiratory failure (multifactorial, pls see below) and was made CMO on [**2171-3-17**] and passed away on [**2171-3-18**]. . . # Hypoxia: Likely [**2-21**] known bibasilar bronchiectasis, initially. Sputum with moderate pan-sensitive pseudomonas. Was treated with suppression ciprofloxacin, aggressive chest PT, mucolytics, nebulizers (many of which were refused). Transitioned from albuterol to xopenex nebs b/c the former left the patient feeling too "jittery". Remained stable on 2L O2 with O2 sat in low 90s. Had a desaturation episode on [**2-22**] in the setting of a prolonged attempt at dobhoff placement. Repeat CT at that time suggested no abscess but RLL nodular densities concerning for spread of infx (aspergillosis or fungal) vs inflammatory nodules. His respiratory status remained stable with a 2L O2 requirment. He was started on atovaquone for PCP [**Name Initial (PRE) **] (bactrim held given possible contribution to LFT elevations and pt did not tolerate daptomycin --> episode of flushing, tachycardia). Pulmonary deferred on bronch vs VATS to bx the peripheral nodule given the patient's strong preference and his aspiration risk. Pulm also suggested an acapella flutter device, [**Doctor First Name **] nebs 3x/wk (started [**3-2**]), and blood testing for CF. On the afternoon of [**3-4**] the patient had a desaturation episode in the setting of a fever to 102F. A CXR at that time demonstrated a new RLL PNA. His antibiotics were broadened and he stayed overnight in the MICU before returning to the floor. He improved gradually and his O2 requirement remained stable 2-3L. On [**3-13**] a CXR performed in the setting of persistent tachycardia demonstrated a flare of his bronchiectasis vs a peri-bronchial PNA. He was broadened to cefepime and the [**Doctor First Name **] nebs were d/c'd. . By [**2171-3-16**], Patient was having trouble clearing secretions, with known pseduomonas colonization of his sputum. Patient was kept on cefepime, with daily aggressive chest PT and frequent reminders to take guaifenisen for mucolytic therapy, as he has significant difficulty clearing secretions. On [**2171-3-17**], respiratory status worsened with tachypnea, venous blood gas showed increased CO2. CXR showed LLL opacification/collapse. Case discussed with the pulmonary fellow and [**Hospital Unit Name 153**] team. The pulmonary fellow discussed with the patient and his wife the code status and recommended against CPAP/intubation as futile measures. The patient became DNR/DNI. A morphine drip to titrate to confort was started, as discussed and agreed by the patient, his wife, the pulmonary fellow, attending Dr [**Last Name (STitle) **] and [**Hospital Unit Name 153**] resident. Patient's antibiotics and every other med including IVIG and CSA were continued. Despite increasing doses of morphine drip, patient continued to exhibit tachypnea and patient was made CMO that evening. Patient received morphine bolus doses on top of drip and all other medications were held. Patient passed away on [**2171-3-18**] at 4:05pm. . # Lichen planus: Worst in mouth but also has diffuse skin lesions. Appreciate dermatology c/s who discussed case w/ multiple colleagues and has been incredibly helpful throughout his course. His multiple skin biopsies are consistent with an exuberant lichen-planus like eruption, which for the moment we are categorizing as severe generalized lichen planus. Our work up for paraneoplastic syndrome, namely the LP varient of PAMS, has thus far been negative: no Dsg1 or Dsg3 antibodies, and indirect immunoflouresence has been negative (although immunoflouresence on rat bladder is still pending - will be run by [**Hospital1 **]). Meanwhile, the search for an underlying cause (i.e. malignancy) has been unrevealing. Flow cytometry from [**2-21**]: no features of leukemia. BM bx suggested possible mastocytosis, but derm felt that skin biopsies were less consistent with this possibility, and a tryptase was negative. Paraneoplastic pemphigus send-out returned negative. Arsenic negative. Based on a discussion between heme/onc and derm, the pt underwent a 4-day course of IVIG 0.5 g/kg/day (25g/day) under the premise that though this is not a treatment for lichen planus per se it might target the underlying pathology. He was maintained on IV steroids briefly but then switched back to po prednisone and is currently on a long taper. After extensive discussion involving GI and heme/onc (appreciate derm's continued input), commenced cyclosporine 25 mg [**Hospital1 **] on [**3-7**] and then increased to 50 [**Hospital1 **] on [**3-10**] and 100 [**Hospital1 **] on [**3-14**]. Has tolerated well so far. The rest of his skin regimen includes clobetasol + plastic wrapping, mupirocin for his lower face and neck, and topical tacrolimus (mixed 1:1 with vaseline) for around his eyes. . # Bacteremia: Grew out MSSA from blood cultures 2/03 in the setting of persistent fevers. Received linezolid [**Date range (1) 19593**] and also daptomycin but had a rxn during infusion. Started on cefepime (narrowed to nafcillin on [**2-28**]), and was afebrile until [**3-4**]. Blood cx grew GPC in clusters until [**2-26**] (last positive cx [**2-25**]). ID narrowed to nafcillin [**2-28**]. ID followed, but signed off [**3-1**] (note: pt should f/u with [**Doctor Last Name 13895**] of ID w/in 2 wks of d/c; need to fax labs qweek to ID dept). Pt had poor quality TTE that did not reveal vegetations but a TEE was deferred given aspiration risk and pt preference. Daily surveillence cultures were obtaiend [**Date range (1) 19594**]. Cultures remained negative and patient was afebrile. On [**3-13**] an infectious workup for tachycardia yielded blood cultures that grew MRSA, and on [**3-14**] he was broadened to cefepime/linezolid. . # Nutrition/deconditioning: Pt's weight down to ~115 from pre-illness weight 170. Poor PO intake [**2-21**] mouth pain a/w eating (due to oral lichen planus). An oral video swallow previously showed no change from prior. An EMG was normal. Pt is adamant in refusal of G-tube and TPN. Dobhoff placed [**2-25**] with help of surgery. TF to 90/hr x 12 hrs (9PM-9AM) on [**2-27**] (~1620 cals); pt tolerating well. Nutrition followed the patient while in house. He required dexamethasone and gelclair along with viscous lidocaine for oral care. He is unable to tolerate a variety of foods (dry, salty, spicy, tangy, etc.). His wife provides high-calorie milkshakes. TF were switched from cycled initially to continuous and then back to cycled (the last change to stimulate the patient's appetite). . # Transaminitis: Pt had mild transaminitis since [**Month (only) **] of [**2170**]. From the 30s to 50s. This increased in [**Month (only) 1096**] to 100s range, thought to be secondary to antibiotic effect. At time of his most recent discharge he was set up to have LFTs followed up after discontinuation of antibiotics to ensure resolution of transaminitis. In follow up appointment he was noted to have LFTs with ALT 627, AST 276, Alk Phos 198, TBili 0.5. He was admitted to the hospital for workup. Hepatology was consulted. Vital hepatitidies, CMV, EBV, VZV, HSV with negative serologies and/or viral loads. RUQ ultrasound unremarkable, as was CT abdomen. He underwent liver biopsy which was suggestive of drug induced immune reaction vs autoimmune hepatitis. He was continued on high dose prednisone throughout. Despite this, during his hosptialization, his LFTs continued to rise peaking in 1400s. The hepatology team also recommended further workup with antiLKM ab, serum VEGF levels to r/o POEMS, which were all unrevealing. He was continued on prednisone (40-60 mg daily) and started on azathioprine with continued worsening of his transaminitis. Ultimately azathioprine was discontinued after 10 days ([**Date range (1) **]). Bactrim was also held given its potential contribution. His LFTs started to improve without clear precipitant. Interestingly his synthetic function was intact throughout this period of liver injury. His LFTs continued to decline, and he was briefly transitioned to IV methylprednisolone before being switched back to prednisone. By the first week of [**Month (only) 956**] his LFTs had more or less stabilized at ALT 200s, AST ~100, AlkPhos ~200. LFTs were followed periodically after this and they continued to decline toward normal range. . # Hyponatremia - Na was persistently low despite IVF with NS, withholding free water from tube feeds, etc. Urine lytes [**3-2**] indicate SIADH (UOsm 799). However, pt was without symptoms per se and strongly preferred that his IVF be maintained (due to perceived dryness/cracking in mouth that prevents him from sleeping). Following a switch in the patient's continuous tube feeds (namely a different formula with a reduced free water content), the hyponatremia resolved. . # Thyroid nodule: 1.1 cm thyroid nodule discovered incidentally on chest CT on [**2-22**]. Given a potential connection between the patient's presumed autoimmune disorder and underlying malignancy, it was thought that this nodule merited further workup. T4 and TSH nl. Thyroid U/S performed [**2-27**]; nodule not concerning; defer further w/u for now. . # Leukopenia: Has been present since last admission. WBC declined < 3K but climbed after conclusion of IVIG tx 5-6K (~[**2-23**] - [**2-26**]). Has been declining since. . # PLASMA CELL DYSCRASIA/MGUS: Patient has 10% plasma cells, negative skeletal survey, normal calcium and no renal insufficiency. He refused BMBX on [**1-15**]. Given other hemotologic abnormalities repeat bone marrow biopsy may be indicated. . # Blepharitis/severe dry eyes: Pt c/o dry eyes; must use artificial tears to keep eyes open. Ophthalmology consulted re possible ocular involvement of lichen planus and additional options for eye care. They suggested gel vs frequent artificial tears. Felt that no ocular involvement per se. . # Anxiety: History of severe anxiety/panic attacks at his prior admission. Social work following ([**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 12471**]); has been a source of incredible support for pt and wife. On low-dose xanax for anxiety and clonazepam for sleep. Medications on Admission: 1. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) Ophthalmic TID (3 times a day). 2. dexamethasone 0.5 mg/5 mL Elixir Sig: Five (5) ML PO Q4H (every 4 hours). 3. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. Systane Balance 0.6 % Drops Sig: One (1) Ophthalmic prn () as needed. 7. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day, decreased to 30mg on Tuesday, [**2171-1-29**] 11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. lorazepam 0.5 mg Tablet Sig: 0.5-1 Tablet PO every 4-6 hours as needed for insomnia 16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day 17. GELCLAIR Gel in Packet Sig: 15ml Mucous membrane three times a day. 18. B Complex-Vitamin B12 Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: none. patient expired. Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired resp failure likely [**2-21**] bronchiectasis, mucous plugging, deconditioning, muscle weakness, and atelectasis. Discharge Instructions: patient expired Followup Instructions: patient expired

[ "697.0", "E930.5", "253.6", "238.75", "288.4", "482.42", "262", "288.50", "518.81", "284.19", "482.1", "373.00", "V49.86", "285.9", "570", "996.62", "279.49", "300.00", "571.42", "492.8", "V58.65", "518.0", "038.11", "494.1", "241.0", "V15.82", "934.9", "V85.0" ]

icd9cm

[ [ [] ] ]

[ "50.11", "86.11", "96.6", "31.42", "00.14", "41.31", "99.14" ]

icd9pcs

[ [ [] ] ]

24028, 24037

12323, 22726

328, 342

24096, 24227

6023, 12300

24291, 24309

4916, 5064

23981, 24005

24058, 24075

22752, 23958

24251, 24268

5079, 5079

244, 290

370, 3993

5093, 6004

4015, 4409

4425, 4900

74,147

149,842

27898

Discharge summary

report

Admission Date: [**2155-10-30**] Discharge Date: [**2155-11-1**] Date of Birth: [**2072-8-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 22964**] Chief Complaint: osteomylitis left knee Major Surgical or Invasive Procedure: left knee fusion; debridement CVL Right IJ A-line History of Present Illness: This is an 83 year-old male with a history of CAD s/p CABG, diastolic CHF, CRI, HTN, DM with recent history of septic left knee who presented on [**2155-10-30**] for fusion of his left knee and is now being transferred to the ICU after intraop blood loss (1500-2000cc) and hypotension requiring pressors. . With respect to his complicated joint history, he underwent left TKA many years ago. In [**5-22**] he was admitted to [**Location (un) **] [**Location (un) 1459**] Hopsital for septic arhtritis w/ S. aureus for which he was d/c on 6 wk course of cetriaxone and rifampin. The course thereafter is not entirely clear, however, he presented to OSH again in [**8-22**] with septic left joint at which time he was transferred to [**Hospital1 18**] and repeat arthrocentesis was performed with fluid showing 406,000 WBC with 91% PMNs. He was started on Ceftriaxone and Vancomycin. Cultures at that time revealed joint fluid with MSSA but tissue with MRSA. With consult from ID, patient was treated with Vancomycin 1gm q48h. He had hardware removed, washout, and antibiotic spacer placed on [**8-27**] and he was discharged to complete vancomycin. He presented again [**9-5**] with septic left knee joint and underwent repeat washout with antibiotic spacer placed on [**9-11**]. Subsequently he reportedly has done "well" with knee immobilization on vancomycin which he completed on [**2155-10-8**]. . He presented today for planned elective left knee fusion. His pre-op course was reportedly unremarkable. Intraop, he lost 1.5-2L blood and received a total of 6Units prbcs. He received an additional 4L crystalloid. His MAPs dipped repeatedly throughout the case in the low 40s and high 30s and he required multiple boluses of neosynephrine throughout the case. His UOP was 100cc throughout the entire case despite the above fluids. Preop hct was 31.1 and was 31.6 postop after the 6 units prbcs. Received calcium, insulin, lasix for K+ 6.6 intraop. Past Medical History: #. CAD - s/p CABG #. s/p Left TKA 20 years ago - s/p septic arthritis complicated by sepsis and ARF - required Operative washout and debridement - plan for potential revision of knee replacement after 6 week antibiotic course with CTX and Rifampin #. DM - Insulin dependent #. Hypertension #. Gout #. BPH #. Afib on coumadin #. CKD stage IV (1.8 last admission prior to sepsis) #. Anemia secondary to CKD and MDS Social History: Occupation: retired school teacher Living situation: lives in 2 story home on [**Location (un) 448**] w/ 12 stairs to enter building, son and daughter-in-law on [**Location (un) **] Key relationships: 2 sons [**Name2 (NI) 1959**] and [**Name (NI) **]) and daughter-in-law [**Doctor First Name 67970**] wife) Smoking, EtOH: [**7-22**] drinks per week, no tob or ilicits Family History: NC Physical Exam: Tmax: 36.7 ??????C (98.1 ??????F) Tcurrent: 36.7 ??????C (98 ??????F) HR: 85 (62 - 87) bpm BP: 106/44(60) {70/30(50) - 141/50(74)} mmHg RR: 17 (0 - 20) insp/min GEN: Intubated, sedated, intermittently diaphoretic. HEENT: Pupils 2mm and minimally reactive but symmetric, sclera anicteric, no epistaxis or rhinorrhea NECK: No JVD, trachea midline COR: RRR, nml S1, S2, no M/G/R appreciated. PULM: Lungs CTAB anteriorly, no W/R/R ABD: Soft, NT, ND, +BS, no masses appreciated EXT: Left leg in knee immobilizer with blood in drain from knee. Toes cool but with good cap refill. NEURO: Pupils as above. Winces with movement of left leg. Moves all extremities very minimally after placing CVL. Does not respond to commands. Downgoing toes B/L. SKIN: Pale, intermittently diaphoretic, No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2155-10-31**] 02:55PM BLOOD WBC-48.82* RBC-4.03* Hgb-12.1* Hct-35.3* MCV-88 MCH-30.1 MCHC-34.3 RDW-16.6* Plt Ct-122* [**2155-10-31**] 05:00AM BLOOD WBC-47.8*# RBC-4.65 Hgb-14.2 Hct-40.3 MCV-87 MCH-30.5 MCHC-35.3* RDW-16.1* Plt Ct-133* [**2155-10-31**] 02:55PM BLOOD Neuts-76* Bands-0 Lymphs-1* Monos-18* Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-2* [**2155-10-31**] 02:55PM BLOOD Neuts-76* Bands-0 Lymphs-1* Monos-18* Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-2* [**2155-10-31**] 02:55PM BLOOD PT-15.5* PTT-31.7 INR(PT)-1.4* [**2155-10-30**] 10:20AM BLOOD Fibrino-187 [**2155-10-31**] 02:55PM BLOOD Glucose-271* UreaN-61* Creat-3.2* Na-141 K-5.5* Cl-115* HCO3-10* AnGap-22* [**2155-10-31**] 02:55PM BLOOD ALT-24 AST-60* LD(LDH)-422* AlkPhos-84 Amylase-39 TotBili-1.0 [**2155-10-30**] 01:19PM BLOOD cTropnT-0.10* [**2155-10-30**] 06:31PM BLOOD CK-MB-38* MB Indx-15.9* cTropnT-1.05* [**2155-10-31**] 12:57AM BLOOD CK-MB-48* MB Indx-19.2* cTropnT-1.73* [**2155-10-31**] 05:00AM BLOOD CK-MB-43* MB Indx-21.1* cTropnT-1.67* [**2155-10-31**] 02:55PM BLOOD Albumin-2.3* Calcium-8.1* Phos-6.8* Mg-1.5* [**2155-10-31**] 05:17PM BLOOD Type-ART Temp-36.2 Rates-25/ Tidal V-500 PEEP-5 FiO2-50 pO2-227* pCO2-19* pH-7.31* calTCO2-10* Base XS--14 -ASSIST/CON Intubat-INTUBATED [**2155-10-31**] 05:17PM BLOOD Lactate-6.5* [**2155-10-31**] 08:54AM BLOOD Lactate-4.9* [**2155-10-31**] 01:29AM BLOOD Lactate-3.5* K-5.7* Joint Fluid: no growth Tissue: no growth Blood Cultures: pending IMAGING: [**10-31**] CT-ABD IMPRESSION: 1. Diffuse pneumatosis intestinalis with superior mesenteric and portal venous gas as well as colonic wall thickening. Overall, this is very concerning for ischemic/infarcted bowel. 2. Moderate left and small right pleural effusion. [**10-31**] ECHO The left atrium is mildly dilated. There is asymmetric left ventricular hypertrophy with normal cavity size and mild to moderate regional systolic dysfunction with hypokinesis of the anterior septum and anterior walls. The remaining segments contract well. There is no resting left ventricular outflow tract obstruction. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal with mild global free wall hypokinesis.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Asymmetric left ventricular hypertrophy with regional systolic dysfunction. Mild mitral regurgitation. Trace aortic regurgitation. Compared with the prior study of earlier in the day, left ventricular systolic function is improved. Brief Hospital Course: # He presented today for planned elective left knee fusion. His pre-op course was reportedly unremarkable. Intraop, he lost 1.5-2L blood and received a total of 6Units prbcs. He received an additional 4L crystalloid. His MAPs dipped repeatedly throughout the case in the low 40s and high 30s and he required multiple boluses of neosynephrine throughout the case. His UOP was 100cc throughout the entire case despite the above fluids. Preop hct was 31.1 and was 31.6 postop after the 6 units pRBC. The patient's blood pressures were maintained on levophed and neo. Additionally, the patient was started on broad spectrum antibiotics of vancomycin, zosyn and flagyl. Pt WBC count continued to rise post-op and on [**10-31**] reached 48.8 with a lactate of 6.5. The patient additionally developed melana and a CT-scan of the abdomin was performed. The results were consistent with severe mesenteric ischemia and after lengthy discussion the family chose to defer further treatment. The patient was made CMO and passed at 12:30am on [**2155-10-31**]. Anemia: Chronic and thought to be in setting of CKD and MDS per last admission note. On epo as outpatient. Now with acute blood loss in the OR. Received 6 units prbcs with hct remaining essentially stable at 31 (no bump). Acute drop likely due to blood loss from surgery as no other clear source of bleed currently. # CAD: As outlined above, clear concern for ischemic event despite no significant EKG changes. Trop elevated, CK now trending down. MBI negative. Not on statin as LDL <100 in [**Month (only) 216**], but HDL also markedly low at 17. # Respiratory failure: Remained intubated post op in the setting of hypotension and multiple metabolic abnormalities. Currently with room to decrease FiO2 given PaO2 in 500 range. Addtionally, not currently breathing over vent and with pCO2 of 23 so also room to decrease minute ventilation. CXR essentially clear so no clear underlying pulmonary process (beyond ? COPD) to suggest obstacle to extubation. However, pt too unstable to wean. # Oligo-/Anuria: Only 100cc out in the OR and 25cc since admission to the ICU. Differential includes poor forward flow [**2-15**] hypovolemia vs. d/t depressed EF/CO vs. ATN secondary to intraop hypotension vs. contrast injury. Pt with worsening renal function. # dCHF: Per OMR. Echo in [**8-22**] showed preserved EF. - holding lasix given hypotension # DM: Will continue home insulin regimen. If BS difficult to control will initiate insulin gtt. # Atrial fibrillation: Brief run of a fib with RVR during CVL placement at which time he dropped his BP. Since has been in NSR. Off coumadin prior to OR with preop INR of 1.4. - holding BB for hypotension - holding coumadin given concern for continued bleeding # HTN: As above, holding antihypertensive med for hypotension. # BPH: Holding doxazosin. Medications on Admission: 1. Ascorbic Acid 1000 mg PO BID 2. Cholecalciferol (Vitamin D3) 400 units daily 3. Miconazole Nitrate 2 % Powder topically [**Hospital1 **] prn 4. Doxazosin 2 mg PO hs 5. Epoetin Alfa 4,000 unit/mL QMOWEFR (Monday -Wednesday-Friday). 6. Folic Acid 1 mg PO daily 7. Multivitamin 1 PO daily 8. Thiamine HCl 100 mg PO daily 9. Aspirin 81 mg PO daily 10. Insulin Glargine 10 units SC hs 11. Humalog SS 12. Thiamine HCl 100 mg PO daily 13. Ipratropium Bromide 0.02 % nebs q6h 14. Albuterol nebs q6h prn 15. Acetaminophen 1000 mg PO Q6H prn pain 16. Oxycodone 5-10 mg PO Q6H prn 17. Metoprolol Tartrate 100 mg PO tid 18. Furosemide 20 mg PO daily 19. Coumadin 2.5 mg alternating with 5mg 20. Allopurinol 100 mg PO once a day 21. Bisacodyl 5 mg PO daily prn 24. Iron 325 mg PO once daily 25. Omeprazole 20 mg PO daily 26. Spiriva inhaled daily Discharge Disposition: Expired Discharge Diagnosis: Cardiac Arrest Mesenteric Ischemia Septic Arthritis Acute Renal Failure CAD - s/p CABG Diastolic CHF DM - Insulin dependent Hypertension Gout BPH Afib CKD stage IV (1.8 last admission prior to sepsis) Anemia secondary to CKD and MDS Discharge Condition: Death Completed by:[**2155-11-1**]

[ "557.0", "997.1", "998.11", "276.2", "707.07", "736.6", "250.00", "V58.67", "V45.81", "285.21", "998.0", "403.90", "427.31", "585.4", "707.20", "600.00", "276.7", "285.1", "518.81", "428.32", "410.91", "428.0", "V58.61", "496", "E878.8", "238.75" ]

icd9cm

[ [ [] ] ]

[ "38.91", "38.93", "84.57", "99.04", "81.22", "86.28" ]

icd9pcs

[ [ [] ] ]

10791, 10800

7024, 9903

340, 391

11077, 11113

4105, 7001

3223, 3227

10821, 11056

9929, 10768

3242, 4086

278, 302

419, 2384

2406, 2820

2836, 3207

31,307

171,383

31076

Discharge summary

report

Admission Date: [**2133-7-17**] Discharge Date: [**2133-7-19**] Date of Birth: [**2075-5-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: LGIB Major Surgical or Invasive Procedure: none History of Present Illness: 58M s/p liver transplant with metastatic cholangiocarcinoma and HCC presents with bloody diarrhea. He was visiting his son-in-law who is a fellow at [**Hospital3 1810**] after starting a new chemo regimen 9 days prior when he developed bloody diarrhea. The diarrhea began 4 days ago and initially was without blood but the following day he noticed stool mixed with blood (~[**1-13**] pint). Since this time he has has loose bloody stools every 3-5 hours. Noted some fatigue and decreased excercise tolerance but otherwise denies LH, syncope, abdominal pain, anorexia, myalgias, arthralgias, SOB, cough, or other complaints. He had a normal c-scope 6 months ago. Called his oncologist who had him present for CBC Tuesday with Hb 9.7, thrombocytopenia to 20s (near baseline values) and then repeat on Thursday where he was found to have Hbg decreased to 5 and sent to the ED. Also was started [**7-16**] on levaquin for possible infectious colitis. . In the ED, T 97.4 HR 96 BP 162/92 RR 18 SaO2 99% on RA. Labs notable for Hgb 5.5 with platelets near baseline. Hemodynamically stable. Started 1 unit pRBC transfusion. GI and Onc made aware and will follow. Admitted to MICU for close monitoring, scope in AM by GI. Past Medical History: As above, metastatic cholangio, s/p liver transplant in 06 with a stable thrombocytopenia usually in the 30s-40s. He also has HTN. Social History: Soc: Married, from [**State 2690**], son-in-law is an infant anesth. fellow at [**Hospital1 **]. Now non-drinker, always non-smoker. Big fan of [**Last Name (un) 3625**] World. Family History: Fam: Mother with [**Name (NI) 73383**] Physical Exam: T 97.6 HR 83 BP 150/73 RR 18 SaO2 100% on RA General: WDWN, NAD, breathing comfortably on RA HEENT: PERRL, EOMi, anicteric sclera Neck: supple, trachea midline, no thyromegaly or masses, no LAD Cardiac: RRR, s1s2 normal, [**2-17**] syst murm at apex, no JVD Pulmonary: CTAB Abdomen: +BS, soft, nontender, nondistended, no HSM Extremities: nonblanching ecchymoses on forearms, otherwise warm, 2+ LE bilateral edema Neuro: A&Ox3, nonfocal Pertinent Results: [**2133-7-17**] 11:20PM HCT-21.2* [**2133-7-17**] 04:46PM HCT-22.5* [**2133-7-17**] 08:11AM GLUCOSE-98 UREA N-26* CREAT-1.2 SODIUM-136 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-9 [**2133-7-17**] 08:11AM CALCIUM-7.7* PHOSPHATE-2.9 MAGNESIUM-1.8 [**2133-7-17**] 08:11AM WBC-2.4* RBC-1.94*# HGB-6.4* HCT-18.1* MCV-93 MCH-33.1* MCHC-35.5* RDW-20.9* [**2133-7-17**] 08:11AM PLT COUNT-33* [**2133-7-17**] 08:11AM PT-11.7 PTT-23.8 INR(PT)-1.0 [**2133-7-17**] 01:53AM COMMENTS-GREEN TOP [**2133-7-17**] 01:53AM GLUCOSE-129* LACTATE-1.3 NA+-136 K+-4.3 CL--110 [**2133-7-17**] 01:45AM GLUCOSE-128* UREA N-29* CREAT-1.3* SODIUM-136 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-21* ANION GAP-13 [**2133-7-17**] 01:45AM estGFR-Using this [**2133-7-17**] 01:45AM ALT(SGPT)-32 AST(SGOT)-21 LD(LDH)-167 ALK PHOS-83 AMYLASE-39 TOT BILI-0.3 [**2133-7-17**] 01:45AM LIPASE-23 [**2133-7-17**] 01:45AM ALBUMIN-3.7 CALCIUM-8.0* PHOSPHATE-2.2* MAGNESIUM-1.8 [**2133-7-17**] 01:45AM WBC-3.9* RBC-1.52* HGB-5.5* HCT-15.0* MCV-98 MCH-35.9* MCHC-36.5* RDW-20.8* [**2133-7-17**] 01:45AM NEUTS-83.3* BANDS-0 LYMPHS-14.5* MONOS-2.0 EOS-0.2 BASOS-0.1 [**2133-7-17**] 01:45AM PLT SMR-VERY LOW PLT COUNT-32* [**2133-7-17**] 01:45AM PT-11.5 PTT-23.5 INR(PT)-1.0 Brief Hospital Course: #LGIB: Felt to be consistent with his new chemo. Pt. recieved 4u PRBC while in the MICU. His hct responded from 15-->22 and then was stable over 48hr. He was seen by GI who thought it wise not to procede with a scope, considering his probable friable mucosa. On the day of discharge patient was given 1 additional unit of PRBC for the airplane trip home. GI cleared him to eat a full diet. . # Transplant: Continued dex and sirolimus; pt. denies any episodes of rejection, no sx. suggestive of rejection currently. Recommended f/u with his transplant team once back in [**State 2690**] . #HTN: Meds held upon admission until his was sent to the floor, where we restarted evening Norvasc and noted him to continue to be mildly hypertensive. We felt it prudent to continue to hold his long-acting beta-blocker, atenolol, and discussed this with the patient and he agreed with this plan. He will f/u with his home docs in [**State 2690**]. . #FEN: Clear liquids, advanced to full diet on [**7-19**]. . #Ppx: Pneumoboots and PPI while in patient . #Code: FULL . #Dispo: To home doctors [**First Name (Titles) **] [**Last Name (Titles) **] once his bleeding stopped and his hct was stable. . #Comms: [**Name (NI) 12589**] [**Name (NI) **] (son-in-law) [**Telephone/Fax (1) 73384**] Medications on Admission: Atenolol 200mg QD Norvasc 5mg qam 10mg qpm Avastin QOweek Tarceva 100mg QD Nexavar 200mg [**Hospital1 **] Nexium 40mg QD Rapammune 3mg DAily Dexamethasone 1mg QD Hydrocortisone for metastatic back pain, no more than 5mg Q6hr Nupogen PRN Procrit Qweek Levoquin 500mg QD (started [**7-16**]) Nifarex 150mg QD Bactrim 400mg QD Discharge Disposition: Home Discharge Diagnosis: LGIB Discharge Condition: Fair Discharge Instructions: Please return to the emergency room if you have any futher bleeding or if you feel weak, lightheaded, dizzy, or experience any symptoms that worry you or your family. Continue to take your medications as directed. Followup Instructions: Please see your transplant team and your PCP and your GI doc once you get back to home.

[ "E933.1", "287.4", "401.9", "V10.07", "198.5", "285.1", "V42.7", "578.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5407, 5413

3741, 5033

318, 324

5461, 5467

2453, 3718

5730, 5820

1938, 1979

5434, 5440

5059, 5384

5491, 5707

1994, 2434

274, 280

353, 1569

1591, 1725

1741, 1922

16,848

138,210

11319

Discharge summary

report

Admission Date: [**2183-9-20**] Discharge Date: [**2183-9-26**] Date of Birth: Sex: Service: GENERAL MEDICIINE ICU DEATH SUMMARY: HISTORY OF THE PRESENT ILLNESS: This is a 76-year-old female transferred to the Coronary Care Unit here at [**Hospital1 346**] initially under the care of Coronary Care Unit Medical Team with history of left lower lobe infiltrate, elevated white count to 22,000, nausea, vomiting, and hypotension. At the outside hospital the patient was noted to have elevated in troponin to 4.8 and EKG changes such as elevations in inferior leads. Transesophageal echocardiogram showed ejection fraction at 30% to 35% with prior study of [**2182-6-1**], noting ejection fraction of 50% to 55%. She was heparinized and transferred to [**Hospital1 346**] for catheterization and further management. On presentation, the catheterization was consistent with cardiogenic shock, notable for 95% stenosis in the proximal LAD, 70% stenosis in the lateral circumflex, with a right dominant system. The patient was unable to be stented. PHYSICAL EXAMINATION: Examination on presentation revealed the vital signs as follows: temperature 96.8, heart rate 87 to 113 and irregular, blood pressure 110/61 to 95/54, breathing at 24, saturation 94% on four liters. HEENT: Examination was remarkable for positive JVD, heart irregularly irregular, S1 and S2 no rubs, gallops, or murmurs. LUNGS: Diffuse rhonchi and wheezing throughout. ABDOMEN: Guaiac positive, diffuse tenderness to palpation. EXTREMITIES: Notable for a 2+ pitting edema bilaterally. NEUROLOGICAL: Examination was difficult to assess. PAST MEDICAL HISTORY: 1. Coronary artery disease, three vessel disease, refusing catheterization or coronary artery bypass graft in the past. 2. Increased cholesterol. 3. Hypertension. 4. Chronic obstructive pulmonary disease. 5. Chronic atrial fibrillation. 6. History of triple A. 7. Arthritis. MEDICATIONS ON PRESENTATION: 1. Aspirin. 2. Lopressor. 3. Norvasc. 4. Zestril. 5. Lipitor. 6. Zantac. 7. Imdur. 8. Lasix. 9. Levofloxacin. 10. Nitroglycerin. 11. Heparin IV. EKG on presentation was notable for atrial fibrillation at 107 beats per minute with a right axis deviation, normal intervals, 1.5-mm ST elevations in leads 2, 3, and AVF; 0.5 -mm ST depressions in 1 and AVL. Chest x-ray was notable for left lower lobe opacity and perihilar infiltrates. On [**2183-9-21**] the Department of Surgery was consulted for question of ischemic bowel. Recommendations: CT abdomen and pelvis, optimizing hemodynamic parameters. The patient was intubated for airway protection and respiratory failure on [**2183-9-21**]. She was begun on Dopamine and Levophed for hypertension. Electrical cardioversion was attempted, yet failed. The patient was switched from Levophed to Pitressin and Digoxin was begun for rate control of rapid atrial fibrillation. On [**2183-9-22**], Infectious Disease consultation was obtained for worsening right cavitary lesion on chest x-ray. Recommendations were Ciprofloxacin, Flagyl, Ceftazidime, and Fluconazole. On [**2183-9-23**], the patient experienced worsening respiratory status. MICU evaluation was obtained. Vasopressin was discontinued and the patient was transferred to the MICU service for further pulmonary management as pulmonary issues were her main focus at that time. On [**2183-9-24**], the patient was begun on TPN for nutrition requirements. From [**2183-9-25**] to [**2183-9-26**], the patient experienced a rising white count from 20 to 33, respiratory requirements worsened. Serum lactic acid levels rose to a high of 12.4 likely due to ischemic valve secondary to hypoperfusion. On [**2183-9-26**], the patient was noted to be quite tenuous in terms of hemodynamic and respiratory requirements. In consultation with the patient's family, the patient was made DNR/DNI. On [**2183-9-26**], the MICU service was called for the patient unresponsive in asystole with no pulse or heart rate. The patient was declared dead on [**2183-9-26**] and the family was contact[**Name (NI) **]. DR.[**First Name (STitle) **],[**First Name3 (LF) 870**] 12-464 Dictated By:[**Last Name (NamePattern1) 14783**] MEDQUIST36 D: T: [**2184-2-6**] 10:08 JOB#: [**Job Number 36309**]

[ "428.0", "410.41", "482.1", "276.2", "518.5", "785.51", "557.9", "584.9", "038.9" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.91", "38.93", "88.72", "37.23", "36.01", "96.04", "88.56", "42.23" ]

icd9pcs

[ [ [] ] ]

1105, 1648

1670, 4335

17,344

137,293

17423+56854

Discharge summary

report+addendum

Admission Date: [**2169-7-7**] Discharge Date: [**2169-7-27**] Date of Birth: [**2106-10-15**] Sex: F Service: Medicne CHIEF COMPLAINT: Change in mental status. HISTORY OF PRESENT ILLNESS: This is a 62[**Hospital 4622**] nursing home resident with a history of end-stage renal disease on hemodialysis with dementia, who presents with a change in mental status. The patient was in her usual state of health (alert and oriented x 3) until 1?????? days ago when she started refusing her meals and had decreased p.o. intake, positive hallucinations. She has been receiving Percocet for pain for several days, but no fevers or chills, no diplopia, no dyspnea, no nausea or vomiting, no diarrhea, positive urinary incontinence, positive phantom limb pain. She has been having visual hallucinations with people in the room and also reports discomfort in her sacral region at the area of a sacral decubitus ulcer. In the emergency room EKG showed T wave inversions in V2 to V6. She was started on a heparin drip. CT of her head was negative. She was given aspirin, ceftriaxone and gentamicin. She denied any chest pain. She reported pain in the gluteal region, no palpitations, admitted to decreased appetite. There was no sinus pain, no current hallucinations or suicidal ideation. PAST MEDICAL HISTORY: (Usual care at [**Hospital1 2025**]) 1. Insulin dependent diabetes mellitus. 2. Hypertension. 3. Coronary artery disease. 4. Peripheral vascular disease status post left below the knee amputation, right above the knee amputation. 5. End-stage renal disease on hemodialysis Monday, Wednesday and Friday. 6. Depression. 7. History of C. difficile, VRE, MRSA. 8. Gout. 9. Anxiety. 10. Diabetic neuropathy. MEDICATIONS: 1. Regular Insulin sliding scale. 2. Percocet. 3. Neurontin 200 b.i.d. 4. Allopurinol 100 q. day. 5. Lopressor 12.5 b.i.d. 6. Nephrocaps. 7. Renagel 400 t.i.d. 8. Nexium 20 q.d. 9. Paxil 30 q. day. ALLERGIES: Flagyl - reaction unknown. SOCIAL HISTORY: She is a nursing home resident and has a close relationship with her family, daughter [**Name (NI) **] [**Name (NI) 48689**]. PHYSICAL EXAMINATION: Temperature 99, heart rate 72, blood pressure 128/48, respiratory rate 20, oxygen saturation 93% on room air. This was a generally ill-appearing woman in mild distress. Extraocular movements were intact. Pupils were equal and reactive. Oropharynx was dry with lip smacking. She had jugular venous pressure 6-8 cm, no lymphadenopathy, regular rate with 2/6 systolic murmur at the right upper sternal border. Lungs were clear to auscultation bilaterally. Abdomen was soft, nontender with positive bowel sounds. She had a stage II sacral decubitus with mild tenderness. The patient refused rectal examination. LABORATORY DATA: White blood cell count was 10.9, hematocrit 36.5, platelet count 114 with 86 neutrophils, 9 lymphocytes. Sodium 141, potassium 3.8, chloride 101, bicarbonate 25, BUN 13, creatinine 2.6, glucose 126. Urinalysis had large blood, moderate leukocytes, [**12-20**] red blood cells, 21-50 white blood cells, occasional bacteria, occasional yeast, 0-2 epithelial cells. CK was 27, troponin less than 0.3. CT of the head showed no bleed. Chest x-ray showed cardiomegaly with obscuring of the costophrenic angle in the lateral view likely secondary to overlying osseous structures. EKG showed sinus rhythm at 74, normal axis, T wave inversions in V2 to V3 and biphasic T waves in V4 to V6. The T wave changes are new compared with prior. The patient was admitted for moderate change in mental status as well as EKG changes and what appears to be cystitis. The initial plan was to cycle her cardiac enzymes, continue her ceftriaxone for her urinary tract infection, hold her percutaneous and see if her mental status would clear, and continue her dialysis. HOSPITAL COURSE: Her complicated hospital course is significant for the following events. On [**2169-7-8**] the patient ruled out for myocardial infarction and the heparin was discontinued. She was noted to have borderline low blood pressure, and her Lopressor was held. She was continued on her ceftriaxone. Preliminary blood cultures showed no growth. She was noted to be agitated and received Zyprexa. Her Neurontin was changed to every other day given a borderline high gabapentin level as per renal. On [**2169-7-9**], the patient still had decreased p.o. and commented that she wanted to die to her daughter. The patient was gently rehydrated and her blood pressure subsequently increased. A TSH was checked which was within normal limits. The patient's mental status also was noted to improve with her intravenous fluid hydration. Psychiatry was consulted to evaluate her depression and passive suicidality. On [**2169-7-10**] psychiatry consult recommended starting Seroquel. This was noted to cause significant sedation in the patient. On [**2169-7-11**] the patient was still noted to have delirium. She also had an elevated INR and was given vitamin K. On [**2169-7-12**] the patient had an episode of hypotension and was given intravenous fluids with some significant improvement however lost IV access. It was unclear whether or not her decreased blood pressure was secondary to dehydration/hypovolemia, medicine effect, infection or some cardiac event. At this time she was increasingly lethargic. Intravenous access was attempted but was difficult given the sudden increase of her INR to greater than 12. At this point liver function tests were checked and they were noted also to be transiently elevated to ALT of 744, AST 3098, alkaline phosphatase of 304, total bilirubin of 1.3. The hepatology team was contact[**Name (NI) **]. It was thought that this was likely something secondary to her hypotension. Also her acetaminophen was mildly elevated and the patient was started on Mucomyst. She was given repeated fresh frozen plasma in order to bring her INR to less than 2. She at that point had attempted placement of her central access, which failed after multiple attempts. She was also noted at this point to be hypothermic with a temperature of 90 and was given external warming and also started on vancomycin. A right upper quadrant ultrasound was performed which showed a fatty liver with some gallbladder sludge but patent portal veins. The patient also had a DIC panel done which was within normal limits. Her platelet count however was noted to be continuing to decrease and at this point was 54. Hepatitis panel was negative. At this point the patient was transferred to the intensive care unit for further care. The remainder of this dictation will be dictated as an addendum. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Last Name (NamePattern1) 9296**] MEDQUIST36 D: [**2169-8-8**] 11:18 T: [**2169-8-8**] 11:37 JOB#: [**Job Number 48690**] Name: [**Known lastname 9016**], [**Known firstname **] Unit No: [**Numeric Identifier 9017**] Admission Date: [**2169-7-7**] Discharge Date: [**2169-7-27**] Date of Birth: [**2106-10-15**] Sex: F Service: MEDICINE ADDENDUM: Until the patient was able to have central access, her Quinton catheter for dialysis was utilized in order to provide antibiotics and blood products. She had an ultrasound guided central line placement; it was not able to be done in the right internal jugular secondary to wall thickening and diminutive size and placement of a triple lumen in the right common femoral vein was obtained without any complication. The patient had an echocardiogram performed on [**2169-7-13**], which showed a mildly dilated left atrium, normal left ventricular size. Hyperdynamic ejection fraction of 75%. Aortic valves were moderately thickened with moderate aortic valve stenosis. Moderate aortic regurgitation. Mitral valve was moderately thickened with moderate to severe mitral regurgitation. There was moderate pulmonary artery systolic hypertension and a mobile mass on the ventricular side of the aortic valve consistent with probable vegetation. At that point, the patient proceeded to have a transesophageal echocardiogram on [**2169-7-14**], which showed that there was a small mobile calcified mass, 0.7 by 0.2 centimeters on the tip of the posterior leaflet on the atrial side of the mitral valve. It was felt that this mass is consistent with probable vegetation but questioned whether it was a healed probable vegetation, although a torn or calcified chordae could not be ruled out. No masses or vegetations were seen on the aortic valve. At this point, there was a question of whether or not this was an old vegetation and the patient's records were requested from [**Hospital6 2241**], which revealed that the patient had had an echocardiogram within the past six months. A request was made for the ultrasound tape to be sent for comparison. She had a nasogastric tube placed in order to provide tube feeds. She was having increased residuals and Reglan was started. She had an episode of coffee ground withdrawal from nasogastric tube which was felt to be secondary to trauma in the setting of thrombocytopenia. Her hematocrit, however, remained stable and withdrawal resolved on its own. On [**2169-7-18**], the patient was transferred out of the Medical Intensive Care Unit to the floor. She again had an episode of coffee ground withdrawal from the nasogastric tube which cleared with 300 cc of water. She had a repeat episode of hypotension with a systolic blood pressure in the 60s, waxing and [**Doctor Last Name 2364**] mental status and hypothermia with a temperature of 93.0 F. She received fluid boluses with improvement in her blood pressure to the systolic of 90s. Her hematocrit was stable at 30 although she still had thrombocytopenia with platelet count of 39. She was discontinued off of her heparin subcutaneously as well as change from Protonix to a Carafate slurry in case this was the cause of her thrombocytopenia. She had a repeat chest x-ray, repeat blood cultures, and EKG and was restarted on her Ceftazidine which had been discontinued the day before. She had repeat HIT antibodies drawn. Endocrine was consulted for hypercalcemia. The patient had PTH and Vitamin D checked which were normal. Her calcitonin was discontinued. On [**7-20**], the patient had another episode of systolic blood pressure down to 60s overnight. She was given 2.5 liters of intravenous fluid with improvement with a systolic blood pressure in the 90s. She had another episode of a gastrointestinal bleed, this time with melena as well as blood from the nasogastric tube. Gastrointestinal was consulted and the patient was changed back to Protonix. Her hematocrit was down to 25 and she was given two units of packed red blood cells, as well as a bag of platelets for platelet count of 35. She was given Vitamin K times one for INR of 1.6. Fibrinogen was checked which was not depressed. On [**7-21**], her blood pressure improved and her hematocrit and platelets had all improved and she had no further evidence of gastrointestinal bleeding. Any endoscopy at this point was deferred given the patient's stabilization. She was attempted to be restarted on her tube feeds. MRI was obtained in order to rule out osteomyelitis given the number of ulcers on her bilateral leg stumps. The MRI did not show any evidence of osteomyelitis but there was a question of soft tissue fluid collection which was felt to likely be hematoma. The patient had an episode of cold hands and decreased radial pulses. Vascular was consulted. They did not feel that her limbs were threatened however, she does have some dry gangrene on her fingers which should be further evaluated at another time. The patient had an episode of green diarrhea and Clostridium difficile was ordered which was negative. On [**7-22**], the patient had repeat hypotension but improvement with fluid bolus. Her tube feeds which had been held for increased residuals were again attempted to be advanced. She had some coffee ground withdrawal. She was given Vitamin K for elevated INR. It was felt that perhaps the Reglan could be contributing to her prior thrombocytopenia and it had been held, however, it was restarted at a lower dose in order to try to promote tolerance of her tube feeds. On [**7-24**], her INR further increased to 4.0 and the patient was given Vitamin K at 10 mg standing. The patient was continued on Ceptaz and Vancomycin, but the gentamicin which she had been on was discontinued. The chest x-ray which was obtained post nasogastric tube placement showed a left pleural effusion as well as considerable ascites. The patient was continuing to have residual with coffee grounds and was given total parenteral nutrition in order to provide nutrition. Her skin had extensive breakdown which was causing considerable pain. Her development of ascites was concerning and the patient had a CA-125 checked which was elevated at 188. She was ordered for a pelvic ultrasound to evaluate the left adnexal mass. Gyn/Onc was consulted and at this point it was felt that the patient would have a paracentesis in order to evaluate for any event of infection as well as cytology, under ultrasound guidance. A family meeting was held at this time in order to discuss goals for care. It was the decision of the family to proceed with the paracentesis but if the patient were to decompensate again, to change to COMFORT MEASURES ONLY. On [**7-27**], the patient was found to be in considerable pain with change in mental status and had a clinical deterioration. The family was consulted again at this time and agreed to change to comfort measures. She was placed on a morphine titration as well as Ativan p.r.n. and expired on [**2169-7-27**]. The family consented to an autopsy. DIAGNOSES AT TIME OF DEATH: 1. End-stage renal disease on hemodialysis. 2. Insulin dependent diabetes mellitus. 3. Coronary artery disease. 4. Peripheral vascular disease. 5. Hypertension. 6. Sacral decubitus ulcer, bilateral leg stump ulcers. 7. Gastrointestinal bleed. 8. Left adnexal mass with ascites. 9. Mass on mitral valve. 10. Urinary tract infection. 11. Aortic regurgitation. 12. Mitral regurgitation. 13. Transaminitis. 14. Thrombocytopenia. 15. Hypercalcemia. 16. Urinary tract infection. [**Name6 (MD) 1662**] [**Last Name (NamePattern4) 4337**], M.D. [**MD Number(1) 4338**] Dictated By:[**Last Name (NamePattern1) 8563**] MEDQUIST36 D: [**2169-8-16**] 18:42 T: [**2169-8-17**] 00:52 JOB#: [**Job Number 9018**]

[ "038.9", "276.5", "599.0", "403.91", "785.59", "707.0", "578.9", "570", "286.9" ]

icd9cm

[ [ [] ] ]

[ "03.31", "99.15", "38.93", "39.95", "88.72", "96.6" ]

icd9pcs

[ [ [] ] ]

3880, 14709

2171, 3862

158, 184

213, 1308

1331, 2004

2021, 2148

48,710

186,570

35518

Discharge summary

report

Admission Date: [**2115-3-5**] Discharge Date: [**2115-3-11**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: AMS, ICH Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Name13 (STitle) **] is an 88-year-old right-handed woman with a history of AAA repair and only recent HTN who presents with confusion, found to have ICH. Her daughter found her at 2 AM this morning in the living room, saying that she had to get dressed to go to work. It's not so unusual for her to fall asleep in a chair and then be disoriented on waking up, so her daughter was not too concerned by this. Her daughter did find it odd, though, that she would not look at her while her daughter was standing to her left; she only looked at her reflection in the mirror straight ahead. Nonetheless, her daughter attributed to the hour of the night and helped her back to bed. At 7:15 AM, her daughter woke her up per usual. Her daughter left her to dress, but then heard a "thud." She came back to find her sitting on a pile of laundry, without evidence of significant trauma. She was however, just as disoriented as last night, and she now had much greater difficulty standing and walking. She was able to stand with her daughter's help, but could only take short shuffling steps. This is quite off her baseline, as she is usually quite active, still working several days per week. Her daughter called EMS, who brought her to [**Hospital1 29405**]. There, a head CT revealed a 3.5 cm x 5.5 cm x 5 cm intraparenchymal hemorrhage in the right fronto-parietal area. Formal ROS is not possible, but her family denies any recent changes or complaints. Past Medical History: HTN (diagnosed 1-2 weeks ago) AAA repaired 2 years ago Cataract surgery OS Social History: Quit smoking over 20 years ago. No significant alcohol use. No drug use. Lives with daughter and requires assistance with cooking and cleaning (She "carbonizes" things rather than cooking them). She still works several days per week folding tissue paper to package balsa wood airplanes. Family History: NC Physical Exam: Vitals: T: 99.7 P: 96 R: 17 BP: 127/52 SaO2: 97%RA General: Awake, uncooperative, constantly brushing her hair or picking at her cervical collar with her right arm. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Hard collar Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake and generally alert, though requires frequent redirection and occasionally closes her eyes but easily arousable. Oriented to self, hospital; believes [**2114-2-2**]. Unable to relate history. Inattentive, requiring repetition of most questions, with tangential speech. Language is fluent. Follows midline and appendicular commands with repetition. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Appeared to neglect left side. -Cranial Nerves: I: Olfaction not tested. II: Pupils 4 to 2mm and brisk OD, post-surgical OS. Appears to blink to threat bilaterally. Uncooperative with funduscopic exam. III, IV, VI: Spontaneous EOMI without nystagmus. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: Not tested. XII: Tongue protrudes in midline. -Motor: No adventitious movements, such as tremor, noted. No asterixis noted. Uncooperative with formal strength testing, but clearly moves right side more frequently and more easily than left. Antigravity in all extremities, but drifts down in 5 seconds in both L UE and L LE. -Sensory: Responds to light touch in all extremities. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 3 2 3 3 2 R 3 2 3 3 2 Plantar response was mute bilaterally. -Coordination: When she spontaneously reached for my hand with her RUE, there was no intention tremor or dysmetria; she was uncooperative with testing of other extremities. -Gait: Deferred due to clinical situation. Pertinent Results: Hematology CBC WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2115-3-11**] 12.8* 4.20 12.1 34.6* 82 28.7 34.9 14.3 322 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2115-3-11**] 06:08AM 144* 43* 1.9* 135 3.3 101 21* 16 [**2115-3-6**] 01:13AM BLOOD CK(CPK)-37 [**2115-3-5**] 01:50PM BLOOD ALT-19 AST-23 AlkPhos-70 TotBili-0.6 [**2115-3-6**] 01:13AM BLOOD CK-MB-3 cTropnT-<0.01 [**2115-3-6**] 01:13AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.7 [**2115-3-5**] 01:50PM BLOOD Albumin-4.2 Calcium-9.5 Phos-3.5 Mg-1.8 Iron-59 [**2115-3-5**] 01:50PM BLOOD calTIBC-428 Ferritn-55 TRF-329 [**2115-3-6**] 01:13AM BLOOD %HbA1c-5.8 NCHCT [**2115-3-5**]: IMPRESSION: Right temporo-parieto-occipital hemorrhage with surrounding vasogenic edema and mass effect as detailed above. Prior imaging has not been submitted at the time of dictation for comparison. NCHCT [**2115-3-6**]: IMPRESSION: No significant change in appearance of large right temporoparieto-occipital hemorrhage with surrounding vasogenic edema and mass effect, as described. NOTE ADDED IN ATTENDING REVIEW: Though the blood/fluid level at time of presentation is often seen in anticoagulated patients (is there any h/o such?), the overall appearance, particularly the paucity of intraventricular hemorrhage, given the size of the lobar hemorrhage, and the associated subarachnoid hemorrhage, is quite suggestive of amyloid angiopathy, in a patient of this age. NCHCT [**2115-3-6**]: No significant short-interval change in the appearance of the large right temporoparietooccipital lobar hemorrhage with layering blood products. There is only a small intraventricular component with rather prominent associated subarachnoid hemorrhage, findings suggestive of underlying amyloid angiopathy. There is equivocal further leftward shift of the septum pellucidum with subfalcine herniation and relative "trapping" of the ipsilateral temporal [**Doctor Last Name 534**]; no herniation at any other level is seen. CT C-spine [**2115-3-5**]: IMPRESSION: Limitation secondary to motion artifact. Grossly no fracture is identified. There is normal alignment. Multilevel degenerative change does result in a central disc protrusion as detailed above. However no critical canal or neural foraminal stenosis results. Thyroid findings are nonspecific. Correlate with clinical exam and biochemical profile. If indicated consider thyroid ultrasound for more sensitive evaluation. CT C-spine [**2115-3-6**]: IMPRESSION: 1. Cervical spondylosis without fracture or acute alignment abnormality. 2. Nonspecific heterogeneous appearance of the thyroid gland with left lobe hyperdensity and dystrophic calcifications. Recommendations as per the [**2115-3-5**] report. CXR [**2115-3-6**]: The heart size is normal. Mediastinal position, contour, and width are unremarkable. Lungs are clear. There are no areas of consolidation worrisome for infection. There is no pleural effusion seen. The patient is after stenting of abdominal aorta. Brief Hospital Course: 88F admitted for ICH as outlined in the HPI. She was admitted to the ICU but did well and was transferred to the floor. The cause of her right parietal bleed was felt to be due to amyloid angiopathy, especially given prior history of dementia. Her exam remained stable, consisting primarily of disorientation and left hemineglect. She spiked fevers but after extensive workup, these were felt to be central in etiology. She was restarted on HCTZ but had a rise in creatinine, likely due to prerenal azotemia. It was therefore discontinued in favor of norvasc and metoprolol. Medications on Admission: HCTZ 25 mg po daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Cerebral hemorrhage likely secondary to amyloid angiopathy Discharge Condition: Stable Discharge Instructions: You were admitted to the stroke service for evaluation of your intraparenchymal hemorrhage. It was likely due to amyloid angiopathy. You should continue to improve. You should return to the ER if you have weakness or numbness. Followup Instructions: Dr. [**Name (NI) 80878**]: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2115-6-5**] 1:00 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2115-3-11**]

[ "E944.3", "348.5", "790.6", "277.30", "401.9", "431", "342.90", "293.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8524, 8596

7459, 8037

270, 276

8699, 8708

4420, 7436

8986, 9283

2182, 2186

8107, 8501

8617, 8678

8063, 8084

8732, 8963

3238, 4401

2201, 2744

222, 232

304, 1763

2759, 3221

1785, 1861

1877, 2166

2,355

191,024

11844

Discharge summary

report

Admission Date: [**2158-1-24**] Discharge Date: [**2158-1-29**] Date of Birth: [**2103-3-7**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: Patient is a 54-year-old male with a history of Hodgkin's lymphoma, coronary artery disease, status post percutaneous transluminal coronary angioplasty times two, hypertension, dyslipidema, prostate cancer, status post 11 cycles of ABVD for his Hodgkin's lymphoma including 330 mg of bleomycin. Patient hospitalized at an outside hospital from [**Date range (1) 17815**] with increasing shortness of breath with a CAT scan that was consistent with increasing subpleural reticular nodular densities consistent with bleomycin lung with an ESR of 188, negative LENIs and negative micro. Patient was started on prednisone and levofloxacin and sent home. Patient returned to an outside hospital on the second of [**Month (only) 404**] for an x-ray, but had a syncopal episode at that time. Had a negative CT angio for PE, an echocardiogram that was normal, and cardiac enzymes that were negative. Also had acid fast bacilli and PAS stains. Ultimately, the patient came to the [**Hospital6 256**] and at that time was admitted to the Medical Intensive Care Unit because of worsening hypoxia. PAST MEDICAL HISTORY: Hodgkin's lymphoma, coronary artery disease, prostate cancer. ALLERGIES: Patient not allergic to any medications. OUTPATIENT MEDICATIONS: Prednisone and levofloxacin. SOCIAL HISTORY: Not applicable. FAMILY HISTORY: Not applicable. PHYSICAL EXAMINATION: On admission, patient had a temperature of 96.4. Heart rate of 75. Blood pressure of 123/75, breathing at 18, and 93% on a nonrebreather. Patient was a pleasant interactive male in respiratory distress after speaking. He was normocephalic, atraumatic. His heart was regular. He had no murmurs, rubs or gallops. He had a right Permacath. Lungs: He had rhonchi and rales bilaterally. The patient also had in place a right-sided chest tube for pneumothorax caused at an outside hospital with a central line placement. Abdomen: Benign. Extremities: No edema. Pulses: 2+ dorsalis pedis and posterior tibial. Alert and oriented times three. HOSPITAL COURSE: The patient had a very complicated hospital course with multiple interventions attempted at trying to improve his breathing, including initiation of Colchicine and pentoxifylline. CT Surgery was also asked to evaluate the patient. Ultimately, to follow the chest tube. The patient had a chest tube removed, but then re-accumulated a pneumothorax. Throughout his hospital course, the patient continued to become increasingly hypoxic. He was given Remicade times one as a non-steroidal anti-inflammatory drugs effort to try to improve his bleomycin lung. He was started on N-acetylcystine as well. All of which did not really change his hospital course. Ultimately, the patient passed away on the [**2158-1-29**] after a code during which after CPR, epi, amp of bicarbonate and defibrillation, there was no sign of life. CONDITION OF DISCHARGE: Patient passed away. DISCHARGE STATUS: Deceased. DISCHARGE DIAGNOSES: Bleomycin lung. [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 15074**] Dictated By:[**Name8 (MD) 24764**] MEDQUIST36 D: [**2158-7-3**] 19:02 T: [**2158-7-3**] 19:02 JOB#: [**Job Number 37390**]

[ "E933.1", "401.9", "V10.46", "V45.82", "427.41", "518.89", "512.1", "492.8", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "34.04", "96.71" ]

icd9pcs

[ [ [] ] ]

1500, 1517

3136, 3450

2209, 3114

1419, 1449

1540, 2191

161, 1254

1277, 1394

1466, 1483

46,108

172,654

15063

Discharge summary

report

Admission Date: [**2134-8-6**] Discharge Date: [**2134-9-14**] Date of Birth: [**2047-12-26**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins Attending:[**First Name3 (LF) 38616**] Chief Complaint: new diagnosis of AML Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname 1968**] is an 86yoF with a history of essential thrombocytosis (previously on hydroxyurea), anorectal cancer in remission s/p resection/ radiation/5-FU and mito [**10/2132**] who is being transferred from [**Hospital3 **] hospital for possible acute leukemia. She was in her usual state of health through last week when she noted general feelings of malaise and unwellness. She had been seen at [**Hospital3 **] by her oncologist with a reportedly normal Hb and plt count, though leuks of 11 with bands and metas which were attributed to a cold. She had chest pain and presented to [**Hospital3 **] yesterday. She was ruled out for MI, though her WBC was elevated to 88 with plts 90. Peripheral smear showed blasts according to oncology, and she was transferred to [**Hospital1 18**] for further management of a possible acute leukemia. She had been off of hydroxyurea since diagnosed with anorectal cancer in [**2134**] and had not restarted. Review of Systems: Denies fever, chills, but endorses sweats, and recent weight loss of 30Ib over the past 3 years. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Endorses current chest pressure but no palpitations, lower extremity edema. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, but constipation, no abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence currently but had an apisode yesterday and reportedly was given abx for UTI. Denies arthralgias or myalgias. Endorses new rashes but no skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: PAST ONCOLOGIC HISTORY: - Anorectal cancer s/p resection, radiation, 5FU and Mito - essential thrombocytosis, previously on hydroxyurea PAST MEDICAL HISTORY: HTN Hypothyroidism DM2 HL Glaucoma s/p hysterectomy Social History: No smoker, lives at her own home and indpendednt in all ADL. Son [**First Name8 (NamePattern2) **] [**Name (NI) 1968**]) is HCP [**Telephone/Fax (1) 44015**] Family History: Mother died from seconday complication to DM in her 80s. Father with ?stroke, died at age 49. Physical Exam: PHYSCIAL EXAM AT ADMISSION Vitals - T: 98.9 BP: 137/53 HR: 82 RR: 18 02 sat: 93% on 2L GENERAL: NAD HEENT: pale conjunctiva, anicteric sclera, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs LUNG: bibasilar crackles 1/3 up ABDOMEN: nondistended, +BS, nontender in all quadrants, EXTREMITIES: 2+ edema, no obvious deformities PULSES: 2+ DP pulses bilaterally SKIN: warm 2+ edema lower calf PHYSICAL EXAM AT DISCHARGE VS: T 98 118/64 61 20 97%RA GEN: awake and alert, NAD. HEENT: OP clear CV: regular rhythm. mild systolic murmur PULM: clear to auscultation bilaterally ABD: +BS, soft, distended, non-tender EXT: trace pitting edema to ankles. SKIN: sacral ulcer healing; erythematous papules on abdomen NEURO: A&Ox3. Upper extremity tremors at rest L > R. VA: Portacath site with no erythema. GU: Foley in place. Pertinent Results: Admission Labs: [**2134-8-6**] 09:18PM BLOOD WBC-93.3* RBC-3.61* Hgb-10.4* Hct-31.5* MCV-87 MCH-28.8 MCHC-33.0 RDW-16.4* Plt Ct-83* [**2134-8-6**] 09:18PM BLOOD Neuts-22* Bands-0 Lymphs-1* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* Other-76* [**2134-8-6**] 09:18PM BLOOD PT-13.6* PTT-30.3 INR(PT)-1.3* [**2134-8-6**] 09:18PM BLOOD Glucose-200* UreaN-27* Creat-1.3* Na-132* K-4.3 Cl-100 HCO3-24 AnGap-12 [**2134-8-6**] 09:18PM BLOOD ALT-23 AST-30 LD(LDH)-2269* CK(CPK)-65 AlkPhos-111* TotBili-0.5 [**2134-8-6**] 09:18PM BLOOD CK-MB-3 cTropnT-0.02* [**2134-8-6**] 09:18PM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.1 Mg-1.8 UricAcd-7.4* Imaging: CXR [**8-7**]: IMPRESSION: Technically limited radiograph due to motion artifact, limiting assessment of lung bases. Considering clinical suspicion for infection, repeat radiograph with suspended inspiration is recommended to exclude subtle basilar consolidation or small pleural effusions. CXR [**8-7**]: IMPRESSION: 1. New interstitial edema. 2. Confluent right infrahilar opacity, which may represent asymmetrical edema, but followup radiographs after diuresis would be helpful to exclude a developing focus of pneumonia. Pheresis catheter placement [**8-7**] (PRELIM): IMPRESSION: Successful placement of a left internal jugular temporary pheresis catheter. The tip lies in the distal SVC and is ready for use. LABS AT DISCHARGE: [**2134-9-14**] 12:00AM BLOOD WBC-7.4 RBC-2.63* Hgb-8.0* Hct-23.2* MCV-88 MCH-30.4 MCHC-34.6 RDW-14.5 Plt Ct-65* [**2134-9-14**] 12:00AM BLOOD Neuts-14* Bands-4 Lymphs-36 Monos-0 Eos-2 Baso-1 Atyps-0 Metas-1* Myelos-1* Blasts-41* NRBC-3* [**2134-9-14**] 12:00AM BLOOD Plt Smr-VERY LOW Plt Ct-65* [**2134-8-10**] 04:48AM BLOOD Fibrino-421* [**2134-9-14**] 12:00AM BLOOD Gran Ct-1486* [**2134-9-14**] 12:00AM BLOOD Glucose-175* UreaN-31* Creat-1.1 Na-134 K-4.0 Cl-98 HCO3-28 AnGap-12 [**2134-9-14**] 12:00AM BLOOD ALT-5 AST-11 AlkPhos-88 TotBili-0.4 [**2134-9-13**] 03:30PM BLOOD CK-MB-1 cTropnT-<0.01 [**2134-9-14**] 12:00AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1 UricAcd-6.3* [**2134-8-31**] 12:05AM BLOOD TSH-6.2* [**2134-8-7**] 04:56PM BLOOD Type-[**Last Name (un) **] pH-7.47* Brief Hospital Course: ASSESSMENT/PLAN: 86 yo female with new diagnosis of AML in the setting of chest pain. Her respiratory status appears stable, chest pain likely related to AML, and unlikely cardiac ischemia give negative cardiac enzymes at outside hospital, and EKG w/o signs of ischemia. ACUTE ISSUES: # AML: Acute AML diagnosed from flow cytometry from peripheral blood at [**Hospital3 417**] Hospital. Likely secondary leukemia from prior chemotherapy and XRT for anal cancer. Admitted with WBC 93.3K with 78-80% blasts and leukemia cutis with papules on trunk. Patient became acutely acutely short of breath on hospital day 2 concerning for leukostasis and was transfered to the ICU for leukophoresis. Patient completed two days of leukophoresis on [**8-7**] and [**8-8**] with WBC of 5.4 on [**8-9**]. Patient completed 7 days of low dose Cytarabine (100 mg/m2 on D1-7). When her counts started to recover, she had again circulating blasts, and she was subsequently treated with 5 days of decitabine. She was started on hydroxyurea during the last days of her hospitalization and it was uptitrated to 500mg in the morning and 1000mg in the evening at time of discharge. She was also started on flucanozole prophylaxis for fungal infections at the time of discharge. She never experienced a febrile complication. Tentatively the plan is to treat with decitabine Q4 weeks as long as tolerated. # Hypoxia: Patient became acutely short of breath with oxygen demands up to 5L. Most likely secondary to volume overload as patient continued to need oxygen after leukophoresis and improved after multiple liters of fluids were diuresed off with Lasix. Patient no longer requires supplemental oxygen. # GI bleed: Patient had an episode of bright red blood from her rectum and passed 3 blood clots the morning of [**2134-8-19**]. GI was consulted and they believed it was most likely secondary to radiation proctitis. Increased transfusion goal to Hct > 27 and Plt > 50 for several days. Her bleeding stopped within 24 hours. Her blood counts were stable in the last days of her hospitalization and there were no clinical signs of acute bleeding reoccurence. At the time of discharge her tranfusion threasholds were Plt >20 and Hct >24. # Atrial Fibrilation. New onset during this hospitalization. Cardiac markers showed no acute ischemia. Patient fluctuates between A. Fib and sinus rhythm during the hospital stay with one episode of A. Flutter in the setting of electrolyte imbalance. Managed with Diltiazem 60 mg PO QID. Patient was not started on anticoagulation in the setting of severe thrombocytopenia. # UTI. UTI with positive culture from [**Hospital3 417**]. Patient was started on Cefepime and Vancomycin initially. Vancomycin was discontinued after verbal confirmation from oncologist at [**Hospital 6451**] culture was positive for pan-sensitive E. Coli. She completed a course of antibiotics and her symptoms resolved and there was no clinical evidence of reoccurance at the time of discharge. A foley catheter was placed due to sacral ulcers which was kept through her discharge. # Blurry vision. Patient complains of blurry vision which has been a chronic issue that began after she started receiving chemotherapy. There were no acute changes during this hospitalization. She was seen by Opthomology who recommended artifical tears TID PRN and dorzolamide/Timolol drops qHS, which were continued at the time of discharge. # Sacral ulcers. There were thought to be related to her urinary incontience. She was seen by wound care who recommended continuing the foley catheter and started sacral ulcer management. These were improving at the time of discharge. CHRONIC ISUSES: # Hypertension: She was normotensive through this admission while blood pressure medications were held so blood pressure medications were not restarted at the time of admission. # DM type 2 on insulin: She was managed with insulin sliding scale during this admission. Her home diabetes medications were restarted at discharge. # Hypothyroidism: TSH mildly elevated at 4.8. Continued home dose of levothyroxine during the hospital stay. TSH should be rechecked in the outpatient setting. TRANSLATIONAL: [] follow up TSH as outpatient [] anticoagulation for A. Fib when thrombocytopnea improves. [] follow up with opthalmology as out patient Medications on Admission: ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Penicillins Preadmission medications listed are correct and complete. Information was obtained from outside hospital transfer note. 1. Allopurinol 300 mg PO BID 2. Pantoprazole 40 mg PO Q24H 3. Zinc Sulfate 220 mg PO DAILY 4. Timolol Maleate 0.5% 1 DROP BOTH EYES [**Hospital1 **] 5. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Hold for K > 6. Losartan Potassium 50 mg PO DAILY 7. Levothyroxine Sodium 25 mcg PO DAILY 8. GlipiZIDE XL 5 mg PO DAILY 9. Furosemide 40 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Nitroglycerin SL 0.3 mg SL PRN pain 12. Mylanta *NF* 200-200-20 mg/5 mL Oral q4h 13. Docusate Sodium 100 mg PO BID 14. Aspirin 325 mg PO DAILY 15. Acetaminophen 650 mg PO Q4H:PRN pain/fever Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Furosemide 40 mg PO DAILY 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Pantoprazole 40 mg PO Q24H 5. Acyclovir 400 mg PO Q8H 6. Artificial Tears 1-2 DROP BOTH EYES TID:PRN dry eyes 7. Diltiazem 90 mg PO QID hold for sbp<90, hr<60 8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES QHS 9. Hydroxyurea 500 mg PO QAM 10. Hydroxyurea 1000 mg PO QPM 11. Glargine 9 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 12. Lorazepam 0.5-2 mg PO/IV Q4H:PRN nausea/anxiety/insomnia 13. Senna 2 TAB PO BID:PRN constipation 14. traZODONE 25 mg PO HS:PRN Insomnia Hold for sedation or rr<10 15. Acetaminophen 650 mg PO Q4H:PRN pain/fever 16. GlipiZIDE XL 5 mg PO DAILY 17. Mylanta *NF* 200 mg/5 mL ORAL Q4H:PRN indigestion 18. Vitamin D 1000 UNIT PO DAILY 19. Zinc Sulfate 220 mg PO DAILY 20. Allopurinol 300 mg PO BID 21. Fluconazole 200 mg PO Q24H Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: AML Secondary: Leukemia cutis Lower GI bleed due to hemmoroids and radiation proctitis Sacral ulcers Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 1968**], It was a pleasure to participate in your care at [**Hospital1 18**]. You were treated here for your AML with a medication called decitabine. We also began giving you a medication called hydrourea to help slow the progression of your disease. You will need to follow up with Dr. [**Last Name (STitle) 11022**] later this week for further management of your AML. You will need to have your blood counts checked 3 times a week. You will need to receive a blood transfusion if your hemocrit is below 24 or a platlet tranfusion if your platelets are below 20. In the hospital you had some bleeding from your rectum. You were seen by the Gastroenterology team and we believe this bleeding was caused by hemmorrhoids and the radiation you received for your anal cancer several years ago. At the time of discharge your rectal bleeding had resolved. Please take all your medications as prescribed. Please keep all of your follow up appointments. [**Name6 (MD) 11021**] [**Name8 (MD) 11022**] MD [**MD Number(2) 38620**] Completed by:[**2134-9-14**]

[ "244.9", "E933.1", "569.49", "V10.06", "427.32", "787.91", "V45.61", "368.8", "455.8", "041.49", "V43.1", "787.60", "401.9", "285.1", "707.8", "786.59", "276.1", "272.4", "V58.67", "427.31", "428.0", "V88.01", "599.0", "584.9", "284.11", "362.03", "428.31", "788.30", "250.50", "E879.2", "277.88", "207.80", "365.9", "205.00", "V49.86" ]

icd9cm

[ [ [] ] ]

[ "99.72", "38.97", "99.25" ]

icd9pcs

[ [ [] ] ]

11739, 11811

5685, 10022

328, 336

11979, 11979

3493, 3493

2489, 2584

10833, 11716

11832, 11958

10048, 10810

12164, 13279

2599, 3474

1352, 2064

268, 290

4886, 5662

364, 1333

3509, 4867

11994, 12140

2244, 2298

2314, 2473

14,245

174,786

7990

Discharge summary

report

Admission Date: [**2147-6-10**] Discharge Date: [**2147-6-16**] Date of Birth: [**2068-2-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: acute on chronic systolic heart failure Major Surgical or Invasive Procedure: none History of Present Illness: 78M with a medical history of CAD s/p CABG ([**2139**] LIMA->diag, SVG->OM1, SVG->LAD), s/p stent to LAD, [**Year (4 digits) **] to RCA ([**2146**]), systolic heart failure secondary to ischemic cardiomyopathy (EF 20-30% [**2141**]), history of NSVT s/p ICD implantation ([**2141**]) transferred from [**Hospital6 17032**] for further management of acute on chronic systolic heart failure, hypotension in setting of diuresis, and worsening acute on chronic renal insufficiency. . The patient has a history of multiple admissions to [**Hospital **] for CHF and COPD exacerbation and was recently discharged to [**Hospital 25576**] Rehabilitation Center on [**2147-5-30**] after hospitalization for one such episode. At the rehab facility he was noted to have progressively worsening dyspnea, lower extremity edema, and orthopnea/paroxysmal nocturnal dyspnea. He was able to ambulate 10 steps but w/ dyspnea. Denies chest pain. He was transferred to [**Location (un) **] for further evaluation on [**2147-6-6**]. . On admission, vitals 110/60, 86, 20 100%RA. The initial exam was notable for bibasilar crackles and severe bilateral LE edema with BNP of 2620 (unclear baseline), felt to be c/w CHF exacerbation, for which he was given IV lasix boluses. With diuresis he developed asymptomatic hypotension (SBP 50s to 90s) and was transferred to the ICU. The diuretics were held (has not gotten lasix in >48 hours) and he was given IV fluid boluses (volume unclear). His renal function deteriorated over the course of his hospitalization from admission creatinine of 2.5 (baseline 1.5-1.8) to 4.2 today. Urine output reported to be 800cc in the past 24 hours. He developed hyperkalemia, with a peak of 6.6 for which he was given kayexcelate, and this AM was 5.5. He had evidence of a UTI on admission UA so was started on ceftriaxone. Chest X-ray reported possible right base infiltrate with effusion so this was broadened to levaquin and ceftriaxone. Liver function tests have worsened from AST/ALT of 179/64 on admission to 2600/1853 today. . Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: -Coronary Artery Disease (s/p MI x2) -Diabetes (Type 2 insulin-dependant) -Dyslipidemia -Hypertension 2. CARDIAC HISTORY: -CABG: -s/p CABG in [**2139**] (LIMA->diag, SVG->OM1, SVG->LAD) -PERCUTANEOUS CORONARY INTERVENTIONS: -s/p prior LAD stent and PTCA of diag -s/p [**Year (4 digits) **] to RCA in [**2146**] -PPM/ICD: - Ischemic cardiomyopathy, s/p ICD implantation [**2141-7-14**] - PPM (unclear when placed) -OTHER CARDIAC HISTORY: - Paroxysmal atrial fibrillation - Nonsustained ventricular tachycardia - Chronic systolic CHF [**2-14**] ischemic cardiomyopathy(last EF 20%) - Mitral regurgitation - Pulmonary Hypertension 3. OTHER PAST MEDICAL HISTORY: -Chronic Obstructive Pulmonary Disease on 3L home O2 since [**2146**] -Chronic Renal Insufficiency (baseline creatinine 1.5-1.8) -s/p right renal artery stent -Severe Peripheral Vascular Disease, s/p left fem-[**Doctor Last Name **] bypass [**2137**] -Obstructive sleep apnea intolerant to CPAP -GERD -Anxiety -Depression -Post Traumatic Stress Disorder Social History: Married and lives with his wife. Retired from Army. Most recently worked as a cook at the [**Hospital **] [**Hospital6 28623**]. He used to drink alcohol heavily, but has had none in 40 years. 40+ pack year h/o smoking, quit 40 years ago. Family History: Father died of an MI at age 48. Brother died of an MI at age 64. Physical Exam: VS:: Afebrile, 99/76, 74, 22 99%3L GEN: WDWN in NAD. Oriented to self, year,location. Mood appropriate. HEENT: Anicteric, moist mucus membranes, PERRL NECK: JVP difficult to assess, at least 6cm at 30 degrees CARDIAC: S1, S2 regular rhythm, normal rate, II/VI systolic murmur LLSP radiate to axilla LUNGS: respirations slightly labored, no accessory muscle use, crackles right base, rhonchi left base, no wheezes ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 3+ pitting edema dependent areas and shins SKIN: cool, venous stasis changes RLE, bilateral UE ecchymosis, right ankle dressed C/D/I, Stage II decubitus and right heel ulcer MSK: left ankle no point tenderness navicular, medial/lateral ankle Dopplerable distal pulses Pertinent Results: 2D-[**Hospital6 **] ([**1-/2147**] OSH) Right sided structures are normal in size and function w/borderline right atrail enlargement. Pacing wires on RV. LA is dialted. MV exhibits tethering to both anterior and posterior leaflets with calcification of posterior mitral annulus noted. LV is dilated and globally hypokinetic with severe hypokinesis involving septum and inferobase. Overall LV fx is severely impaired and estimated 20-25%. Aortic valve is tricuspid, sclerotic and adequate excursions. Aortic root is normal. Severe MR w/ [**3-16**]+ with jet that extends to base of LA. Moderate severe TR. Mild AI. Pulse doppler reveals increased E/A ratio w/ elevated E/E prime with grade III diastolic dysfunction. pulmonary HTN with estimated pulmonary systolic of 50-60. Conclusions: 1. LV dilation w/ global hypokinesis most prominent involving the left ventricular apex, anterobase, and inferobase. Overall LV function is severely impaired with EF of 20-25%. 2. Tethering of anterior and posterior mitral valve leaflets with mitral valve calcifications and severe MR. 3. Moderate to severe tricuspid regurgitation and pulmonary hypertension, with pulmonary systolic 50mm to 60mm 4. Mild aortic insufficiency 5. Grade III diastolic dysfunction 6. Pacing wire, RV 7. Biatrial enlargement . CARDIAC CATH: 6/ [**2146**] Cardiac cath ([**5-13**]): 1. Coronary angiography of this right dominant system revealed native three vessel coronary artery disease. The LMCA had a distal 50% stenosis. The LAD was occluded in the mid-vessel. The major diagonal branch had an ostial 60% stenosis. The LCx had a long 60% lesion in OM1. The RCA had a 90% stenosis just beyond the origin of the PDA. 2. Arterial conduit angiography demonstrated patent LIMA-D1 and SVG-OM grafts. The SVG-OM was occluded proximally. 3. Resting hemodynamics revealed elevated right and left sided filling pressures (RVEDP 16 mm Hg, PCWP mean 28 mm Hg). There was moderate to severe pulmonary arterial hypertension (PASP 61 mm Hg). The systemic arterial blood pressure was normal (SBP 122 mm Hg). The cardiac index was normal at 2.7 l/min/m2. The systemic vascular resistance was normal (911 dynes-sec/cm5). The pulmonary vascular resistance was normal (PVR 135 dynes-sec/cm5). 4. Successful PTCA and stenting of the distal RCA jailing the right PDA with a Xience (3x18mm) drug eluting stent postdilated with a 3.25mm balloon. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel (See PTCA comments). 5. Successful closure of the right femoral arteriotomy site with a Mynx closure device. FINAL DIAGNOSIS: 1. Native three vessel coronary artery disease. 2. Patent LIMA-D1 and SVG-LAD grafts. 3. Occluded SVG-OM graft. 4. Moderate biventricular diastolic dysfunction. 5. Moderate pulmonary hypertension. 6. Successful PTCA and stenting of the distal RCA with a Xience drug eluting stent. 7. Successful closure of the right femoral arteriotomy site with a Mynx closure device. . CHEST (PORTABLE AP) Study Date of [**2147-6-10**] 8:40 PM FINDINGS: Comparison is made to the prior study from [**2146-5-12**]. There is mild bibasilar atelectasis. Heart is mildly enlarged. Dual-lead pacer is present. There is increased bibasilar atelectasis since the prior study. CBC [**2147-6-11**] 04:23AM BLOOD WBC-13.3* RBC-4.68 Hgb-13.5* Hct-43.9 MCV-94 MCH-28.9 MCHC-30.9* RDW-17.0* Plt Ct-186 [**2147-6-10**] 04:38PM BLOOD WBC-14.7*# RBC-4.51* Hgb-13.4* Hct-41.7 MCV-93 MCH-29.7 MCHC-32.1 RDW-17.0* Plt Ct-191 Coags [**2147-6-11**] 04:23AM BLOOD PT-19.9* PTT-29.5 INR(PT)-1.8* [**2147-6-10**] 04:38PM BLOOD PT-22.1* PTT-29.3 INR(PT)-2.1* Chemistry [**2147-6-11**] 02:52PM BLOOD Glucose-341* UreaN-88* Creat-3.2* Na-132* K-4.1 Cl-91* HCO3-30 AnGap-15 [**2147-6-11**] 04:23AM BLOOD Glucose-300* UreaN-92* Creat-3.5* Na-132* K-4.8 Cl-89* HCO3-24 AnGap-24* [**2147-6-10**] 04:38PM BLOOD Glucose-196* UreaN-97* Creat-3.9*# Na-132* K-5.3* Cl-90* HCO3-27 AnGap-20 [**2147-6-11**] 02:52PM BLOOD Calcium-8.5 Phos-4.4 Mg-2.5 [**2147-6-11**] 04:23AM BLOOD Albumin-3.6 Calcium-8.7 Phos-5.3* Mg-2.7* [**2147-6-10**] 04:38PM BLOOD Albumin-3.9 Calcium-8.6 Phos-6.3*# Mg-3.0* LFTs [**2147-6-11**] 04:23AM BLOOD ALT-1765* AST-2200* LD(LDH)-575* AlkPhos-92 TotBili-1.9* [**2147-6-10**] 04:38PM BLOOD ALT-2221* AST-4086* LD(LDH)-1418* AlkPhos-98 TotBili-2.1* Brief Hospital Course: 78M with a medical history of CAD s/p CABG ([**2139**] LIMA->diag, SVG->OM1, SVG->LAD), s/p stent to LAD, [**Year (4 digits) **] to RCA ([**2146**]), systolic heart failure secondary to ischemic cardiomyopathy (EF 20-30% [**2141**]), history of NSVT s/p ICD implantation ([**2141**]) transferred from [**Hospital6 17032**] with acute on chronic systolic heart failure, hypotension limiting diuresis, worsening acute on chronic renal insufficiency, and worsening liver function. . #Acute on Chronic systolic Heart failure/Dyspnea: Patient was initally treated for HCAP at OSH but this was stopped given his CXR was without evidence of infiltrates. Patient volume overloaded on exam with elevated BNP. He was diuresed for acute on chronic systolic heart failure with lasix gtt. An echo was done that showed dilated LA, RA, RV and LV; LV systolic function depressed with EF 20-25%. His outpatient cardiologist was contact[**Name (NI) **] who confirmed that patient was on diovan, aldactone, and coumadin as an outpatient. Ultimately, his lasix gtt was switched to torsemide. Valsartan was and metoprolol were restarted. EP was also consulted for possible biv upgrade of patient's ICD as he was 90% RV pacing with widened QRS. Patient's ICD was interogated and revealed underlying sinus rhythm with 1:1 AV conduction. His ICD was reprogrammed to allow native conduction. Patient was discharged with plans for follow up with EP as an outpatient. . #. Atrial Fibrillation: Confirmed with outpatient cardiologist that patient had been on coumadin and was in favor of restarting this. Patient wsa restarted on coumadin with lovenox bridge. Amiodarone was continued. EP consulted as stated above, pacer interrogated showing underlying sinus with 1:1 AV conduction. . #Hypotention: No infectious etiology identified. Patient diuresed cautiously; sbp ranged from 70s-110s but mentating well. His [**Last Name (un) **] and beta blocker were started slowly as blood pressure tolerated. . # Acute on Chronic Renal Insufficiency: Creatine improved with diuresis; diovan restarted later on his hospital course. . # Elevated LFTs: Improved with diuresis, likely hepatic congestion secondary to acute on chronic heart failure. . #. CAD: Patient was continued on aspirin, zocor, and [**Last Name (un) **]/bb were restarted at later date. Plavix was stopped as patient was over a year out from his catheterization. . # Diabetes: Continued NPH and sliding scale. . #Hyperlipidemia: continued zocor and tricor . #STAGE II HEEL/DECUBITUS: wound care consulted. Patient was set up with an appoitnment to follow up with vascular surgery as outpatient. . #SUBCLINICAL HYPOTHYROIDISM: Noted to have elevated TSH w/ normal T4 at OSH. Outpatient follow up. . GERD: Ranitidine renally dosed at 150mg daily . DEPRESSION: continued home dose Effexor XR and Trazadone. Medications on Admission: - Humalog 50/50 16u [**Hospital1 **] - Aldactone 12.5mg [**Hospital1 **] - Duoneb INH QID - Amiodarone 100mg daily - ASA 81mg daily - plavix 75mg daily - colase 100mg [**Hospital1 **] - tricor 145mg daily - advair 250/50 [**Hospital1 **] - flonase 1 spray daily - lasix 80mg [**Hospital1 **] - zestril 2.5mg [**Hospital1 **] - MVI daily - Nystatin S/S QID - Miralax 1 tblsp daily - zantac 150mg [**Hospital1 **] - zocor 10mg daily - trazadone 50mg QHS - Effexor XR 112.5mg daily Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Venlafaxine 75 mg Tablet Sig: 1.5 Capsule, Sust. Release 24 hrs PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for constipation. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-14**] Puffs Inhalation Q6H (every 6 hours). 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day. 14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Humalog Mix 50-50 100 unit/mL (50-50) Suspension Sig: Ten (10) units Subcutaneous twice a day. 16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM for 2 days: Then continue Warfarin according to INR, goal 2.0-3.0. 17. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours): continue until INR > 2.0, then d/c. . 18. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 19. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale units Subcutaneous three times a day: before meals. 20. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. 21. Outpatient Lab Work Please check chem7 and INR on [**First Name8 (NamePattern2) 1017**] [**6-18**]. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Acute on Chronic Systolic Congestive Heart Failure Coronary Artery Disease Diabetes Mellitus Type 2 Paroxysmal Atrial Fibrillation Acute on chronic Kidney Disease 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 had another episode of congestive heart failure and needed to be transferred to [**Hospital1 18**] for low blood pressure. Your kidneys were not working well initially but have improved now. You did not have a urinary tract infection here. You will return to see Dr. [**Last Name (STitle) **] next month to discuss a revision of your pacemaker that may help with the congestive heart failure. We started you on coumadin to prevent blood clots and stroke with your irregular heart beat. You will need to take this medicine every day and follow your blood levels closely. Information about coumadin was given to you here. Medication changes: 1. Discontinue Zestril, furosemide, flonase, Plavix and spironolactone 2. Start Diovan 40 mg to lower blood pressure and help your heart work better 3. Start Torsemide to prevent fluid overload 4. Start senna to help with constipation 5. Start Lovenox to prevent blood clots until the coumadin level is > 2.0. Then d/c Lovenox 6. Start coumadin at 5mg daily for 2 days, check INR on [**First Name8 (NamePattern2) 1017**] [**6-18**] and adjust coumadin accordingly. Goal INR is 2.0-3.0. 7. Start Troprol to lower your heart rate and help your heart pump better. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Cardiology: Electrophysiology Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2147-7-20**] 9:00 . Cardiology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] Phone: [**Telephone/Fax (1) 11650**] Date/time: [**6-22**] at 2:00pm . Primary Care: [**Month (only) **],[**Female First Name (un) **] Phone: [**Telephone/Fax (1) 24306**] Date/Time: Pls make an appt to see Dr. [**Last Name (STitle) 24305**] when you get out of rehabilitation Completed by:[**2147-6-16**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

14417, 14503

9142, 11995

353, 359

14710, 14710

4735, 7375

16211, 16778

3895, 3963

12524, 14394

14524, 14689

12021, 12501

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274, 315

387, 2532

14725, 14869

3263, 3618

2554, 2685

3634, 3879

20,395

122,579

2644

Discharge summary

report

Admission Date: [**2161-10-16**] Discharge Date: [**2161-11-2**] Date of Birth: [**2115-7-22**] Sex: F Service: ADMISSION DIAGNOSES: 1. Postoperative neck hematoma. 2. Status post right thyroid lobectomy. 3. Hypercholesterolemia. 4. History of lichen simplex chronicus. 5. Status post right breast lumpectomy. DISCHARGE DIAGNOSES: 1. Recurrent postoperative neck hematoma. 2. Status post tracheostomy. 3. Subglottic stenosis--status post flexible and rigid bronchoscopy with intrabronchoscopic debridement. 4. Hypercholesterolemia. 5. Status post right breast lumpectomy. 6. History of lichen simplex chronicus. ADMISSION HISTORY AND PHYSICAL: Ms. [**Known lastname 13260**] [**Known lastname 13261**] is a 46-year-old female who initially presented on [**2161-10-16**] after having a right hemithyroidectomy on [**2161-10-13**] for a multinodular goiter. About a day or two postoperatively, she had noted increased neck swelling which had gotten significantly worse over the prior 24 hours, and then some mild shortness of breath and difficulty swallowing along with some associated nausea and vomiting. When she was seen, her temperature was 98.5, with a pulse of 101, and a blood pressure of 142/68, respiratory rate 16, and she was satting 100% on room air. She was awake, alert and oriented, and did not appear to be in distress. Neurologically, she was intact. EXAMINATION: The neck revealed tense swelling anteriorly with ecchymoses extending into the anterior chest, and superiorly to the submandibular area, and bilaterally around the lateral aspects of the neck. The lungs were otherwise clear. The heart was regular. The abdomen was soft. The extremities were warm. ADMISSION LABS: White count 15.2, hematocrit 30.3, platelet count 235, PT 11.7, INR 0.9, PTT 25.4. Her BUN and creatinine were 10 and 0.6, and her K was 3.0. ASSESSMENT: This patient's exam was consistent with postoperative neck hematoma with some evidence of airway compromise. HOSPITAL COURSE: Therefore, the patient was taken urgently to the operating room for exploration of the neck by Dr. [**Last Name (STitle) **]. Intraoperatively, no bleeding vessels were found. The wound was again closed with evidence of good hemostasis. The patient remained hospitalized during that day for observation, and it was determined that if she was not feeling 100% that she should be kept overnight again for observation. Approximately 24 hours after the second surgery, the patient was noted to have some increased respiratory difficulty and noted to have an expanding neck hematoma once again, and was taken emergently to the operating room where she underwent emergent placement of tracheostomy. This was secondary to airway compromise and inability to intubate the patient. Again, there was no note of a bleeding vessel intraoperatively, and the patient was taken to the Intensive Care Unit postoperatively for observation and management of her tracheostomy. The patient remained stable in the Intensive Care Unit postoperatively without any evidence of respiratory distress or difficulty with breathing, and had no other postoperative events of bleeding. Her course was prolonged secondary to issues with tracheostomy management in terms of size and assurance that there was no cuff leak. The patient was transferred to the floor with her tracheostomy where she did well, but as noted postoperatively, the patient was unable to vocalized. A pulmonary consult was obtained, and it was determined via bronchoscopy that the patient was suffering from subglottic stenosis. This required again repeat flexible and rigid bronchoscopy with intraprocedural debridement of excess granulation tissue, after which the patient was able to breathe well and vocalize properly. It was also during this same procedure that the patient's tracheostomy was removed, and the wound was left to close on its own. The patient had no respiratory distress after this. Otherwise, the patient's postoperative course was relatively uncomplicated. She had no cardiac issues. She had no issues in terms of infectious disease. Her urine output was excellent. She had no elevations of her BUN or creatinine. In terms of evaluating this possible coagulopathy, the patient actually had work-up which included Factor V leiden which showed no mutation, functional protein S, coags and platelet count were as noted before and were normal. The patient's Factor VIII was slightly elevated at 178. Her [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was normal at 180, and her protein C was slightly elevated at 150. A hematology outpatient visit was set-up for the patient in order to have further work-up of this possible clotting deficiency. Otherwise, the patient was discharged to home in good condition with Roxicet elixir for pain, and colace for stool softener. She was to follow-up with Dr. [**Last Name (STitle) **] in 2 weeks, and also to follow-up with interventional pulmonology in 1 week, and follow-up with hematology as per her set-up outpatient visit. It should be noted that a CT scan obtained prior to patient's bronchoscopy did not evidence any fasciitis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11126**] Dictated By:[**Last Name (NamePattern1) 13262**] MEDQUIST36 D: [**2161-11-2**] 13:29 T: [**2161-11-2**] 14:11 JOB#: [**Job Number 13263**]

[ "E878.6", "478.74", "518.82", "272.0", "998.12" ]

icd9cm

[ [ [] ] ]

[ "31.5", "30.09", "86.09", "31.1", "33.21", "31.99" ]

icd9pcs

[ [ [] ] ]

352, 1710

2012, 5464

153, 331

1727, 1994

74,253

138,344

36190

Discharge summary

report

Admission Date: [**2194-12-22**] Discharge Date: [**2195-1-15**] Date of Birth: [**2111-3-25**] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Cefepime Attending:[**First Name3 (LF) 398**] Chief Complaint: unresponsiveness Major Surgical or Invasive Procedure: Tracheostomy PICC line placement Central line placement and removal History of Present Illness: This is a 82 year-old female with a history of CVA and dementia (nonverbal at baseline with PEG), CHF, h/o c diff, Afib, hypertension, hypothyroidism who presents from the ED after being found unresponsive at her nursing home. In late [**Name (NI) **], pt was admitted to an OSH for UTI complicated by c diff colitis. Per her daughter, pt has been more sleepy than usual for the past week with increasing O2 requirement. According to NH records, pt was diagnosed with LLL pneumonia yesterday and started on levofloxacin. She developed worsening respiratory distress and was found unresponsive early this morning. Had temp to 101 with SaO2 96% on 4L. EMS found her unresponsive and tachypneic. Pt was intubated in the field by EMS after receiving fentanyl and versed. Her initial BP in the field was 200/100--> 140s systolic. She was brought to [**Hospital3 1280**]. Vitals on arrival were notable for temp of 100.1 and BP 89/66. CXR showed RLL infiltrate. WBC was 15.9 with left shift and 6 bands. Received NS 2L, levo 500mg IV and vanco 1g IV. ABG prior to transfer was 7.59/36/504/35. She was transferred to [**Hospital1 18**] for further management. . In the ED, initial vitals were T 100.0, HR 67, BP 149/63, RR 14, SaO2 100% intubated. She remained hemodynamically stable. Head CT and CT c-spine with no acute process. CXR showed R-sided infiltrate. WBC was 21 with 88% neutrophils (no bands). Trop was elevated to 0.18 with CK of 50 and EKG unremarkable. Additional notable labs include lactate of 4.9, INR of 4.9, K of 2.7, and BUN/Cr 39/0.4. UA was negative. Urine and blood cultures sent. She received 2L NS, 40 mEq K, levo 250mg, and ceftriaxone 1g. Pt was transferred to the [**Hospital Unit Name 153**] for further management. . ROS: Unable to obtain as patient is intubated and sedated. Past Medical History: CHF (EF unknown) h/o C diff in late [**Month (only) **] A fib Anemia h/o CVA [**7-15**] s/p PEG-- was fully functional prior to CVA, now nonverbal at baseline and dependent for all ADLs Hypertension Hypothyroidism Social History: Divorced. Lives at [**First Name4 (NamePattern1) 3403**] [**Last Name (NamePattern1) 5261**] House. Otherwise unknown. Family History: non-contributory Physical Exam: Vitals: T: BP: 151/85 HR: 74 RR: 20 O2Sat: 96% on AC 400/14 PEEP 5 FiO2 50% GEN: elderly female, intubated, no acute distress HEENT: PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry mucous membranes with poor dentition and oral hygiene, no oral lesions NECK: No JVD, no bruits, no cervical lymphadenopathy, trachea midline COR: a fib, no M/G/R, normal S1 S2, radial and DP pulses +2 PULM: coarse upper airway breath sounds anteriorly, no wheeze or crackles ABD: Soft, NT, ND, +BS, no HSM, no masses; PEG in place with no surrounding erythema or drainage EXT: No C/C/E, no palpable cords NEURO: Opens eyes to voice and tracks. Follows simple commands (open eyes, squeeze fingers). Plantar reflex downgoing on L and upgoing on R. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2194-12-22**] 07:30AM PLT COUNT-519* NEUTS-87.9* LYMPHS-7.7* MONOS-4.0 EOS-0.1 BASOS-0.3 WBC-21.2* RBC-3.79* HGB-10.8* HCT-33.0* MCV-87 MCH-28.6 MCHC-32.9 RDW-16.5* GLUCOSE-159* UREA N-39* CREAT-0.4 SODIUM-144 POTASSIUM-2.8* CHLORIDE-99 CO2-36* ANION GAP-12 PT-44.2* PTT-30.9 INR(PT)-4.9* CK-MB-NotDone cTropnT-0.18* CK(CPK)-50 POTASSIUM-2.9* HGB-11.5* calcHCT-35 GLUCOSE-146* LACTATE-4.9* NA+-144 K+-2.7* CL--92* TCO2-37* [**2194-12-22**] 09:48AM URINE HYALINE-0-2 RBC-[**3-12**]* WBC-[**3-12**] BACTERIA-NONE YEAST-NONE EPI-0-2 BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024 [**2194-12-22**] 02:23PM PT-35.3* PTT-28.1 INR(PT)-3.7* PLT COUNT-558* WBC-27.4* RBC-4.13* HGB-11.7* HCT-36.7 MCV-89 MCH-28.4 MCHC-31.9 RDW-16.1* DIGOXIN-2.4* TSH-4.8* CALCIUM-7.5* PHOSPHATE-2.6* MAGNESIUM-1.7 CK-MB-7 cTropnT-0.11* proBNP-6848* CK(CPK)-75 [**2194-12-22**] 02:23PM GLUCOSE-173* UREA N-36* CREAT-0.4 SODIUM-145 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-29 ANION GAP-16 LACTATE-3.1* TYPE-ART O2-50 PO2-157* PCO2-37 PH-7.54* TOTAL CO2-33* BASE XS-9 Discharge labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2195-1-15**] 04:04AM 5.5 2.68* 7.9* 24.9* 93 29.3 31.5 17.8* 498* BASIC COAGULATION PT PTT INR(PT) [**2195-1-15**] 08:00AM 15.7 25.2 1.4* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2195-1-15**] 04:04AM 122* 7 0.2* 130* 3.6 98 26 10 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2195-1-15**] 04:04AM 7.6* 3.2 1.7 Head CT [**12-22**] IMPRESSION: 1. No evidence of hemorrhage or recent infarction. 2. Large area of encephalomalacia in the left MCA distribution. C-Spine CT [**12-22**] IMPRESSION: 1. No evidence of fracture in the cervical spine. 2. Multilevel severe degenerative changes with bilateral multilevel neural foraminal narrowing. CT Torso [**12-22**] 1. Diverticulitis with adjacent inflammatory change and phlegmon; no discrete abscess or drainable fluid collection. 2. Right basilar airspace opacification likely due to pneumonic consolidation. 3. Right upper lobe segmental atelectasis. CHEST (PORTABLE AP) Study Date of [**2194-12-22**] 6:40 AM IMPRESSION: 1. Endotracheal tube in the appropriate position. 2. Multiple rib fractures. 3. Right hemidiaphragm elevation, probably due to atelectasis, recommend followup to document resolution. TTE [**12-26**]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. The right ventricular cavity is dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild to moderate ([**1-9**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CXR [**2195-1-13**]: In comparison with study [**1-12**], there is now a tracheostomy tube in place with no evidence of pneumomediastinum or pneumothorax. Little overall change in the cardiomegaly, pulmonary vascular congestion, basilar atelectasis, and bilateral pleural effusions. Brief Hospital Course: # Respiratory failure: Likely secondary to aspiration given altered mental status and recent lethargy. She was able to wean to pressure support and FiO2 of 40% upon arrival to ICU. Was initially broadly covered with vanco/cefepime in case of pnuemonia, but without any evidence of pneumonia on cxr or culture data, these antibx were stopped. Urine legionella negative. On HD#3 patient developed HTN and increased WOB in the setting of flash pulmonary edema. Improved with Lasix and acute blood pressure treatment. Developed Right sided pleural effusion and was slowly diuresed in the ICU. Although patient carries a dx of CHF, TTE demonstrated intact EF of 55%. Due to her prolonged intubation and failure to wean from the ventilator, a trach was placed on [**2195-1-13**]. # C Diff Colitis: Hypotension resolved with IV fluid on admission. Treated with Vancomycin po and Flagyl IV that was later transitioned to po. Remaining culture data was negative. CT abdomen demonstrated colitis and diverticulitis. Planned treatment course for 2 weeks starting with cessation of all other antibiotics on [**2195-1-7**]. Last day of antibiotics should be [**2195-1-21**]. She was also given probiotics provided by her family by their request. # Elevated troponin with lateral ST depressions: Enzymes peaked on admission and trended down over hospital course; CK was flat. Lateral ST depressions had been noted previously. Cardiac changes felt to be due to myocardial strain. # Afib: On coumadin, digoxin, and carvedilol as an outpatient. Afib remained rate controlled. Digoxin was supratherapeutic and held for the first 3 days and restarted at a lower dose. Her last dig dose was [**1-5**] at 0.4. Coumadin was held because her INR was supratherapeutic. LFTs were wnl. Supratherapeutic INR was felt to be [**2-9**] Flagyl use. Prior to trach placement she was systemically anticoagulated on a heparin gtt. After her trach placement she was restarted on coumadin at 5 mg daily. The day of discharge her INR was 1.4. Given her low daily risk for stroke, no anticoagulation bridge was started with the coumadin. Her goal INR is [**2-10**]. # CHF: TTE demonsrated intact EF. Initially restrated on digoxin, lisinopril and carvedilol in the ICU, and Lasix and spironolactone were held. She developed hypotension in the setting of C.diff diarrhea so her lisinopril and carvediolol were stopped. On discharge she is only on digoxin. She was being diuresed with IV lasix prn for a goal of 500 cc to 1 L negative daily. Prior to discharge she was still positive 10.7 L from admission. # HTN: The patient is on Carvedilol 25mg [**Hospital1 **], Lasix 40mg PO daily, Lisinopril 40mg [**Hospital1 **], and Spironolactone 25mg daily as an outpatient. Here these were all held given hypotension early on during her ICU course which required levophed support. As her pressures stabilized she was diuresed with IV lasix as needed to maintain 0.5 to 1 L negative daily, but her other medications were not restarted given the diuresis. Her BPs remained well controlled. # Elevated TSH: Her TSH was mildly elevated at 4.8 on admission. Unclear if she was supposed to be on levothyroxine as it was not on her outpatient medication list. As this likely represented sick euthyroid syndrome she was not started on levothyroxine. She will need her TSH rechecked in [**4-13**] weeks after discharge. # Hyponatremia: The patient??????s Na has decreased to 130 today from 132 from 136. She is volume overloaded, but does not appear to have CHF, cirrhosis, or nephrotic syndrome, so she most likely has SIADH. Also her K is low, making adrenal insufficiency unlikely. Diuresis with lasix will likely help get rid of excess free water. She will need to be continue on diuresis as above. # Rash: The patient developed a maculopapular rash over her torso and extremities which eventually faded and desquamated. It was thought to be secondary to a cefepime drug rash. Cefepime was stopped on [**1-1**]. It has greatly improved. She is now being given eucerin cream daily. # Anemia: HCT stable at 24.9 today (was 23.7 yesterday). Her Hct was in the low 30??????s on admission and has trended downward over her stay. No clinical evidence of bleeding. Likely secondary to her acute illness. # FEN: She was continue on tube feeds through her PEG. # PPx: PPI, SQH until her INR is therapeutic, VAT prophylaxis # Code: Full code (confirmed with daughter) Medications on Admission: Coumadin 4mg daily Levaquin 500mg (started [**12-21**]) Regular insulin sliding scale Acidophilus [**Hospital1 **] Calcium carbonate 500mg PO BID Carvedilol 25mg [**Hospital1 **] Digoxin 0.025 daily Lasix 40mg PO daily Lisinopril 40mg [**Hospital1 **] Prevacid 30mg PO daily Spironolacton 25mg daily Fentanyl patch 25mcg q72 Albuterol/Atrovent inh prn Discharge Medications: 1. Digoxin 125 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: 6-10 Puffs Inhalation Q4H (every 4 hours) as needed. 3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff Inhalation QID (4 times a day). 4. Fentanyl 25 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Morphine Sulfate 2 mg IV Q4H:PRN pain with turning please give when repositioning if needed for pain 7. Lactobacillus Acidophilus Oral 8. White Petrolatum-Mineral Oil Cream [**Last Name (STitle) **]: One (1) Appl Topical DAILY (Daily). 9. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection ASDIR (AS DIRECTED): Insulin sliding scale. 10. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) inj Injection TID (3 times a day). 11. Vancomycin 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every 6 hours) for 6 days: Last day [**1-21**]. 12. Metronidazole 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q8H (every 8 hours) for 6 days: Last day [**1-21**]. 13. Warfarin 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Once Daily at 4 PM: Titrate to a goal INR of [**2-10**]. 14. Chlorhexidine Gluconate 0.12 % Mouthwash [**Date Range **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Primary - Respiratory failure Inability to wean from the ventilator requiring trach placement Clostridium difficile colitis Secondary - Drug-induced rash Atrial fibrillation History of CVA with a PEG in place Discharge Condition: Stable, afebrile, continuing to require a ventilator. Discharge Instructions: You were transferred to this hospital with unresponsiveness and respiratory failure which was thought to be due to infection with pneumonia. You were already intubated (tube to help you breathe) before being transferred. You were treated with antibiotics and several attempts at weaning you off the ventilator were made, however you could not be weaned. A tracheostomy was placed for chronic ventilatory support. You also had an infection with Clostridium difficile which caused you to have diarrhea. You were treated with oral vancomycin and flagyl and will need to finish the 2 week course. Medication changes: 1. You will need to take 6 more days of po vancomyin and po flagyl (last day of antibiotics is [**1-21**]). 2. You will need to continue on coumadin 5 mg daily and have your INR check daily until you are therapeutic (INR [**2-10**]) on a stable dose. The dose may need to be adjusted. 3. Your BP medications (lisinopril, spironolactone, lasix, and carvediolol) were stopped and you were given IV lasix for diuresis. You should continued to be diuresed for a goal of 500 cc to 1 L negative daily and eventually restarted on a regimen similar to you previous one. You will need to have your TSH checked in [**4-13**] weeks to determine if you require thyroid hormone replacement. Followup Instructions: You should follow up with you primary doctor within 1-2 weeks, Dr. [**Last Name (STitle) 28003**] ([**Telephone/Fax (1) 41434**]). You should also follow up with an Interventional Pulmonologist (the doctor who placed your tracheostomy) in [**4-13**] weeks. You should schedule the appointment with Dr. [**Last Name (STitle) **], ([**Telephone/Fax (1) 27079**]. Completed by:[**2195-1-15**]

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icd9cm

[ [ [] ] ]

[ "38.93", "33.23", "96.04", "96.05", "96.72", "31.1", "93.90", "96.71" ]

icd9pcs

[ [ [] ] ]

13771, 13845

7157, 11607

320, 390

14099, 14155

3466, 4626

15506, 15900

2610, 2628

12010, 13748

13866, 14078

11633, 11987

14179, 14778

4642, 7134

2643, 3447

14798, 15483

264, 282

418, 2220

2242, 2458

2474, 2594

10,990

191,134

12117

Discharge summary

report

Admission Date: [**2127-1-6**] Discharge Date: [**2127-1-21**] Service: Neurosurgery NOTE: THIS IS ALSO PATIENT'S DEATH SUMMARY. Patient was declared deceased on [**1-21**] at 4:30 p.m. HISTORY OF PRESENT ILLNESS: This is a 88-year-old Greek speaking white male with history of coronary artery disease, status post coronary artery bypass graft times two in [**2123**] with a placement of a pacemaker at that time and an ejection fraction of 60%, history of hypertension, status post syncopal episodes and fall on [**1-4**] with positive loss of consciousness times ten minutes, who was found to have a PE at that time and ruled out for myocardial infarction at that time. He was started on heparin drips on the evening of [**1-4**] and had a normal neurological exam at that time, however, at 11 a.m. on [**1-5**], he was noted to be ambulating with a right-sided weakness. A CT scan of the head showed a large subarachnoid hemorrhage with parenchymal hemorrhage and the heparin drops were discontinued and the patient was given four units of FFP and Vitamin K 10 mg subcutaneously times one. At 4 p.m., the patient was noted to have decreased responsiveness with tongue deviated to the left, right pupil more sluggish than the left and not opening his eyes spontaneously. Repeat CT scan at 10 p.m. showed increased hemorrhage and hydrocephalus and the patient was intubated prior to transfer from an outside hospital to the [**Hospital1 **] Hospital. MEDICATIONS AT TIME OF ADMISSION: Aspirin, Accupril, Atenolol, Zoloft, Lasix, multivitamins, Colace and Dilantin. PAST MEDICAL HISTORY: He had a previous medical history of coronary artery disease, a gastrointestinal bleed, hypertension and depression. ALLERGIES: He had no known drug allergies. SOCIAL HISTORY: History of past cigarette smoking, one pack per day, no history of alcohol intake and was currently married and had a supportive family. A head CT done urgently at the time of admission showed a large subarachnoid hemorrhage with interventricular clot and extension into the right thalamus with sylvian fissure blood and the ventricles were markedly enlarged. PHYSICAL EXAMINATION: On exam, the patient's blood pressures were 180/59 to 93/46. He was receiving Nipride to control the blood pressure. His heart rate was 60 and paced with his indwelling pacemaker. The patient's respiratory rate was 14 on a ventilator at 100% 02 saturation. He was intubated. There was no spontaneous eye opening and there was a positive gag. Pupils were equal, 2 mm and sluggishly reactive. There was slight spontaneous movements of the bilateral legs, but no spontaneous movement of the upper extremities. The right leg externally was rotated, left greater than right, and he withdrawals to nailbed pressure of the bilateral extremities and the toes were bilateral upgoing. HOSPITAL COURSE: Due to the clinical findings, the patient was admitted to the hospital and underwent urgent placement of a ventricular drain. Patient tolerated the procedure well and was admitted to the Neursurgical Intensive Care Unit. Unfortunately, the patient's comatose condition did not change. He remained comatose and decerebrated on the right with withdrawal on the left and the toes bilaterally were upgoing. After discussion with the family, it was decided not to place a cable filter for the DVT and not do a cerebral angiogram for identification of the source of bleeding. Therefore, the family agreed to make the patient "Do Not Resuscitate" and plan was to continue current therapy for at least 72 hours and if no improvements, then discuss withdrawal of care. The patient's clinical condition did not improve over the next several days and on the [**1-13**] with the patient's condition stabilized and his ICP intercerebral pressure stabilized, his ventricular drain was removed and the patient was moved from the Neurosurgical Intensive Care Unit to the regular hospital floor. The patient's clinical condition continued to remain stable as comatose and essentially all but unresponsive and after several discussions with the family, it was decided on the [**12-23**], that the patient would be made comfort measures only and therefore comfort measures were begun and the patient expired on the [**2127-1-21**] at 4:30 p.m. CONDITION ON DISCHARGE: Deceased. [**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**] Dictated By:[**Doctor Last Name 7311**] MEDQUIST36 D: [**2127-5-1**] 10:20 T: [**2127-5-1**] 10:20 JOB#: [**Job Number 37993**]

[ "V45.01", "275.41", "V45.81", "276.0", "415.19", "431", "276.8", "401.9", "780.09" ]

icd9cm

[ [ [] ] ]

[ "02.2", "38.93", "38.91", "96.72" ]

icd9pcs

[ [ [] ] ]

2876, 4308

2175, 2858

228, 1587

1610, 1773

1790, 2152

4333, 4576

27,337

166,098

32966

Discharge summary

report

Admission Date: [**2195-12-2**] Discharge Date: [**2195-12-18**] Date of Birth: [**2153-12-30**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4679**] Chief Complaint: Pectoral / Claviculat / Mediastinal infection Major Surgical or Invasive Procedure: Partial sternotomy with right clavicle resection History of Present Illness: Mr. [**Known lastname **] is a 41 year old man with hx IVDU, Hepatitis C, and DM who was initially admitted to [**Hospital3 15286**] from [**12-2**] for a 10 day history of pain and swelling of his right upper chest. He was afebrile with a WBC of 16.8. A CT chest revealed a soft tissue mass along the clavical and pectoralis major containing air bubbles with extension into the anterior mediastinum. Of note his liver was also noted to be nodular. Blood cultures were drawn and he was given a dose of Ertapenem and transferred to [**Hospital1 18**] for surgical management. In our ED repeat blood cultures were drawn and he was given Vancomycin and 160 mg of Gentamicin and admitted to the surgical service. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: DM ? HTN HCV: dx 3 years ago, no liver bx, no treatment IVDU Depression Social History: SOCIAL HISTORY: Lives alone. On disability EtOH: {x}N {}Y Amount: Tobacco: {}N {x}Y 2PPD Drugs: {}N {x}Y Heroin Married: {x} N {} Y Divorced {} SO {} Occupations: Unemployed Exposures: None, no spas, gyms, water exp Travel: None Pets: Cat, frequent scratches HIV Risk: check all that apply {} no HIV risk factors {} unprotected sex with men {x} unprotected sex with women {x} IVDU {} transfusion {} CSW Diabetes: ? Immunodeficiency: relative, HCV [**Name2 (NI) 3730**]: N Family History: Noncontributory Physical Exam: PHYSICAL EXAM: General: Obese, pale, NAD HEENT: OP poor dentition, + caries, no lesions Neck: Supple, no LAD Cardiovascular: Tachycardic, [**12-23**] murmur loudest at LSB Respiratory: Clear anteriorly Gastrointestinal: +BS, obese, soft, unable to appreciate liver or spleen edge Musculoskeletal: No edema Skin: Area of marked erythema over right clavicle extending to midline and up to right shoulder, firm, no crepitance or fluctuance noted. No splinter hemorrhages or [**Last Name (un) **] nodules noted. Old scarred lesion on right arm. Pertinent Results: [**12-2**] Chest CT IMPRESSION: 1. Focal thickening of the medial pectoralis major muscle contiguous with soft tissue mass-like density of the superior anterior mediastinum. While there is no drainable fluid collection, several bubbles of gas are noted within the soft tissue mass. Findings are concerning for infection. No definite local bony erosion is identified to suggest osteomyelitis, although this cannot be excluded. 2. Nodular contour of the liver suggests underlying cirrhosis. 3. Cholelithiasis. Pathology with acute osteomyelitis of resected clavicle Brief Hospital Course: The patient was admitted to Thoracic surgery for management of his chest wall/mediastinal swelling/infection. Neuro: Neurology was consulted for work up of acute onset headache. LP was performed and CSF sent for cx, which eventually came back negative. CTH was also done, which showed no intracranial hemorrhage or mass effect. ID: The patient was started on Vanc/Gent in the ED prior to admission, and changed to Vanc/Zosyn upon transfer. Infectious disease was consulted and recommended echo to r/o intracardiac/endovascular focus of infection. TTE was done which showed no intracardiac vegetation. Post operatively, the patient was changed to Zosyn/Nafcillin and eventually just to Nafcillin for which he will need to complete a 6 week course. Endocrine: [**Last Name (un) **] was consulted to manage blood glucoses which were uncontrolled for much of the hospitalization. Under the most recent regimen and sliding scale, the sugars have been improved. MSK: On [**12-4**], the patient was taken to the operating room for a resection of the medial right clavicle, first rib, and sternoclavicular joint, and a partial sternectomy. The patient tolerated the procedure well with no complications and was transfered to the ICU postoperatively. The patient was continued with WTD dressing changes until [**12-7**] when a wound vac was placed. The wound vac was changed several times with no events. The wound required minimal debriding and has continued to heal well. Pain: The patient has a h/o IVDA and required high amounts of pain medication throughout the hospitalization. Chronic pain was consulted and recommendations followed. Addiction was also consulted and discussed with the patient his issues and concerns. Psych: Psychiatry was consulted for management of the patients meds and post operative hallucinations. Psych recommendations were followed regarding liberalizing Klonopin for anxiety. Furthermore, Psych assessed the patient capacity when he decided he did not want to go to rehab, he was deemed uncapable of leaving AMA, but the patient eventually agreed to rehab after witnessing the extent of his wound. The patient had rehab all set up and was set to go to [**Hospital1 **] on IV Nafcillin and with a wound vac, but the patient decided to leave AMA. We warned him of the implications of not receiving IV antibiotics and not having a wound vac, but the patient decided to leave anyway. We had social work discuss other options and he refused any of our assistive measures. The patient is leaving on keflex for 4 weeks and with [**Hospital1 **] wet to dry dressing changes Medications on Admission: HOME MEDICATIONS: Lisinopril Clonodine Remeron Klonopin Percocet Amitryptyline Discharge Medications: Leaving AMA on 1. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 4 weeks. Disp:*112 Capsule(s)* Refills:*0* If he were to leave to rehab, this is the regimen he wound have gotten 1. Amitriptyline 50 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 2. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 4. Lisinopril 20 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. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Nafcillin 2 gm IV Q4H 10. 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. 11. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN Peripheral IV - Inspect site every shift 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthru pain. 17. Insulin Sliding Scale See attached sheet 18. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 19. Oxycodone 30 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 20. glargine Sig: Seventy Four (74) Units During lunch. 21. Insulin Regular Human Injection Discharge Disposition: Home Discharge Diagnosis: Chest Wall Abscess s/p partial sternotomy with right clavicle resection Diabetes Mellitus Hepatitis C Hypertension Depression IV Drug User Discharge Condition: stable Discharge Instructions: You are leaving against medical advice. Please be advised that the current dressing you are leaving on is suboptimal to the wound vac, and the antibiotics that you are leaving on are suboptimal to the IV antibiotics we were planning on giving you at rehab. You have a serious wound that will require your attention while you are at home. You are advised not to use illegal drugs, drink alcohol, or smoke. Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 170**] if you experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Purulence from wound -Or any other concern Complete Course of antibiotics: 4 weeks Keflex Wound: Change your dressing twice a day. Take out all dressings dry. Then wet the roll of gauze (kerlex) and ring it out to make it damp and not wet. Then start at the perimeter and stuff the gauze under your skin edges then completely pack the wound with the rest of the kerlex. Cut it where appropriate. Do not have any damp parts of the gauze roll touch any of your skin as it will cause it to breakdown over time. Then cover the whole wound with 1 pack of 4x8inch gauze sheets. There are two sheets in each pack so stagger it so the whole wound is covered. Then stick an abdominal pad over the gauze and use paper tape to completely cover the bandage. If you return to a hospital you can tell them that we had your on Nafcillin 2g IV every 4 hours and that we had a white sponge wound vac over your chest wound changed every 3-4 days. Followup Instructions: You have a follow up appointment with Dr. [**First Name (STitle) **] [**12-29**] at 10:30pm on the [**Hospital Ward Name **] [**Hospital Ward Name 23**] clinical center. Please arrive 45 minutes prior to your appointment and report to the [**Location (un) **] rdaiology for a CXR.

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icd9cm

[ [ [] ] ]

[ "83.45", "88.72", "03.31", "77.81", "38.93", "93.59" ]

icd9pcs

[ [ [] ] ]

7832, 7838

3118, 5731

369, 420

8021, 8030

2529, 3095

9591, 9875

1920, 1937

5861, 7809

7859, 8000

5757, 5757

8054, 9568

1967, 2510

5775, 5838

284, 331

448, 1159

1181, 1286

1318, 1904

56,116

161,138

37292

Discharge summary

report

Admission Date: [**2121-2-5**] Discharge Date: [**2121-2-18**] Date of Birth: [**2061-3-20**] Sex: F Service: NEUROLOGY Allergies: Vicodin Attending:[**Doctor Last Name 15044**] Chief Complaint: Dehisence of right below-knee amputation site with bone exposure Major Surgical or Invasive Procedure: * Revision of right below-knee amputation History of Present Illness: PER ADMITTING VASCULAR TEAM: Patient is a 59F who initially [**Doctor Last Name 1834**] a R BKA by Dr. [**Last Name (STitle) 83920**] at [**Hospital2 **] [**Hospital3 6783**] hospital for severe PVD on [**2120-9-29**]. Patient later developed wound dehiscense with exposed bone. R BKA wound culture grew out multi-resistent pseudomonas sensitive only to vanc and tobramycin. She was treated with vanc from [**Date range (1) 80992**], when abx were stopped due to her needing surgical treatment for osteomyelitis. A wound vac was placed, and she was set up for a follow-up appointment with Dr. [**Last Name (STitle) 1391**] on [**2-12**]. However, at rehab she developed elevated temperatures to 100.7 and was brought back to [**Hospital2 **] [**Hospital3 6783**] Hospital on [**2121-2-1**]. An MRA of the R BKA showed 2.58cm of distal tibia/fibula osteo with surrounding myositis. Past Medical History: - HTN - DM2 associated with retinopathy, neuropathy, nephropathy - Hyperlipidemia - PVD - Osteomyelities with MRSA - OA - obesity - seizures . PAST SURGICAL HISTORY: - [**2-25**] R CEA - [**9-25**] R BKA - [**10-25**] Tracheostomy in the setting of seizure, PEA, arrest and vocal cord edema Social History: - married . HABITS: - Tobacco: remote - ETOH: - Recreational Drug Use: Family History: n/c Physical Exam: ON ADMISSION: Vital Signs: Temp: 98.1 RR: 18 Pulse: 68 BP: 150/68 Neuro/Psych: NAD. Skin: Abnormal: Stage 2 decub ulcers. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: No masses, abnormal: Obese. Rectal: Not Examined. Extremities: No RLE edema, No LLE Edema, abnormal: R BKA with exposed bone edges. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. LUE Radial: P. RLE Femoral: P. Popiteal: P. LLE Femoral: P. Popiteal: P. DP: D. PT: D. DESCRIPTION OF WOUND: open R BKA wound with exposed tib/fib, tissue planes easily separated, no prurulent material expressed from wound Pertinent Results: Admission Labs: WBC-13.9*# RBC-3.79* Hgb-11.1* Hct-33.3* MCV-88 MCH-29.3 MCHC-33.4 RDW-13.9 Plt Ct-416 Glucose-127* UreaN-23* Creat-1.0 Na-141 K-3.5 Cl-96 HCO3-36* AnGap-13 Calcium-9.1 Phos-4.4 Mg-1.6 . Microbiology Data [**2121-2-6**] 12:54 am SWAB Source: R BKA wound. **FINAL REPORT [**2121-2-9**]** WOUND CULTURE (Final [**2121-2-9**]): PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. OF THREE COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 32 R CEFTAZIDIME----------- 32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S MEROPENEM------------- =>16 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ <=1 S . [**2121-2-6**] 1:10 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2121-2-6**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2121-2-6**]): [**2121-2-6**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 83921**] AT 10:35 AM. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). . Blood Cx ([**2121-2-6**]) x 2: No Growth Urine Cx ([**2121-2-6**]): contaminated Urine Cx ([**2121-2-11**]): No Growth MRSA screen ([**2121-2-11**]): Positive . Discharge Labs: . IMAGING: Non-contrast CT of Head ([**2121-2-11**]): IMPRESSION: No acute hemorrhage or large territorial infarct. Chronic right lacunar infarct. . CT Angiogram and Perfusion ([**2121-2-11**]): IMPRESSION: 1. Highly unusual perfusion pattern, involving the left cerebral hemisphere, globally, with marked abnormally-low MTT (supranormal and increased CBV/CBF. In light of patient's history and right-sided localizing symptoms, this may represent global hyperperfusion related to focal seizure activity, with generalization. This appearance should be correlated with clinical semiology and EEG results. 2. No region of prolonged MTT or reduced CBV to suggest either ischemia or infarction. 3. 50% stenosis of the mid-right basilar artery. No other intracranial vascular abnormality including stenosis, occlusion or aneurysm. . EEG ([**2121-2-12**]): IMPRESSION: This is an abnormal portable EEG due to slowing, disorganization, and attenuation of the background rhythm consistent with a mild to moderate encephalopathy. Medications, toxic/metabolic disturbances, and infection are common causes. No focal, lateralized, or epileptiform features were seen during this recording. . EEG ([**2121-2-13**]): IMPRESSION: This is an abnormal video EEG study due to sharp transients, focal delta slowing, and attenuatio in the left mid to posterior temporal region. These findings suggest cortical irritability and cortical and subcortical dysfunction in this region. This telemetry captured no pushbutton activations. There were no electrographic seizures contained in this study. . MRI Head ([**2121-2-12**]): IMPRESSION: 1. Limited examination demonstrates no evidence for acute infarct. 2. The hyperperfusion previously seen within the left cerebral hemisphere has no definite correlate. Focus of abnormal T2 signal involving the left postcentral gyrus is of unclear etiology, though could relate to seizure activity, accounting for the hyperperfusion. Alternatively, this could represent an old infarct, particularly given the mild associated volume loss. 3. Subtle region of signal abnormality within the left thalamus on the diffusion sensitive sequence could potentially relate to a subacute evolving infarct and/or artifact. 4. Bilateral mastoid air cell effusions. Discharge Labs: 140 | 100 | 16 ---------------< 143 3.9 | 35 | 0.7 Ca: 8.3 Mg: 1.7 PO4: 3.4 10.2 11.1 >-----< 412 32.1 Tobra trough: 0.5 Brief Hospital Course: Ms. [**Known lastname **] is a 59 year-old woman with a complex past medical history including hypertension, hyperlipidemia, DM, seizure disorder, and PVD s/p right below the knee amputation (BKA) who was transferred from [**Hospital2 **] [**Hospital3 6783**] Hospital to the [**Hospital1 18**] Vascular Surgery Service [**2121-2-5**] for a revision of the right BKA. She was admitted to the Vascular Service from [**2121-2-5**] to [**2121-2-12**]. She was then transferred to the Neurology Service [**2121-2-12**] to [**2121-2-18**] following a change in mental status. . PERIPHERAL VASCULAR # Historical Data: Ms. [**Known lastname **] initially [**Known lastname 1834**] a right BKA in [**9-25**]. [**Doctor Last Name 6783**]. She was re-admitted to [**Hospital2 **] [**Hospital3 6783**] at the end of [**12-25**] in the setting of respiratory distress and fever. After a bronch demonstrated a possible tracheal tissue mass, she was transferred to the [**Hospital1 18**] for further pulmonary evaluation. In the course of that admission, a vascular consult was called for apparent wound right BKA wound dehisence and exposure of bone. It was recommended that cultures of the wound be obtained and the patient returnin a few weeks for a right BKA revision. . # Current Data: As planned, Ms. [**Known lastname **] [**Last Name (Titles) 1834**] the planned right below-knee amputation revision on [**2121-2-6**] in the setting of right distal tibia osteomyelitis with surrounding myositis and dehisence of the amputation site wound. Operative notes suggest the procedure went smoothly and was associated with minimal blood loss. Following the operation, she reportedly noted phantom pain which remained at a baseline level of discomfort. . RESPIRATORY # Historical Data According to records, a tracheostomy was initially placed in [**10-25**] for "seizures, respiratory failure, and vocal cord edema." The patient suffered a hypoxic episode in [**12-25**] for which a tracheostomy tube was placed at [**Hospital2 **] [**Hospital3 6783**] Hospital. Following transfer to the [**Hospital1 18**] in [**1-26**], bronchoscopy revealed a false passage in the pre-tracheal area in addition to a tracheal laceration and necrotic cartilage in the vicinity of the tracheal defect. She was then intubated and decanulated while at [**Hospital1 18**]. She was extubated [**2121-1-23**]; since that time, her respiratory status was reported to be stable. . # Current Data On [**2121-2-11**], the patient was transported to the Interventional Pulmonology Clinic for a scheduled re-assessment of the tracheal defect s/p tracheostomy and decannulation. Prior to the procedure, she was noted to be unresponsive with open eyes. A code stroke was called (please see below). . NEUROLOGY In the setting of a bronchoscopy on [**2121-2-11**], the patient was thought to develop an acute change in mental status. A code stroke was called. Physical examination was thought to be concerning for a seizure versus stroke. Since the patient was on keppra (500 mg po bid), a keppra load was administered and the dose was increased to 1 gram [**Hospital1 **]. She also [**Hospital1 1834**] CT with angiography and perfusion studies. The neuroimaging revealed a decreased mean transit time with increased cerebral blood flow and blood volume in the left parieto-occipital lobe. Converse to the appearance of scans indicative of stroke (with which increased mean transit time and decreased cerebral blood flow and volume are often observed), the findings were thought to possibly be consistent with seizure activity with a left focus. An EEG revealed changes consistent with encephalopathy. While an MRI revealed a hyperintensity in the left post-central gyrus, the finding was thought to be non-contributory to the patient's syndrome. . In the setting of the event, the patient was transferred to the Neurology Service and Keppra was increased to 1g [**Hospital1 **]. No clinical seizure activity was observed. On physical examination, the patient continued to demonstrate disorientation, an inability to consistently follow verbal requests correctly, and verbal and motor perseveration. In the absence of focal findings on neuroimaging, EEG, and laboratory studies (eg metabolic, electrolytes, the etiology of the change in mental status remained unclear. . CARDIOVASCULAR In the course of the hospitalization, the patient's blood pressure was quite difficult to maintain in normal range. Therefore, a nicardipine drip was started with a goal SBP of 160. She was then transitioned back to her home blood pressure regimen of HCTZ and metoprolol INFECTIOUS DISEASE # Historical Data During the patient's admission in early [**2121-1-17**], right BKA wound cultures demonstrated multi-drug resistant pseudomonas. An ID consult at that time recommended the team refrain from antibiotic treatment. She was discharged to rehab and returned for the current admission without the start of antibiotic treatment. The wound cultures were repeated during the current admission, presumably in the setting of leukocytosis. . # Current Data: C. Difficile Colitis: Stool cultures from [**2121-2-6**] returned positive for c. difficile colitis. Accordingly, a 14-day course of treatment with Flagyl was initiated to be continued through [**2121-2-20**]. . Pseudomonal Wound Infection: Repeat cultures of the right BKA site ([**2121-2-6**]) again demonstarted pseudomonas; further analysis ultimately revealed the organism was sensitive to tobramycin. Therefore, a 6-week course of the antibiotic was started to be continued through [**2121-3-20**]. . Blood cultures and urine cultures have been negative. A routine MRSA screen suggests that Ms. [**Known lastname **] is a carrier. . ENDOCRINE Insulin scale was initiated with a goal of normoglycemia. . REHAB Members of the physical therapy, occupational therapy, and speech therapy teams contributed to Ms. [**Known lastname 83922**] care throughout the hospitalization. Medications on Admission: Albuterol Sulfate Ergocalciferol (Vitamin D2) [Vitamin D] Gabapentin Heparin (Porcine) Insulin Aspart [Novolog] Insulin Glargine [Lantus] Levetiracetam Metoprolol Tartrate Metronidazole Morphine Pantoprazole Acetaminophen [Tylenol] Ascorbic Acid Aspirin Cyanocobalamin Lactobacillus Acidophilus Multivitamin Zinc Sulfate Discharge Medications: 1. Multivitamin Tablet [**Known lastname **]: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Known lastname **]: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Known lastname **]: One (1) Capsule PO 1X/WEEK (TU). 4. Ascorbic Acid 500 mg Tablet [**Known lastname **]: Two (2) Tablet PO DAILY (Daily). 5. Zinc Sulfate 220 mg Capsule [**Known lastname **]: One (1) Capsule PO DAILY (Daily). 6. Aspirin 325 mg Tablet [**Known lastname **]: One (1) Tablet PO DAILY (Daily). 7. Cyanocobalamin 500 mcg Tablet [**Known lastname **]: One (1) Tablet PO DAILY (Daily). 8. Simvastatin 10 mg Tablet [**Known lastname **]: One (1) Tablet PO DAILY (Daily). 9. Gabapentin 300 mg Capsule [**Known lastname **]: One (1) Capsule PO DAILY (Daily). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Known lastname **]: One (1) Inhalation twice a day as needed for SOB. 11. Outpatient Lab Work Tobramycin through every 4th day (goal <0.5 and under) CBC, Chem 10, CRP weekly. Fax results to Dr. [**Last Name (STitle) 1391**] ([**Telephone/Fax (1) 72961**], Phone: [**Telephone/Fax (1) 1393**] 12. Insulin sliding Scale Humalog Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 1 Units 1 Units 1 Units 1 Units 201-250 mg/dL 4 Units 4 Units 4 Units 4 Units 251-300 mg/dL 7 Units 7 Units 7 Units 7 Units 13. Glargine [**Telephone/Fax (1) **]: 15 Units injection subcutaneously at bedtime. 14. 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. 15. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1) injection Injection TID (3 times a day). 16. Levetiracetam 500 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO BID (2 times a day). 17. Tobramycin Sulfate 40 mg/mL Solution [**Telephone/Fax (1) **]: Five Hundred (500) mg Injection Q48H (every 48 hours) for 4 weeks: Please check trough level every 4 days, goal <1.0. 18. Aspirin 325 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 19. Metronidazole 500 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q8H (every 8 hours) for 1 days. 20. Metoprolol Tartrate 50 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO BID (2 times a day). 21. Hydrochlorothiazide 12.5 mg Capsule [**Telephone/Fax (1) **]: Three (3) Capsule PO DAILY (Daily). 22. Miconazole Nitrate 2 % Powder [**Telephone/Fax (1) **]: One (1) Appl Topical PRN (as needed) as needed for incontinence/fungal irritation. Discharge Disposition: Extended Care Facility: [**Location (un) 32674**] - [**Location (un) **] Discharge Diagnosis: Breakdown of right below-knee amputation stump, osteomyelitis-cultures came back positive for Psuedumonas sensitive to Tobramycin, d/c'd on Tobramycin for 6 weeks. History of: HTN DM2 Hyperlipidemia PVD OM with MRSA OA Retinopathy Neuropathy Nephropathy ARF Obesity Seizures Aspiration PNA Dysphagia bedside swallow - pureed honey thick diet PSH: [**2-25**] R CEA [**9-25**] R BKA [**10-25**] Tracheostomy [**2-18**] seizure, PEA arrest and vocal cord edema 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 call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. Please continue po ciprofloxacin for 2 weeks Please continue IV vancomycin and tobramycin for 6 weeks *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-26**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Followup Instructions: Please call Dr.[**Name (NI) 1392**] office to schedule an appointment ([**Telephone/Fax (1) 4852**]. Please follow up in clinic in 3 weeks.

[ "583.81", "997.62", "707.23", "008.45", "357.2", "348.30", "250.50", "250.60", "401.9", "362.01", "707.09", "250.40", "584.9" ]

icd9cm

[ [ [] ] ]

[ "33.23", "38.93", "84.3" ]

icd9pcs

[ [ [] ] ]

15615, 15690

6376, 12378

335, 379

16193, 16193

2390, 2390

18267, 18410

1716, 1721

12751, 15592

15711, 16172

12404, 12728

16370, 17931

6214, 6353

17947, 18244

1483, 1610

1736, 1736

230, 297

407, 1295

2406, 3913

1750, 2371

16207, 16346

1317, 1460

1626, 1700

22,191

116,976

28231

Discharge summary

report

Admission Date: [**2142-9-30**] Discharge Date: [**2142-10-15**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Presyncope Major Surgical or Invasive Procedure: [**2142-10-2**] Aortic Valve Replacement(27mm [**Company 1543**] Mosaic Porcine Valve). Replacement of Ascending Aorta and Hemiarch(30mm Gelweave Graft) with Reimplantation of Innominate Artery History of Present Illness: This is an 82 year old male with known aortic stenosis and increasing episodes of presyncope. Recent echocardiogram showed severe aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.8cm2, peak 87 and mean 53 mmHg. There was trace aortic insufficinecy and 2+ mitral regurgitation. His LVEF was estimated at 70%. Subsequent cardiac catheterization showed heavily calcified aorta and dilated ascending aorta, measuring 5.1 centimeters. Angiography revealed a left dominant system and an 80% lesion in the right coronary artery. Based upon the above, he was admitted for cardiac surgical intervention. Past Medical History: Congestive Heart Failure, Aortic Stenosis, Ascending Aortic Aneurysm, Coronary Artery Disease, Peripheral Vascular Disease with Claudication, History of Stroke, Atrial Fibrillation, Sick Sinus Syndrome, Type II Diabetes Mellitus, Hypertension, Obesity, History of Silent MI, Prostate Cancer - Lupron Injections, Gout, Macular Degeneration, Neuropathy, Osteoarthritis Social History: 30 pack year history of tobacco - quit 20 years ago. Denies ETOH. Married. Retired. Family History: No premature coronary artery disease Physical Exam: Vitals: BP 126/70, HR 82, RR 18, SAT 95 on room air General: obese, slow moving male in no acute distress HEENT: oropharynx benign, no peripheral vision in right eye Neck: supple, no JVD, hard to asses JVD due to squat neck Heart: irregular rate, normal s1s2, 2/6 systolic ejection murmur Lungs: clear bilaterally , diminished at bases Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, 2+ edema, rubor present Pulses: decreased distally Neuro: PERRL, EOM not intact, CN 2-12 grossly intact, nonfocal, slightly decreased strength on left side, moves all extremities Pertinent Results: [**2142-9-30**] 09:30PM BLOOD WBC-6.0 RBC-3.48* Hgb-11.0* Hct-33.6* MCV-97 MCH-31.8 MCHC-32.8 RDW-16.2* Plt Ct-191 [**2142-9-30**] 09:30PM BLOOD PT-13.0 PTT-37.5* INR(PT)-1.1 [**2142-9-30**] 09:30PM BLOOD Glucose-108* UreaN-21* Creat-0.9 Na-137 K-4.9 Cl-100 HCO3-27 AnGap-15 [**2142-10-1**] Carotid Ultrasound: No evidence of hemodynamically significant stenosis in the carotid arteries bilaterally. [**2142-9-30**] Chest x-ray: Cardiomegaly. Increased linear markings involving both lung bases. Findings represent atelectasis versus scarring. Pneumonia is not entirely excluded. COPD. No effusion detected. Brief Hospital Course: Mr. [**Known lastname 68565**] was admitted for heparinization and preoperative evaluation. Workup was unremarkable, and carotid ultrasound showed only minimal disease of the internal carotid arteries. He was subsequently cleared for surgery. On [**10-2**], Dr. [**Last Name (STitle) 1290**] performed an aortic valve replacement and replacement of his ascending aorta and hemiarch with reimplantation of his innominate artery. For additional surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. He initially required atrial pacing for junctional bradycardia. Within 24 hours, he awoke neurologically intact and was extubated on postoperative day one. Initially hypoxic, he required aggressive diuresis. Antihypertensives were titrated to maintain systolic blood pressures less than 120mmHg. Over several days, his heart rate improved as did his hypoxia. Pacing wires were removed on postoperative day three and he transferred to the SDU for further care and recovery. He remained in a rate controlled atrial fibrillation. Warfarin was resumed and dosed for a goal INR between 2.0 - 2.5. Warfarin was intermittently held for a subtherapeutic prothrombin time. He experienced urinary retention which required reinsertion of a foley catheter. Before discharge, foley catheter was removed and he was voiding without difficulty. He remained fluid overloaded with oxygen requirements. He continued to require aggressive diuresis and responded well to intravenous Lasix. He concomitantly had a productive cough. Serial chest x-rays were significant for improving bilateral pleural effusions with persistent lower lobe atelectasis. He was empirically started on antibiotics. Sputum cultures were obtained due to thick, green secretions. Microbiology showed gram negative rods and gram positive cocci, for which he was treated with levaquin. Over several days, he made significant clinical improvements with diuresis. Postop, he was also noted to have left upper extremity edema. Ultrasound was obtained which showed no evidence of left upper extremity deep venous thrombosis. Given his prior history of stroked with persistent left sided weakness, he worked with physical and occupational therapies to improve strength and mobility. Medical therapy was optimized and he was eventually cleared for discharge to rehab on postoperative day 13. Medications on Admission: Glipizide 5 qd, Avandia 2 qd, Warfarin, Colchicine 6 qd, Altace 5 qd, Levothyroxine 175 mcg qd, Lopid 600 [**Hospital1 **], Allopurinol 300 qd, Prilosec 20 qd, Neurontin, Torsamide 100 qd, Lupron, Darvon prn Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. 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* 3. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*0* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 13. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Tablet(s) 14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: Check INR [**10-17**]. 15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day: x 1 week when reassess need for diuresis. Tablet(s) 16. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days. Levaquin Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Aortic Stenosis, Ascending Aortic Aneurysm - s/p Aortic Valve Replacement and Replacement of Ascending Aorta, Congestive Heart Failure, Coronary Artery Disease, History of Stroke, Peripheral Vascular Disease with Claudication, Atrial Fibrillation, Sick Sinus Syndrome, Type II Diabetes Mellitus, Hypertension, Obesity, History of Silent MI, Prostate Cancer, Gout, Macular Degeneration Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Resume preoperative Warfarin management with Dr. *********. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in [**2-28**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**12-29**] weeks, call for appt Dr. [**First Name (STitle) **] in [**12-29**] weeks, call for appt Completed by:[**2142-10-15**]

[ "491.22", "E849.7", "278.00", "274.9", "398.91", "997.1", "427.31", "441.2", "250.00", "414.01", "440.21", "427.89", "V64.1", "790.92", "E878.2", "V10.46", "396.2", "486" ]

icd9cm

[ [ [] ] ]

[ "37.78", "38.91", "35.21", "38.45", "39.59", "39.61" ]

icd9pcs

[ [ [] ] ]

7338, 7412

2929, 5351

280, 476

7841, 7848

2296, 2906

8226, 8460

1642, 1680

5609, 7315

7433, 7820

5377, 5586

7872, 8203

1695, 2277

230, 242

504, 1135

1157, 1525

1541, 1626

67,533

140,303

33938

Discharge summary

report

Admission Date: [**2151-9-17**] Discharge Date: [**2151-10-17**] Date of Birth: [**2128-9-29**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: Status-post bicycle accident versus car with polytrauma Major Surgical or Invasive Procedure: [**2151-9-16**] 1. Exploratory laparotomy with control of liver hemorrhage with argon, Gelfoam and packing. 2. Suture control of mesenteric vessels. 3. Placement of negative pressure dressing. [**2151-9-17**] 1. Irrigation and debridement down to and inclusive of bone right tibia shaft fracture. 2. Intramedullary nailing with 10 x 3.15 nail. 3. Placement of vacuum sponge in right tibia. 4. Irrigation and debridement left knee joint. 5. Arthrocentesis left knee joint. [**2151-9-18**] 1. Exploratory laparotomy. 2. Removal of lap pads x3. 3. Suture repair of stomach and right colon. [**2151-9-24**] 1. Irrigation and debridement down to and inclusive of bone. 2. Placement of split-thickness thickness graft on soft- tissue muscle bed. 3. Vacuum sponge to skin graft 5x5 cm. [**2151-10-1**] ERCP [**2151-10-4**] ERCP with sphincterotomy, pigtail catheter placed in pancreatic duct for cannulation, then removed and placement of stent in hepatic duct. [**2151-10-7**] Pigtail placement of right pleural catheter for pleural effusion History of Present Illness: 23 y/o F helmeted bicyclist struck by car today presents to ED. Patient was taken emergently to the OR by trauma for a tenuous abdomen. Per report, patient was a GCS of 14 at scene and then deteriorated. She was intubated on route and taken to CT scan where a L acute EDH was found. Patient was then taken to the OR for exploratory laparoscopy. In the OR, patient was coagulopathic with an INR of 3; she was given 5 units FFP and PRBCs. Past Medical History: Anxiety, depression, history of proteinuria, history of alcohol abuse/IVDU Social History: past use of narcotics, +ETOH Family History: noncontributory Physical Exam: Upon presentation: Temp 97 HR: 89 BP: 104/70 Resp: 17 O(2)Sat: 100 Normal Constitutional: intubated, sedated HEENT: Pupils equal, round and reactive to light, stable midface, laceration to R occiput, lip ETT tube in place Chest: equal breath sounds Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, distended GU/Flank: abrasions to R flank Extr/Back: RLE with open fx at tib/fib, soft compartments, intact distal pulses Skin: lacerations to scalp, R elbow, R knee Neuro: intubated, sedated, making purposeful movements Psych: intubated and sedated Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Upon discharge: General: in no acute distress, comfortably lying in bed HEENT: pupils equal, round, reactive. EOM intact. Sclera anicteric. mucus membranes moist, nares clear, trachea at midline CV: regular rate/rhythm, no murmurs, rubs, or gallops Pulm: clear to auscultation bilaterally down to bases Abd: + BS, soft, nontender, nondistended. Midline incision clean, dry and intact. MSK: warm, well perfused. Right lower extremity wound clean, dry; distal aspect of wound with wick in place. Neuro/Psych: alert, oriented to person, place, time. Mildly flattened affect. Pertinent Results: [**9-16**]: CT head: 1. Acute epidural hematoma (8mm thickness) along the left middle cranial fossa with mixed attenuation suggesting active bleeding. No signs of herniation at this time. 2. Parenchymal contusion and small extra-axial hemorrhage involving the right temporal lobe. 3. No fracture. Soft tissue/scalp hematoma posteriorly. [**9-17**] CT head: IMPRESSION: No change in left subdural or right temporal fossa hemorrhages [**9-17**] Tibia/Fibula/Ankle bilateral: Right lower extremity: comminuted mid shaft tibial and fibular fracture Left lower extremity: left knee is congruent. Cross-table lateral demonstrates no lipohemarthrosis. Left tibia,fibula, ankle joint appear intact. [**9-17**] Lower extremity fluoroscopy, intra-operative for ORIF right tibia/fibula: Status post ORIF of the tibia with antegrade intramedullary nail and interlocking screws. The hardware is intact. Improved alignment of the comminuted tibial diaphyseal fracture. Improved alignment of the comminuted fibular diaphyseal fracture. [**9-24**] CT Abdomen/pelvis: 1. Liver laceration in the right lobe of the liver, through segment VII extending to the IVC, with no definite active extravasation of contrast to suggest active bleeding. 2. High-attenuation ascites in the abdomen and pelvis, consistent with old hemorrhagic component. 3. Large bilateral pleural effusions with overlying atelectasis. [**9-27**] CT head: 1. Expected evolution of a right inferior temporal lobe intraparenchymal hemorrhage. 2. Evolution of blood products within a left parietal epidural hematoma. Stable non-displaced left parietal skull fracture. 3. Left temporal lobe extra-axial collections are much less apparent. No new hemorrhage. [**9-28**] HIDA scan: 1. Probable bile leak with accumulation of radiotracer just above the superolateral aspect of the right lobe of the liver. 2. Delay in gallbladder filling. [**9-28**] RUQ U/S: 1. Large right hepatic lobe hematoma with central liver laceration extending from the liver capsule to the intrahepatic IVC. The laceration itself has decreased in size from the CT, however, the surrounding hematoma is more apparent on the current examination. 2. Moderate subcapsular hematoma with mass effect on the superior and posterior right hepatic lobe appears essentially stable from CT, although, direct comparison is difficult. [**10-7**] CXR: Large right pleural effusion has markedly increased. The cardiomediastinum is mildly shifted towards the left side. Left lower lobe retrocardiac atelectasis is unchanged. Drains project in the upper abdomen. [**10-7**] CXR: the patient has received a new right-sided catheter. The tip of the catheter projects close to the midline. The previously placed right pleural catheter is in unchanged position. Extent of the pre-existing right pleural effusion has further increased. Only a minimal part of right apical lung is ventilated. The left lung is unremarkable, apart from a small left basal atelectasis. No left pleural effusion. Known right clavicular fracture [**10-10**] CT Chest: 1. Pulmonary emboli. 2. Decreased amount of right pleural effusion but with new loculation. 3. Interval drainage of subcapsular fluid collection with large persistent hypodense area in the liver associated with parenchymal injury 4. Small lung nodule (4 mm) in the left upper lobe, of doubtful clinical significance. 5. Comminuted complete right-sided clavicle fracture. [**10-16**] CXR: Since the prior study, there is no substantial change in the partially loculated right pleural effusion. Right basal atelectasis as well as the position of the right chest tube are unchanged. Left lung is clear. Cardiomediastinal silhouette is unremarkable. Brief Hospital Course: Ms. [**Known lastname **] is a 23 year-old female, unhelmeted bicyclist struck by car who was admitted to Acute Care Surgery and subsequently transferred from field, and intubated after deterioration of her neurologic status. Her immediate list of injuries included: - Left acute epidural hematoma - Left subdural hematoma - Liver laceration - Right open tib/fib fracture - Right midclavicular fracture Pt was emergently transferred to operating room for exploratory laparotomy and 2 quadrant packing with open abdomen and RLE ORIF/VAC placement which went well without complication (reader referred to the Operative Notes for details) and subsequently transferred to the Trauma Surgical Intensive Care Unit for evaluation and treatment of polytrauma. Attending of record was Dr. [**First Name (STitle) **] of the Acute Care Surgical Service. The patient arrived to the Trauma Surgical Intensive Care Unit intubated/sedated, on IV fluids, IV antibiotics, with a foley catheter, nasogastric tube, VAC dressing, and fentanyl for pain control. The patient required minimal single-[**Doctor Last Name 360**] vasopressor for BP parameters. Neuro: The patient received fentanyl/propofol with good effect and adequate pain control while intubated in TSICU. When extubated, pt transitioned to IV pain medication with good effect. Parents noted significant history of alcohol use, and the patient was started prophylactically on CIWA protocol without evidence of DTs. When tolerating oral intake, the patient was transitioned to oral pain medications. Serial neuro exams were stable with and seizure prophlaxis was administered without evidence of seizure activity. Repeat head CT stable. Neurosurgery subsequently signed-off. When on the floor, the patient's pain was managed with po dilaudid on a scheduled basis in addition to oxycodone given the patient's history of drug and alcohol use. CV: The patient arrived to the ICU with single-[**Doctor Last Name 360**] vasopressor for BP parameters for ICP which was weaned HD2. Pt remained hemodynamically stable throughout remainder of hospital admission. Pulmonary: The patient arrived to the ICU intubated on minimal vent settings and was subsequently extubated HD 2 s/p abdominal closure without issue. On [**2151-10-6**], however, the patient spiked a temperature to 103.1F one week after drain placement for a RUQ fluid collection, likely bile leak or biloma secondary to her liver laceration. A CXR that day demonstrated a large right pleural effusion, for which she subsequently received a pigtail drain by interventional pulmonology. Drain output was monitored on a frequent basis, which progressive decreases in sero-sanguinous output prior to discharge. Her drain was pulled on [**2151-10-16**] by interventional pulmonology, as an ultrasound of the right lung showed very minimal pleural fluid. Good pulmonary toilet, incentive spirometry and early ambulation was encouraged throughout this admission. CT chest on [**2151-10-10**] showed a pulmonary embolus and patient was bridged from a heparin drip to coumadin for PE treatment. Her goal INR is [**2-4**] and her INRs were followed closely daily and coumadin dosed daily as well. Her PCP was [**Name (NI) 653**] and was willing to follow her INRs for her coumadin dosing. She has an appointment with Dr. [**Last Name (STitle) 13311**] on Monday [**2151-10-18**]. GI/GU/FEN: Diet was advanced when extubated and appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. LFTs were monitored given her liver laceration. Her total bilirubin peaked at 9.2 on [**9-21**], however, began trending downward thereafter. AST and ALT both peaked on initial presentation on [**9-17**] and remained an a downward trend until the next week when her alk phosphatase began to trend upwards, with corresponding RUQ pain per patient; a HIDA scan was ordered on [**9-28**] which demonstrated a subdiaphragmatic fluid collection. The next day a CT-guided drain was placed within the subcapsular hepatic fluid collection with approximately 100cc bile immediately drained. The drain output was frequently monitored, which plateaued within 2 days. The patient then underwent an ERCP on [**10-1**], but was not successful as the operators were not able to visualize or cannulate the CBD, with repeat attempt on [**10-4**] which showed a leak from the right hepatic duct; a sphincterotomy was performed and a plastic biliary stent placed. The patient's LFTs have since been trending downwards back to normal range, with last Total bilirubin on [**2151-10-12**] at 0.6. The patient will be discharged with the biliary drain in place with one-month follow-up in [**Hospital **] clinic for stent evaluation/possible removal. Diet: the patient's diet was advanced when appropriate, which she tolerated well. She was discharged home on a regular diet. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Please defer to GI and Pulmonary sections for specific details regarding bile leak secondary to liver laceration and pleural effusion, likely reactive. Once the RUQ collection was found on HIDA scan ([**9-28**]), the patient was started on Zosyn and fluconazole for appropriate coverage for one week. Cytology and culture from the pleural fluid collection was negative, but bile drain contents demonstrated questionable [**Female First Name (un) **] but was deemed likely a contaminant. Wound care: Incisional wounds were regularly monitored for signs of infection of which there were none. RLE ORIF site VAC'd and subsequently changed per Ortho Trauma service; a split-thickness skin graft was also performed intra-operatively, which appeared not to completely take within several days; Antibiotics: The patient received peri-operative intravenous antibiotics for RLE extremity per Ortho Trauma which was subsequently discontinued. Fever curve and WBC was closely followed without signs of infection from the lower extremity wound. Endocrine: The patient's blood sugar was monitored throughout this admission. Insulin dosing was adjusted accordingly during her brief ICU stay. She did not require insulin for the majority of her days while on the floor and maintained blood sugars within normal range without insulin prior to discharge. Hematology: The patient's complete blood count was examined routinely. The patient was transfused 6 units pRBC intra-op for active intraabdominal hemorrhage and coagulopathy, post-transfusion hematocrit of 37; she also received an additional 5FFP, 1 unit of platelets, 1 unit of cryoprecipitate. Pt received Rh+ transfusion with Rh- status and subsequently pt received WinRho. Hct downtrending throughout admission without hemodynamic instability. Coagulapathy corrected as above. As noted earlier, the patient was found to have a pulmonary embolus in her left lung and was placed on heparin drip on [**2151-10-10**] and subsequently bridged to coumadin for long-term PE treatment/prevention. Prophylaxis: The patient received subcutaneous heparin and venodyne boot during this admission and was encouraged to get up and ambulate as early as possible. She was bridged from heparin to coumadin for a pulmonary embolus found on CT on [**2151-10-10**]. Please refer to Hematology/Pulmonology sections for further details. MSK: The patient initially underwent an ORIF for her right tibia-fibula fracture, with continuous measurements of compartment pressures without evidence of compartment syndrome in the first few post-operative days. She was followed by the orthopedics service throughout her admission and was weight bearing as tolerated. She was able to ambulate with crutches prior to discharge. She also sustained a right clavicular fracture, which was managed non-operatively. Medications on Admission: klonipin Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain for 14 days. Disp:*60 Tablet(s)* Refills:*1* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation for 30 days. Disp:*30 Tablet(s)* Refills:*2* 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation for 30 days. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*3* 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety for 14 days. Disp:*28 Tablet(s)* Refills:*1* 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:*30 Tablet(s)* Refills:*2* 8. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 9. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain for 10 days. Disp:*60 Tablet(s)* Refills:*1* 10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Please check PT/INR daily until INR is therapeutic and stable between [**2-4**]. Disp:*30 Tablet(s)* Refills:*2* 11. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once for 1 doses: Take around 4 pm today. . Disp:*1 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNACare Network Discharge Diagnosis: S/P Bike v. car 1. Parenchymal contusion and small extra-axial hemorrhage involving the right temporal lobe 2. Acute epidural hematoma 3. Soft tissue/scalp hematoma posteriorly 4. Right clavicle fracture 5. Grade 3 liver laceration 6. Right open tibia and fibula shaft fracture 7. Left knee open wound 8. Right shoulder laceration 9. Bile leak 10.Pulmonary embolism 11.Subhepatic fluid collection 12.Right pleural effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: * You were admitted to the hospital after being struck by a car while riding your bicycle. You suffered multiple injuries including bleeding and bruising in your brain, a laceration on your scalp, a laceration of your liver, a broken right collar bone, a right leg fracture, left knee laceration and a right shoulder laceration. * You required multiple operations to repair your injuries and you are recovering well. * Your tib/fib fracture was repaired and a skin graft was placed on it. You still have a small wound in the area that will require wet-to-dry dressing changes twice a day until it is healed. * Another injury found after your admission was a bile leak from one of the ducts in your liver. This was diagnosed with blood tests and an ERCP. A stent needed to be placed to stop the leak and it was successful. You will need another ERCP in 4 weeks. You have a drain in place to drain the bile leak, which has decreased. That drain will need to stay in until your stent is removed in order to make sure the leak has completely stopped. * You also developed a clot in your lung called a pulmonary embolism. This likely occurred due to your immobility. You will need to be on a blood thinner called Coumadin and the dose will be regulated by your primary care doctor based on a blood test called an INR. You will need to be very careful with any sharp objects as you will bleed easily on a blood thinner. * Eat well and stay well hydrated. * You will need to continue with close follow up at [**Hospital3 **]. * If you develop any increased yellow jaundice, abdominal pain,nausea or increased pain please call your doctor or return to the Emergency Room. Followup Instructions: Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**2-4**] weeks. Call your primary care doctor for a follow up appointment next week. You have an appointment on Monday, [**10-18**] at 11AM at Dr.[**Name (NI) 78394**] clinic: please call ([**Telephone/Fax (1) 78395**] for directions. Her clinic will be following your coumadin levels. The clinic address is: [**Street Address(2) 78396**], [**Location (un) 5028**], MA Call Dr. [**Last Name (STitle) **] from ERCP at [**Telephone/Fax (1) 2799**] for a follow up appointment in 4 weeks for a repeat ERCP for stent removal and re evaluation. Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up appointment in 2 weeks. Call Dr. [**Last Name (STitle) **] from Neurosurgery at [**Telephone/Fax (1) 1669**] for a follow up appointment in 4 weeks. You will need a non contrast head CT prior to the appointment and the secretary can arrange that for you. Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] from Plastic surgery at [**Telephone/Fax (1) 31444**] for a follow up appointment in 2 weeks if you feel it is necessary for your wound that currently is dressed with wet to dry dressings daily. Completed by:[**2151-10-17**]

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Discharge summary

report+report

Admission Date: [**2104-10-24**] Discharge Date: [**2104-10-28**] Date of Birth: [**2051-3-24**] Sex: M Service: MEDICINE Allergies: Colchicine / Protein Powder Attending:[**First Name3 (LF) 477**] Chief Complaint: Hematemesis. Major Surgical or Invasive Procedure: Upper endoscopy with cauterization of bleeding esophageal cancer. IVC filter placement. Radiation therapy to esophageal cancer. History of Present Illness: Mr. [**Known lastname 36365**] is a 53 year-old man with history of stage IV esophageal CA, PUD, ESRD with live donor transplant, PE and DVT on lovenox who presents with hematemesis since this morning. Note, receiving palliative radiation therapy to T-spine with last dose [**2104-10-21**]. . First noticed early today, vomiting bright red blood at home. The patient reports that at approximately midnight, he felt nauseous, went to the bathroom, began coughing and then vomited up a toilet bowl full of bright red blood, some clots and food. His wife drove him to the hospital where he had further episodes. There is some question whether this is emesis or sputum with blood. No prior episodes and no new SOB or leg swelling. Reports chest wall pain similar to chronic discomfort for which radiation therapy is being administered to palliate his symptoms. Last dose of Lovenox was 6pm. He presented to [**Hospital1 18**] ED for evaluation. . In the ED, his vitals were T 99.5, HR 107, BP 138/67, satting 99%RA. Labs notable for nl coag, HCT 31 up from baseline 26-28. Guaiac positive. CXR negative. NG lavage not performed due to esophageal stent. GI consulted and recommended PPI [**Hospital1 **], serial Hct, and close monitoring. He remained HD stable but concern for potential for worsening of hematemesis. Admitted to MICU. . Of note, he had one episode of coffee ground emesis in the ED on last admission in the setting of heparin bolus for PE. Past Medical History: # Esophageal CA stage IV (metastatic to bones, liver, lung; diagnosed [**4-8**] after esophageal mass discovered; progressive dysphagia s/p palliative esophageal stent [**8-8**]), has been on cisplatin and irinotecan therapy as first line treatment, currently receiving palliative radiation therapy to chest wall and spine, plan for initiating high-dose Taxotere following completion of his palliative radiation therapy # DVT [**8-/2104**] # PE [**9-/2104**] # Remote hx of gastric ulcer not seen on recent EGDs. # ESRD [**2-2**] to IgA nephropathy s/p kidney transplant [**2091**] and [**2101**] # Status post right arm AVF # Avascular necrosis of the bilateral hips # HTN # Hyperlipidemia # Cataracts status post extraction, # Gout # Squamous cell carcinoma of the face x3 # Status post umbilical hernia repair # Status post ventral hernia repair mass Social History: Lifetime nonsmoker. He is a civil engineer working in tunnel building. He lives with his wife and three children. He drinks occasionally and notes no exposure to asbestos or radiation. Family History: Mother had a CVA, father had CHF, had a grandfather with gastric cancer. Physical Exam: T 100.0 HR104 BP 124/80 RR15 SaO2 97%RA General: WDWN, in pain HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink Neck: supple, trachea midline, no thyromegaly or masses, no LAD Cardiac: tachycardic, s1s2 normal, no m/r/g, no JVD Pulmonary: CTAB Abdomen: tender at epigastrium, non-distended. Extremities: warm, 2+ DP pulses, no edema Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves all extremities Pertinent Results: Labs at Admission [**2104-10-24**] 08:20PM HCT-26.8* [**2104-10-24**] 05:30PM CK(CPK)-56 [**2104-10-24**] 05:30PM CK-MB-NotDone cTropnT-0.02* [**2104-10-24**] 12:30PM HCT-27.4* [**2104-10-24**] 07:25AM GLUCOSE-85 UREA N-17 CREAT-0.9 SODIUM-137 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-29 ANION GAP-12 [**2104-10-24**] 07:25AM estGFR-Using this [**2104-10-24**] 07:25AM CK(CPK)-50 [**2104-10-24**] 07:25AM CALCIUM-9.1 PHOSPHATE-3.7 MAGNESIUM-1.5* [**2104-10-24**] 07:25AM CK-MB-2 cTropnT-0.02* [**2104-10-24**] 07:25AM WBC-6.7 RBC-3.41* HGB-10.4* HCT-31.9* MCV-94 MCH-30.5 MCHC-32.6 RDW-16.4* [**2104-10-24**] 07:25AM NEUTS-80.0* LYMPHS-15.6* MONOS-4.0 EOS-0.3 BASOS-0.1 [**2104-10-24**] 07:25AM PLT COUNT-300 [**2104-10-24**] 07:25AM PT-12.6 PTT-35.0 INR(PT)-1.1 .. Studies CT C/A/P ([**2104-10-27**]): IMPRESSION: 1. Apparent mild wall thickening of the descending and sigmoid colon may be due to underdistension. However, given change in appearance from prior study and mild stranding around the ascending and left colon, a focal/segmental colitis secondary to diverticulitis, or other infectious or ischemic etiologies could be considered in the appropriate clinical setting. 2. Increased size of large hepatic metastases, many of which bulge the liver capsule, though there is no sign of capsular rupture. Two new lesions are also noted. 3. New small bilateral pleural effusions. 4. Interval partial resorption of right lower lobe pulmonary emboli. 5. No significant change in bilateral pulmonary nodules and metastatic lymphadenopathy in the chest. Brief Hospital Course: In summary a 53 year-old man with history of stage IV esophageal CA (mets to lungs and spine) s/p esophageal stenting, recent PE and DVT on lovenox, ESRD s/p transplant presents with hematemesis due to bleeding at site of esophageal cancer. . # Hematemesis EGD was performed [**10-24**] that showed bleeding at the site of known esophageal mass, which was cauterized to one area. Following the procedure, his hematocrit remained stable and he did not require any transfusions. He was put on IV proton-pump inhibitor at twice daily dosing. Once stabilized several days post-procedure this was switched back to PPI in the morning and H2 blocker at night. . In addition to the cauterization, he had XRT to his esophageal lesion on the day prior to discharge. This therapy was completed without complication. . # Esophageal CA Stage IV with distant metastasis. He is followed by Dr. [**Last Name (STitle) **] in oncology clinic. At time of admission he was undergoing palliative XRT to his T-spine. During this hospitalization, XRT was administered to his esophageal mass in order to stabilize the site and prevent further bleeding. Prior to discharge, he reported mild abdominal pain and a CT was performed that showed increasing size of liver metastases with stretching of the hepatic capsule. The full report is provided above. . He was continued on long acting morphine with oxycodone for breakthrough pain. At time of discharge, his pain was well-controlled on regimen of MS Contin and oxycodone. He will proceed with two more weeks of XRT followed by systemic chemotherapy. . # History of Pulmonary Embolism He has recent a diagnosis of DVT and PE and had been on Lovenox. However, due to his hematemesis at admission, the Lovenox was held. GI was consulted and recommended stopping anticoagulation altogether given his high risk of re-bleeding from the esophageal tumor. An IVC filter was therefore placed. At time of discharge, he is no longer on anticoagulation. . # End-stage Renal Disease He is status post living donor transplant and was followed by the renal transplant service. He was continued on tacrolimus and Bactrim SS during hospitalization. . Although initially NPO, his diet was slowly advanced as tolerated, careful to avoid hot foots and liquids. DVT prophylaxis was achieved with pneumoboots; he was kept on PPI and bowel prophylaxis throughout hospital course. Code status is full. Medications on Admission: Emend 125 mg (1)-80 mg (1)-80 mg (1) Capsule, Dose Pack 1 Capsule(s) by mouth once a day Atorvastatin 40 mg once a day Dexamethasone 8 mg PO bid for 3 days beginning a day before chemo ?4mg daily Ativan 0.5 mg by mouth every 6 hours as needed for nausea Lovenox 80mg Q12H MS Contin 30 mg by mouth twice a day Zofran 8 mg Tablet by mouth every 8 hours as needed for nausea Oxycodone 5 mg by mouth every 4 - 6 hours as needed Percocet 5 mg-325 mg 1-2 Tabs PO every 4-6 hours as needed for pain Protonix 40 mg by mouth once a day ?tid Prochlorperazine 10 mg PO every 4-6hours as needed for nausea Ranitidine 300 mg po qhs ?150mg [**Hospital1 **] Sirolimus 4 mg po daily Bactrim SS 1 tab daily Docusate Sodium 100 mg Capsule [**Hospital1 **] prn Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours) as needed for transplant. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 9. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*40 Tablet Sustained Release(s)* Refills:*0* 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*120 Tablet(s)* Refills:*0* 11. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 12. Ranitidine HCl 300 mg Capsule Sig: One (1) Capsule PO at bedtime. 13. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day. 14. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO q6h prn. 15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. Emend 125 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Bleeding from metastatic esophageal cancer . SECONDARY DIAGNOSES History of deep venous thrombosis s/p IVC filter placement End stage renal disease s/p kidney transplant Discharge Condition: Vital signs stable. Pain adequately controlled. Discharge Instructions: You were hospitalized for treatment of bleeding from your esophagus. You underwent endoscopy and the bleeding mass was cauterized. You subsequently underwent radiation therapy treatment. . You will continue to have radiation therapy for your esophageal cancer for the next two weeks. After this, you will follow-up with Dr. [**Last Name (STitle) **] in clinic to discuss beginning chemotherapy. . Due to your history of pulmonary embolism (blood clot to the lungs), a filter was placed in one of you veins to prevent blood clots from traveling to your lungs. Due to the risk of bleeding associated with anticoagulation therapy, we have decided not to treat you with anticoagulation. Please stop taking the Lovenox. . We have added one new medicine to your medications. It is called omeprazole and should be taken in the morning to prevent gastrointestinal bleeding. This should be taken in addition to the ranitidine you are already taking. Please stop taking the Lovenox. . Please return to the emergency department or call your doctor if you experience any new or worsening pain, any fever, or any other symptoms that are concerning to you. Followup Instructions: Provider [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2104-10-31**] 9:00 . Provider [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2104-11-7**] 9:00 . Provider [**Name9 (PRE) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**] Date/Time:[**2104-11-11**] 1:30 [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**] Completed by:[**2104-10-29**] Admission Date: [**2104-10-30**] Discharge Date: [**2104-11-1**] Date of Birth: [**2051-3-24**] Sex: M Service: MEDICINE Allergies: Colchicine / Protein Powder Attending:[**First Name3 (LF) 477**] Chief Complaint: Abdominal pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [**Known lastname 36365**] is a 53 year-old man with history of renal transplant, esophageal cancer undergoing XRT, and DVT who presented with abdominal discomfort for a few days. He was discharged on [**10-28**] from [**Hospital1 18**]. During that admission he had an EGD and cauterization for hematemesis [**2-2**] bleeding from his CA site. After discharge he continued his XRT daily. He had abdominal pain even during his last admission which has been getting somewhat worse after his discharge. He also notes that he has not had a bowel movement for the past 4 days. He also complains of low grade fevers (~100) at home since this morning. . He has been having decreased appetite with mild nausea. He denied any vomiting/hematemesis/melena/hematochezia. . In the ED his vital signs were stable; he had CT abdomen which was not changed compared to his previous admission. There was no evidence of progression or SBO. He got Cipro/Flagyl for presumed diverticulitis. Past Medical History: # Esophageal CA stage IV (metastatic to bones, liver, lung; diagnosed [**4-8**] after esophageal mass discovered; progressive dysphagia s/p palliative esophageal stent [**8-8**]), has been on cisplatin and irinotecan therapy as first line treatment, currently receiving palliative radiation therapy to chest wall and spine, plan for initiating high-dose Taxotere following completion of his palliative radiation therapy # DVT [**8-/2104**] # PE [**9-/2104**] # Remote hx of gastric ulcer not seen on recent EGDs. # ESRD [**2-2**] to IgA nephropathy s/p kidney transplant [**2091**] and [**2101**] # Status post right arm AVF # Avascular necrosis of the bilateral hips # HTN # Hyperlipidemia # Cataracts status post extraction, # Gout # Squamous cell carcinoma of the face x3 # Status post umbilical hernia repair # Status post ventral hernia repair mass Social History: Lifetime nonsmoker. He is a civil engineer working in tunnel building. He lives with his wife and three children. He drinks occasionally and notes no exposure to asbestos or radiation. Family History: Mother had a CVA, father had CHF, had a grandfather with gastric cancer. Physical Exam: Review of Systems . GEN: + fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: + Nausea, - Vomitting, - Diarhea, + Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache .. Physical Exam at Admission: VSS: 99.3, 110/78, 88, 20, 95%/RA GEN: NAD, appears comfortable Pain: [**3-10**] discomfort in middle of abdomen HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: mild tenderness in periumblical region, no guarding/rigidity, - CVAT EXT: left LE circumference>right LE, no edema NEURO: CAOx3, Non-Focal . Physical Exam at Discharge: Vital: T 97.8, BP 123/80, HR 88, RR 20, O2 100% RA General: AAOx3; NAD CV: RRR, normal S1/S2 Lung: CTA Abdomen: no tenderness to palpation; normal bowel sounds; no guarding; no rigidity; no cough or percussion tenderness Pertinent Results: Labs at Admission . [**2104-10-30**] 01:15PM BLOOD WBC-5.5 RBC-3.16* Hgb-9.8* Hct-28.3* MCV-90 MCH-30.9 MCHC-34.5 RDW-16.0* Plt Ct-256 [**2104-10-30**] 01:15PM BLOOD Glucose-108* UreaN-12 Creat-0.8 Na-131* K-3.8 Cl-96 HCO3-24 AnGap-15 [**2104-10-30**] 01:15PM BLOOD ALT-24 AST-37 AlkPhos-340* TotBili-0.5 [**2104-10-30**] 01:22PM BLOOD Lactate-1.9 . Chest X-ray Unremarkable . CT Abdomen/Pelvis ([**2104-10-30**]) 1) Decompressed colon, with no significant change in the appearance of the bowel from prior. Colonic diverticulosis without evidence of diverticulitis. 2) Diffuse metastatic disease involving the lungs, liver, lymph nodes, and osseous structures. 3) Small left pleural effusion. . CT Abdomen ([**2104-10-27**]) 1. Apparent mild wall thickening of the descending and sigmoid colon may be due to underdistension. However, given underlying diverticulosis, and mild stranding around the ascending and left colon, a focal/segmental colitis secondary to diverticulitis, or other infectious or ischemic etiologies could be considered in the appropriate clinical setting. 2. Increased size of multiple liver metastases, some of which bulge the liver capsule. 3. New small bilateral pleural effusions. Brief Hospital Course: In summary this is a 53 year-old man with history of metastatic esophageal CA, DVT, renal transplant, and hypertension presenting with abdominal pain, low grade fevers and concern for diverticulitis vs colitis. . # Abdominal Pain There was concern for diverticulitis/colitis, especially in the setting of past h/o diverticulitis and current immunosuppression. He was continued on IV antibiotics with Cipro and Flagyl. He was made NPO initially but quickly progressed to clears than solids on HD 2. Blood cultures returned negative x2 and abdominal pain improved significantly by HD 2. He will be sent home to complete a ten-day course of ciprofloxacin and metronidazole. . # Esophageal CA stage IV (metastatic to bones, liver, lung) He is currently undergoing XRT and will resume this next week. . # History of DVT/PE He had been on Lovenox but this was stopped during previous admission due to hematemesis. He has an IVC filter in place. . # ESRD [**2-2**] to IgA Nephropathy s/p Kidney Transplant [**2091**] and [**2101**] He was continued on tacrolimus and dexamethasone. The transplant team came by and recommended no changes to his current regimen. He was continued on Bactrim for prophylaxis. . # H/o GI bleed He is s/p recent upper endoscopy and cauterization to bleeding esophageal mass. The XRT is being administered in part to prevent future bleeding. While in house, he was continued on protonix twice daily. His outpatient regimen consists of protonix in the morning and ranitidine at night. . # Hyperlipidemia We continued his outpatient Lipitor. . Prophylaxis with subcutaneous heparin, then discontinued once ambulating. He was kept on Bactrim, PPI, and bowel regimen throughout. He was NPO initially but quickly progressed diet as tolerated. Medications on Admission: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours) as needed for transplant. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 9. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*40 Tablet Sustained Release(s)* Refills:*0* 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*120 Tablet(s)* Refills:*0* 11. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 12. Ranitidine HCl 300 mg Capsule Sig: One (1) Capsule PO at bedtime. 13. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day. 14. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO q6h prn. 15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. Emend 125 mg Capsule Sig: One (1) Capsule PO once a day. 17. Dexamethasone 4 mg daily Discharge Medications: 1. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 3. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release(s)* Refills:*0* 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days: Please do not drink alcohol while taking this medicine. Disp:*24 Tablet(s)* Refills:*0* 11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days. Disp:*16 Tablet(s)* Refills:*0* 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO qam. Tablet, Delayed Release (E.C.)(s) 13. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Compazine Oral 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Acute diverticulitis . SECONDARY DIAGNOSES Metastatic esophageal cancer End stage renal disease s/p kidney transplant Hypertension Hyperlipidemia Discharge Condition: Vital signs stable. Afebrile. Pain adequately controlled. Discharge Instructions: You were hospitalized for treatment of diverticulitis. You received intravenous antibiotics for two days and will need to take an additional eight days of antibiotics to complete a ten day course. . The antibiotics are ciprofloxacin and metronidazole. Cipro is to be taken twice daily, and metronidazole to be taken three times daily. Please do not drink alcohol with the metronidazole. . We have increased the dose of your pain medicines. The MS Contin has been increased to 45 mg twice daily from 30 mg twice daily. Please continue to take 5-10 mg of oxycodone for breakthrough pain. . There have been no other changes to your medications. . Please follow-up with Dr. [**Last Name (STitle) **]. Your next appointment is listed below. Followup Instructions: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2104-11-7**] 9:00 . [**Name6 (MD) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**] Date/Time:[**2104-11-11**] 1:30 . [**Name6 (MD) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**] Date/Time:[**2104-11-20**] 2:00 [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**] Completed by:[**2104-11-1**]

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24486

Discharge summary

report

Admission Date: [**2185-2-15**] Discharge Date: [**2185-2-17**] Date of Birth: [**2104-2-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Diagnostic cardiac catheterization History of Present Illness: This is an 81 yo female with metastatic neuroendocrine tumor on home hospice, h/o CVA, rheumatoid arthritis, diabetes, hypertension, hyperlipidemia who presented to the [**Hospital1 **] emergency room with chest discomfort and malaise. She began experiencing chest discomfort at 12:30 during the night, and took some nitroglycerin with partial relief, but did not tell the family because she was hoping it would resolve. By the morning, patient was becoming dyspneic and felt nauseous, and requested to come to the hospital. Chest pain had resolved on arrival to [**Hospital1 **] Emergency room, but she was noted to have ST elevations in III and aVF with prominent R-wave with ST depressions in V1-V2. She was given aspirin 324mg, clopidogrel 600mg, aotrvastatin 80mg, eptifibatide 5mL bolus, heparin 3100 Unit bolus, metoprolol 5mg IV x 3, and transferred to [**Hospital1 18**] for further management. . On arrival to cardiac catheterization lab at [**Hospital1 18**], patient was noted to be hypertensive 200/85. She was started on nitroglycerin continuous infusion. Left heart catheterization demonstrated LVEDP of 40mmHg, LAD with diffuse disease and a 99% mLAD stenosis, LCx with diffuse disease, 50% pLCx stenosis, 90% mLCx lesion after OM1, 70% OM1, pRCA occlusion with large conus with 80% stenosis giving collaterals to LAD and RCA. Given elevated LVEDP, patient was given 80mg IV furosemide. She was transferred to CCU for further management of blood pressure and CHF. . On review of systems, she denies any prior history deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS:: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: Ventricular tachycardia #. History of MI and Ventricular tachycardia in [**8-/2184**], on amiodarone, ICD declined #. Ischemic cardiomyopathy with LVEF 35% in [**1-/2184**] at [**Hospital1 **] 3. OTHER PAST MEDICAL HISTORY: #. H/o right-sided CVA in [**2157**] #. H/o Bell's Palsy with residual deficits of facial muscles. #. History of Neuroendocrine tumor with liver metastasis #. History of Renal cell CA #. H/o small-bowel obstruction, S/p exploratory laparotomy #. Rheumatoid arthritis #. Hypertension #. Diabetes mellitus - on oral metformin #. Hyperlipidemia #. SP TKR x 2 in [**2171**] and [**2172**] #. S/P Left total hip replacement in [**2170**] #. S/p Right metacarpal head revision Social History: Widowed, formerly lived alone with hospice but now lives with son. Also have 4 daughters. [**Name (NI) **] tobacco or alcohol use. Family History: Non-contributory Physical Exam: GENERAL: Elderly HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVP flat. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. II/VI systolic murmur. No thrills, lifts. + S3 LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [**2185-2-15**] 10:30AM BLOOD WBC-4.2 RBC-3.24* Hgb-9.3* Hct-27.9* MCV-86 MCH-28.7 MCHC-33.4 RDW-21.9* Plt Ct-480*# [**2185-2-15**] 10:30AM BLOOD Neuts-62 Bands-2 Lymphs-21 Monos-10 Eos-1 Baso-0 Atyps-4* Metas-0 Myelos-0 [**2185-2-15**] 10:30AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-2+ [**2185-2-15**] 10:30AM BLOOD PT-16.1* PTT-84.7* INR(PT)-1.4* [**2185-2-15**] 10:30AM BLOOD Glucose-136* UreaN-30* Creat-1.3* Na-138 K-3.8 Cl-102 HCO3-24 AnGap-16 [**2185-2-15**] 10:30AM BLOOD ALT-17 AST-31 CK(CPK)-36 AlkPhos-92 Amylase-39 TotBili-0.9 [**2185-2-15**] 10:30AM BLOOD CK-MB-NotDone cTropnT-0.12* [**2185-2-16**] 06:16AM BLOOD CK-MB-NotDone cTropnT-0.27* [**2185-2-17**] 05:25AM BLOOD CK-MB-NotDone cTropnT-0.21* [**2185-2-16**] 06:16AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.0 [**2185-2-15**] 10:30AM BLOOD VitB12-229* [**2185-2-15**] 10:30AM BLOOD %HbA1c-6.0* [**2185-2-15**] 10:32AM BLOOD pO2-94 pCO2-34* pH-7.50* calTCO2-27 Base XS-3 Intubat-NOT INTUBA [**2185-2-15**] 10:32AM BLOOD Glucose-131* Na-137 K-4.0 Cl-101 [**2185-2-15**] 10:32AM BLOOD Hgb-10.8* calcHCT-32 O2 Sat-96 . EKG [**2185-2-16**] - Sinus rhythm. Compared to the previous tracing of [**2185-2-15**] the rate has slowed. The previously mentioned multiple abnormalities persist without diagnostic interim change. . [**2185-2-15**] - Echo: The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is moderate to severe regional left ventricular systolic dysfunction with an apical left ventricular aneurysm and an inferobasal left ventricular aneurysm. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-14**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. There is a small (~0.5 cm) mobile echodense structure adjacent to the apical anterior wall consistent with probable thrombus. . Cardiac catherization - 1. Selective coronary angiography of this right dominant system revealed three vessel disease. The LMCA had mild disease. The LAD was diffusely diseased with 99% stenosis at the mid segment. The LCX was diffusely diseased with 50% stenosis at the proximal segment, 90% stenosis at the mid segment after the first OM, and there was 70% stenosis within the first OM. 2. Limited resting hemodynamics demonstrated elevated left sided filling pressures consistent with diastolic dysfunction, with LVEDP 40 mm Hg. The systemic arterial pressure was elevated with central aortic pressure 184/79 mm Hg. Careful pullback across the aortic valve did not reveal a significant gradient. 3. Patient was symptom free, and ECG done during catheterization showed resolution of ST segment changes. Conservative management with blood pressure control and diuresis was elected with plan for CT surgery consult. . FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe diastolic ventricular dysfunction. Brief Hospital Course: 81 yo female with history of ischemic cardiomyopathy, apical aneurysm, CVA, CHF, presents with chest pain in setting of uncontrolled hypertension now s/p cardiac catherization. As patient was pain free with resolution of ST changes elected to pursue conservative management with BP control and diuresis and would consider PCI if recurrent symptoms. . # Chest pain: ST-elevations may have been secondary to aneurysmal changes noted on [**Hospital3 4107**] echocardiogram and confirmed on echocardiography today at [**Hospital1 18**]. Lack of significant biomarker elevation suggests against significant ischemic territorial STEMI, and angiography suggests chronic RCA given collateralization. Patient may have had symptoms secondary to uncontrolled hypertension. Patient was continued on aspirin, statin. Patient was continued on atorvastatin, metoprolol, enalapril. STarted patient on Imdur 30 mg PO daily for both blood pressure and anginal control. Increased Beta blocker dose. Decided against starting patient on plavix. . # Hypertension - Patient maintained as outpatient on BB, ACEi. Initially started on nitroglycerin drip which was discontinued and oral Imdur started. Increased BB dose as above, continued same dose of enalapril. . # Chronic systolic congestive heart failure: Euvolemic with ischemic cardiomyopathy. Echocardiogram with aneurysmal changes, possible thrombus in LV. Patient was continued on outpatient furosemide dose, enalapril. Increased beta blocker dose. Patient already on ACEi, lasix, aspirin, statin. . # Chronic renal failure - baseline unknown, Cr currently 1.5 and stable, potassium stable, continue to monitor. Medications were renally dosed, nephrotoxins avoided. . # Rhythm - history of ventricular tachycardia, continued amiodarone and BB, repleted electrolytes as needed. . # Diabetes - Insulin sliding scale in house, cahnged back to metformin on discharge. . # Neuroendocrine carcinoma - Continue fentanyl patch, senna, docusate, lorazepam, acetaminophen. Patient in hospice care for this. . # Rheumatoid arthritis - restart methotrexate and prednisone on discharge. . # B12 deficiency- patient with low b12 on admission. Patient got B12 injection once and discharged on PO vitamin b12. Needs outpatient follow up and may require monthly B12 injections. . FEN: Regular diet, MVI , folate, B12 . ACCESS: PIV's . PROPHYLAXIS: Heparin SC, regular diet, PPI, bowel regimen . CODE: DNR/DNI confirmed with healthcare proxy [**Name (NI) 11320**] (daughter), [**Telephone/Fax (1) 61897**] Medications on Admission: #. Aspirin 81mg daily #. Atorvastatin 20mg daily #. Enalapril 5mg daily #. Metoprolol succinate 25mg daily #. Nitroglycerin sublingual PRN #. Amiodarone 200mg daily #. Furosemide 20mg daily #. Metformin 500mg PO daily #. Fentanyl patch 25mg Q72H #. Prednisone 1mg daily #. Methotrexate 10mg qTuesday #. Docusate 100mg [**Hospital1 **] #. Folate 1mg daily #. Pantoprazole 40mg daily #. Multivitamin daily #. Acetaminophen 650mg PO q6H PRN #. Lorazepam 0.5mg PO q4H PRN Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). Disp:*60 Tablet, Chewable(s)* Refills:*2* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as needed as needed for chest pain: please hold for BP < 100. 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day: please do not start until [**2185-2-18**]. 8. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 9. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Methotrexate (Anti-Rheumatic) 2.5 mg Tablets, Dose Pack Sig: Four (4) Tablets, Dose Pack PO every Tuesday: 10mg every Tuesday. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*5* 16. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for nausea. 17. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours. 18. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please hold for BP < 100, HR < 55. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Hospice of [**Location (un) 86**] and Greater [**Hospital1 1474**] Discharge Diagnosis: Primary: acute coronary syndrome . Secondary: rheumatoid arthritis, CAD, neuroendocrine tumor Discharge Condition: Afebrile, vital signs stable, chest pain free Discharge Instructions: You were admitted for chest pain. . We did a catheterization which showed chronic heart disease but no clear signs of an acute heart attack. We also did blood tests which showed that you did not have a heart attack. We optimized your heart medications. . Please continue to take your medications as prescribed. We have made the following changes: 1. Please take aspirin 162mg every day 2. Please take Imdur (isosorbide mononitrate) 30mg every day 3. Your beta blocker dose was increased, you are being a prescription for this 4. You were started on oral B12 supplements as you were noted to be B12 deficient on admission . Please attend your follow up appointments. . Please call your doctor or come to the nearest emergency room if you experience chest pain, palpitations, shortness of breath, bleeding, or other concerning symptoms. Followup Instructions: We have made you a follow up appointment with your primary care physicin for Wednesday, [**2185-2-23**] at 11:00am with [**Last Name (LF) 61898**],[**First Name3 (LF) 278**] T. [**Telephone/Fax (1) 61899**], F. [**Telephone/Fax (1) 33401**]. . In addition, you should follow up with your outpatient cardiologist with 2-4 weeks. Please schedule an appointment at your convenience. Completed by:[**2185-2-18**]

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icd9cm

[ [ [] ] ]

[ "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

12462, 12559

7532, 10062

325, 362

12696, 12743

4055, 7404

13626, 14036

3277, 3295

10581, 12439

12580, 12675

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3310, 4036

2416, 2609

275, 287

390, 2302

2640, 3113

2324, 2396

3129, 3261

27,289

182,503

30365

Discharge summary

report

Admission Date: [**2192-11-1**] Discharge Date: [**2192-11-10**] Date of Birth: [**2134-8-14**] Sex: M Service: CARDIOTHORACIC Allergies: Clarithromycin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Constrictive pericarditis Major Surgical or Invasive Procedure: [**2192-11-1**] - 1) Right VATS 2) Pericardiectomy via sternotomy History of Present Illness: 58 y/o gentleman with idiopathic liver failure. A cardiac MRI suggested a constrictive physiology and he was thus referred for surgical management. Past Medical History: # Cirrhosis of unclear etiology. Initially presented with ascites. Started on lasix and aldactone, which were stopped due to ARF. Autoimmune, viral hepatitis serologies, and genetic liver disease w/u negative, except isolated positive [**Doctor First Name **] at 1:40 and heterozygosity for H63D hemachromotosis mutation. Has persistently elevated alk phos and GGT with slightly elevated bilirubin. MRI to r/o PBC suboptimal due to ascites. EGD demonstrating one tiny varix in the lower esophagus. He also had a normal colonoscopy with normal biopsies. He does not drink alcohol and has never been a drinker. His transaminases have always been normal. Referred for transplant [**5-3**]. -diuretic refractory ascites w/ h/o SBP -tiny varix lower esophagus -no h/o hepatic encephalopathy, GI bleed -AFP 3.4 in [**1-/2192**] # h/o Legionella pneumonia # Rheumatic fever as a child with TTE demonstrating # Osteoarthritis Social History: Patient lives in [**State 3914**], works as an organic chemist with some "classified projects." Very knowledgeable about drugs and metabolites. Divorced twice, with female relationships thereafter. No tattoos, military service, IV drug use. No tobacco/ETOH/illicits. One daughter and two sons. Family History: Father deceased age 67 from etoh related cirrhosis, DU Mother deceased age 76, non alcohol related cirrhosis, DU ? ulcerative colitis 2 sisters, both living 2 brothers, both living, one brother with IBS Physical Exam: Admission GENERAL: He is a somewhat frail-appearing middle-aged man in no acute distress. VITAL SIGNS: His weight today is 226 pounds. HEENT: Normal. NECK: Supple. LUNGS: Clear to auscultation bilaterally. CARDIAC: Normal. There are no murmurs, gallops, or rubs. ABDOMEN: Quite distended with ascites, and his spleen and liver are nonpalpable. EXTREMITIES: On lower extremity exam, he does have 3+ pitting edema to the thigh. Discharge VS 97.1 80 SR 98/52 18 97% RA Gen: NAD Neuro: A&O, nonfocal exam Pulm: CTA-bilat CV: RRR, no murmur. Sternum stable, no erythema or drainage. Abdm: soft, NT/+BS Ext: warm, 2+ pedal edema Pertinent Results: [**2192-11-6**] Chest CT 1. Small right pleural effusion, free of mass or hematoma, layers posteriorly, following right thoracotomy and pleural drainage of previously large right pleural effusion. Large consolidative areas in the previously collapsed right middle and lower lobes probably due to atelectasis, though pneumonia and pulmonary hemorrhage cannot be excluded. 2. Small pericardial or pseudopericardial effusion present following presumed pericardiectomy. No mediastinal hematoma. 3. Moderate to large left pleural effusion increased with more left lower lobe atelectasis. Increased ascites. [**2192-11-1**] ECHO 1. The left atrium is moderately dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. 2. Mild spontaneous echo contrast is seen in the body of the right atrium. No thrombus is seen in the right atrial appendage 3. No atrial septal defect is seen by 2D or color Doppler. 4. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 5. Right ventricular chamber size and free wall motion are normal. 6. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are simple atheroma in the descending thoracic aorta. 7. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is minimal excusion of the RCC. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. 8. The mitral valve appears structurally normal with trivial mitral regurgitation. Trivial mitral regurgitation is seen. 9. There is a trivial/physiologic pericardial effusion. The pericardium may be thickened. There are no echocardiographic signs of tamponade. There is no evidence of pericardial constriction. The pulmonary vein flow pattern shows no systolic blunting and no A wave increase. There is minimal repiratory change in both the tricuspid and mitral inflow patterns. 10. There are large bilateral pleural effusions. 11. There is a large amount of abdominal ascites. 12. Post pericardiectomy, there is fluid in the pericardial space. Biventricular systolic function is normal. MR is trace. AI is 2+. [**2192-11-8**] Chest X-Ray During the short time interval, increase in left pleural effusion is demonstrated although mild. There is no change in the right basilar consolidations with increase in the left pericardiac opacities suggesting a combination of atelectasis and pleural effusion. The cardiomediastinal silhouette is stable. Minimal right apical pneumothorax is present. [**2192-11-1**] 07:34PM GLUCOSE-88 NA+-134* K+-4.0 [**2192-11-1**] 07:28PM UREA N-16 CREAT-0.8 CHLORIDE-104 TOTAL CO2-24 [**2192-11-1**] 07:28PM WBC-12.7*# RBC-3.67* HGB-11.3* HCT-35.8* MCV-97 MCH-30.9 MCHC-31.7 RDW-15.2 [**2192-11-1**] 07:28PM PLT COUNT-414 [**2192-11-1**] 07:28PM PT-17.2* PTT-33.0 INR(PT)-1.6* [**2192-10-31**] 09:11AM ASCITES TOT PROT-3.3 ALBUMIN-1.3 [**2192-10-31**] 09:11AM ASCITES WBC-875* RBC-2100* POLYS-20* LYMPHS-59* MONOS-3* MACROPHAG-18* COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2192-11-9**] 07:05AM 7.0 3.26* 9.6* 30.7* 94 29.6 31.3 15.5 264 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2192-11-9**] 07:05AM 264 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2192-11-9**] 07:05AM 86 18 0.8 140 3.8 97 36* 11 Brief Hospital Course: Mr. [**Known lastname 1968**] was admitted to the [**Hospital1 18**] on [**2192-11-1**] for surgical management of his constrictive pericarditis. He was taken to the operating room where he underwent a right VATS followed by a pericardiectomy via a sternotomy. Please see operative note for details. Postoperatively he was transferred to the intensive care unit for monitoring. Albumin and aggressive diuresis were used to prevent further third spacing of fluids. As he had large amounts of secretions, he remained initially intubated. On postoperative day three he awoke neurologically intact and was extubated. The physical therapy service was consulted for assistance with his postoperative strength and mobility. The hepatology service followed him daily for assistance with his care. On postoperative day five, he was transferred to the step down unit for further recovery. He developed a left pleural effusion which required thoracentesis. 1300cc of serous fluid were removed without incident. The wound care specialist was consulted for assistance with a sacral/coccyx pressure ulcer. Wound cleansing was recommended with Allevyn foam dressing changes. An attempt to drain his ascites was made on [**2192-11-9**] however was unsuccessful for only 5cc's. Intravenous albumin and lasix were used to reduce the volume of ascites. Mr. [**Known lastname 1968**] continued to make steady progress and was discharged home on postoperative day nine. He will follow-up with Dr. [**Last Name (STitle) **], the hepatology service, the thoracic surgery service, his cardiologist and his primary care provider as an outpatient. Medications on Admission: Bumex 1mg daily Tylenol PRN Discharge Medications: 1. Aspirin 81 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* 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Inhaler* Refills:*2* 4. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*1 Inhaler* Refills:*2* 5. Bumex 1 mg Tablet Sig: Two (2) Tablet PO once a day: [**Hospital1 **] x 10 days then QD. Disp:*40 Tablet(s)* Refills:*0* 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 10 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**State **] vna Discharge Diagnosis: Constrictive pericarditis Idiopathic liver failure Ascites Rheumatic fever Osteoarthritis Right heart failure Bicuspid Aortic valve with enlarged aortic root Legionella pneumonia H. Pylori Pleural effusion Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Take lasix and potassium for 10 days and then stop. Resume your Bumex when completed lasix. Take lasix with potassium twice daily as instructed. 8) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up Dr. [**Last Name (STitle) 5749**] in 5 days. [**Telephone/Fax (1) 72232**] Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 62**] Follow-up for Abdominal Paracentesis Please call all providers for appointments. Scheduled appointments: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2192-11-28**] 3:00 Completed by:[**2192-11-12**]

[ "746.4", "428.32", "571.5", "428.0", "707.03", "423.2", "789.59", "511.9" ]

icd9cm

[ [ [] ] ]

[ "34.91", "38.93", "37.24", "99.04", "37.31" ]

icd9pcs

[ [ [] ] ]

9120, 9167

6405, 8028

308, 376

9417, 9426

2691, 6382

10317, 10860

1824, 2029

8106, 9097

9188, 9396

8054, 8083

9450, 10294

2044, 2672

243, 270

404, 553

575, 1497

1513, 1808

18,642

138,073

28378

Discharge summary

report

Admission Date: [**2124-8-4**] Discharge Date: [**2124-8-11**] Date of Birth: [**2051-5-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4765**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac catheritization median sternotomy History of Present Illness: 73 M c PMH of HTN, hyperlipidemia who developed chest pain on AM of [**2124-8-4**] while walking. Described as "cold" and diffuse over chest. Accompanied by diaphoresis. No reported light headedness or radiation of the pain. Pain resolved somewhat with rest. Pain occurred again several minutes later while patient at rest. Called son who drove pt. to OSH. At OSH, noted to have + biomarkers (CK 182, CKMB 4.1, trop 0.09) and EKG showing ST elevations in V2-V6 and depressions in II,III,F. Received SLNTG and [**Last Name (LF) 63084**], [**First Name3 (LF) **], plavix 600, heparin bolus/drip, metoprolol 5 IV * 3, and morphine but pt. continued to have chest pain and was transfered for cath. Past Medical History: Hypertension CAD Social History: no tobacco, no ETOH. Spanish speaking. 2 sons live in area. Family History: Noncontributory Pertinent Results: [**2124-8-4**] 11:54PM HCT-30.5* [**2124-8-4**] 11:31PM TYPE-ART PO2-71* PCO2-37 PH-7.38 TOTAL CO2-23 BASE XS--2 [**2124-8-4**] 11:31PM O2 SAT-94 [**2124-8-4**] 10:21PM TYPE-MIX PO2-32* PCO2-50* PH-7.31* TOTAL CO2-26 BASE XS--2 INTUBATED-INTUBATED VENT-SPONTANEOU [**2124-8-4**] 10:21PM O2 SAT-61 [**2124-8-4**] 10:16PM TYPE-ART PO2-63* PCO2-42 PH-7.36 TOTAL CO2-25 BASE XS--1 INTUBATED-INTUBATED VENT-IMV [**2124-8-4**] 10:16PM O2 SAT-92 [**2124-8-4**] 10:07PM GLUCOSE-175* UREA N-16 CREAT-1.1 SODIUM-146* POTASSIUM-3.0* CHLORIDE-107 TOTAL CO2-23 ANION GAP-19 TTE: [**2124-8-7**] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.5 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 4.4 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.8 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.2 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 40% (nl >=55%) Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm) Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A Ratio: 1.83 TR Gradient (+ RA = PASP): *26 mm Hg (nl <= 25 mm Hg) LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild-moderate regional LV systolic dysfunction. No LV mass/thrombus. LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - hypo; mid anteroseptal - hypo; septal apex - hypo; apex - hypo; remaining LV segments contract normally. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Normal RV wall thickness. AORTIC VALVE: Normal aortic valve leaflets (3). Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild mitral annular calcification. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Borderline PA systolic hypertension. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal image quality - bandages, defibrillator pads or electrodes. Based on [**2114**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Left pleural effusion. Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with focal hypokinesis of the distal half of the septum and apex. The remaining segments contract well. 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. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: Initial Course: Mr. [**Known lastname 68864**] is a 72-year-old male who was admitted with an anterior STEMI. Upon transfer from an OSH, he was taken to the cath lab and underwent a percutaneous intervention to the proximal LAD. This resulted in a localized perforation, resulting in tamponade, necessitating placement of a LAD Wallstent and pericardiocentesis. A hematoma developed which caused compression of left main resulting in need for stenting of left main CA. The pt. left cath lab on dobutamine with pericardial drain in place. On arrival to CCU, he was found to be hypotensive, in tamponade with frank venous blood draining from pericardial drain. Subsequently, 3.5L of frank venous blood drained from pericardium. A total of 10 units of blood were transfused. The patient also recieved 10 units of platelets and 2 units of FFP, as well as wide open IVF; dobutamine was discontinued and levophed and dopamine were started. . A median sternotomy was urgently performed through which the pericardium was exposed. The pericardium was opened and there were massive amounts of dark blood within the pericardium. The tip of the right atrial appendage was clearly the source of bleeding, with a 1 x 1 mm hole expressing dark blood freely. That perforation was repaired. 2 mediatinal tubes and epicardial pacing wires were placed. chest tubes and a mediastinal drain were placed, and he was transferred to the CSRU overnight and then transferred to the CCU. . The following issues were addressed during his subsequent hospital course: 1. CV: a) CAD: S/P STEMI, S/P stenting of LAD and LM, c/b RA laceration (as above). The patient was started on a regimen of aspirin, plavix, betablocker, and a statin. He was continued on an ace inhibitor. b) Pump: The patient developed cardiogenic shock during cath. This resolved with drainage of the pericardial effusion/tamponade, repair of the R atrial laceration and medical management, with an EF of 40% on [**8-7**]. c) Rhythm: sinus. No issues this admission. . 2. GI: The patient had an episode of hemetemesis after cath. His hematocrit is stable after 10 units of PRBC (as above). GI was consulted; they feel the hematemesis was likely due to stress gastritis. He was H pylori negative. GI did not feel an EGD was necessary as the hemetemesis was limited to 1 episode with rapid resolution. He was started on [**Hospital1 **] PPI. The patient will followup with his PCP for this issue; we recommend a follow up EGD in [**12-24**] months. . 3. ID: The patient was started on empiric Zosyn for 7 day course for presumptive aspiration pneumonia as it is felt that the patient aspirated after his episode of hemetemesis. At discharge he was afebrile and had completed a full course of antibiotics. . 4. FEN: The patients electrolytes were followed and repleted PRN; he was given a low-salt, cardiac diet. . Full code Medications on Admission: Lisinopril 20 mg qday (patient had not taken for 2 weeks) Discharge Disposition: Home With Service Facility: all care vna of greater [**Location (un) **] Discharge Diagnosis: STEMI. LAD dissection resulting in tamponade. RA laceration. Discharge Condition: Good, medically stable. Stable on medication regimen, appropriate followup arranged. Discharge Instructions: During this admission you have been treated for a heart attack and tamponade. It is very important to continue to take all medications as prescribed and to follow up as listed below. If you experience chest pain, sweating, shortness of breath, pain at the wound sites, fever, or any other symptom that is concerning to you, please call your doctor immediately or go to the emergency room.

[ "998.11", "285.1", "287.5", "507.0", "423.0", "998.2", "410.41", "272.4", "414.01", "401.9", "518.5", "785.51", "578.0" ]

icd9cm

[ [ [] ] ]

[ "00.47", "99.04", "36.07", "37.49", "37.0", "00.66", "00.40", "99.07", "96.71", "89.64", "00.17", "88.56", "37.23", "99.05" ]

icd9pcs

[ [ [] ] ]

7570, 7645

4581, 6108

325, 368

7750, 7837

1268, 4558

1232, 1249

7666, 7729

7488, 7547

6125, 7462

7861, 8254

275, 287

396, 1098

1120, 1138

1154, 1216

54,934

155,913

41655

Discharge summary

report

Admission Date: [**2121-9-18**] Discharge Date: [**2121-9-24**] Date of Birth: [**2079-12-22**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1185**] Chief Complaint: AMS Major Surgical or Invasive Procedure: -Endotracheal intubation History of Present Illness: 41 yo M with history polysubstance abuse found down on the street and brought to the ED by EMS. Per ED, patient has another medical record registered under the same name but with a different date of birth- [**2079-12-22**]. Therefore, history is based on ED report and his other record with the birthdate of [**2079-12-22**]. . Per ED, patient became very combative when IVs were getting placed. Initial vitals were difficult to obtain and HR was 90. He required multiple people to restrain him for medical care. It was noted that there was a bottle of propanolol 10 mg tab with 7 tabs missing, and it was filled today. He received a total of 10 mg Haldol IV, 4 mg of Ativan IV. He continued to be very agitated, requiring intubation with propoful given concern of self-harm and CT head/neck, per ED. Per ED report, EKG showed sinus rhythm with non-specific ST changes. WBC was 21.6, but UA and CXR were negative. CK was 166. Initial lactate was 10.5, for which he received total of 4 liters of NS IVF, and improved to 1.7. Tox screen showed positive benzo and cocaine in the urine and TCA in the serum. His CT head was negative, CT neck was positive for osteophytes. CXR was without infiltrate and ETT was advanced by 1 cm. Vitals upon transfer were 96.4F (rectal), HR 52, BP 119/59, RR 16, 100% vent (fio40%, peep 5, VT 500). 2 PIV on the arms. . On the floor, patient is intubated . Will make note of his other medical record file, but will have to verify everything with him or his next of kins when possible. Past Medical History: PSYCHIATRIC HISTORY: -h/o depression, anxiety, polysubstance abuse -1st hospitalization 10yrs ago -Hosp x2 in [**2119**] (depression when grandfather died and [**Name2 (NI) **] with razor) -SA: OD on benzos "a few years ago" where pt went to the hospital, pt does not know if he went to the ICU or was intubated, h/o cutting wrist which required stitches per pt -h/o Celexa Rx (not currently taking) -no out pt treaters Social History: SOCIAL HISTORY: -dropped out of school in 10th grade -worked in "labor" -never had his own apartment or home -lives with his sister and with other friends -gets some money from his sister -incarcerated for shop lifting -says he has no friends or family that we can call ("My sister does not have a phone.") SUBSTANCE ABUSE HISTORY: -extensive substance history -ETOH: pt has been drinking 1 liter of vodka per day, his last drink was late yesterday afternoon -pt says he has a h/o shakes in the morning when he does not drink -h/o ETOH withdrawal seizures and DTs -Benzos: Pt says he has been using Ativan 3-4mg a day. He says that sometimes he uses Xanax instead, about 2-3 mg a day (he says that the dose varies day to day.) -Opiates/Cocaine: h/o cocaine and heroine use since he was a teenager, pt denies IVDU, last use a few weeks age [**12-25**] financial reasons -Marijuana: uses rarely -Tobacco: [**11-24**] pack a day since age 22 Family History: Unable to obtain at time of admission ? patient's father passed away when he was 4, also had alcohol use issue ? sister on methadone and multiple substance use ? grandfather and mother are alcoholics ? grandmother in and out of [**Name (NI) 55051**] State with nervous breakdown Physical Exam: Physical Exam on Arrival to MICU General: NAD, intubated HEENT: Sclera anicteric, mucous membrane dry, intubated, + laceration on his left parietal scalp with staples 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 GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge Physical Exam: GENERAL - well-appearing man in NAD, appropriate, agitated and pacing. HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear. Parietal scalp lesion ~2cm appears well healing and non tending. Occipital scalp lesion (~2cm) less erythematous than prior, no vesicles noted; improving. No other scalp lesions noted. NECK - supple, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use. Right anterior ribs mildly TTP yesterday (pt refuses exam again this am), no skin breakdown, no ecchymosis noted. HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes, +tattoos. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**3-27**] throughout, sensation grossly intact throughout, steady gait. Very mild tremor in b/l upper extremities. Pertinent Results: Admission Labs: [**2121-9-18**] 08:10PM BLOOD WBC-21.6* RBC-4.94 Hgb-15.4 Hct-47.3 MCV-96 MCH-31.2 MCHC-32.5 RDW-13.4 Plt Ct-334 [**2121-9-18**] 08:10PM BLOOD Neuts-76.7* Lymphs-17.8* Monos-2.8 Eos-2.2 Baso-0.5 [**2121-9-18**] 08:10PM BLOOD PT-12.1 PTT-21.0* INR(PT)-1.0 [**2121-9-18**] 08:10PM BLOOD Glucose-100 UreaN-19 Creat-1.4* Na-145 K-4.5 Cl-102 HCO3-15* AnGap-33* [**2121-9-18**] 08:10PM BLOOD ALT-95* AST-43* CK(CPK)-166 AlkPhos-95 [**2121-9-18**] 08:10PM BLOOD Calcium-10.8* Phos-5.7* Mg-2.5 [**2121-9-19**] 04:07AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2121-9-23**] 04:00PM BLOOD HIV Ab-NEGATIVE [**2121-9-18**] 08:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-POS [**2121-9-19**] 04:07AM BLOOD HCV Ab-POSITIVE* Discharge Labs: [**2121-9-22**] 04:42AM BLOOD WBC-7.0 RBC-4.06* Hgb-12.7* Hct-36.7* MCV-90 MCH-31.4 MCHC-34.8 RDW-13.5 Plt Ct-248 [**2121-9-22**] 04:42AM BLOOD Glucose-76 UreaN-13 Creat-0.9 Na-139 K-3.9 Cl-102 HCO3-28 AnGap-13 [**2121-9-22**] 04:42AM BLOOD ALT-65* AST-37 LD(LDH)-184 AlkPhos-72 TotBili-0.4 [**2121-9-22**] 04:42AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.1 . Microbiology: . Imaging: CT Head- No acute intracranial process. CT Cspine- 1. No acute fracture. 2. Severe degenerative changes at C4 through C7. Posterior osteophytes impinging on the thecal sac anteriorly at level C4-C5, C5-C6, and C6-C7, placing the cord for high risk of injury in appropriate clinical setting. RUQ Ultrasound- No specific son[**Name (NI) 493**] evidence of cirrhosis. However, splenomegaly is noted with a enlarged periportal lymph node, which could be related to liver disease. Clinical correlation recommended. Brief Hospital Course: 41 yo M with polysubstance abuse presented with AMS, requiring intubation for medical evaluation. # AMS. Most likely [**12-25**] polysubstance abuse in the setting of benzodiazepine, cocaine, and TCA. Per ED report, has had history of overdose requiring multiple ED visits. Cultures were sent and were negative. Lactate was normal. CXR was unrevealing. Patient was given a banana bag in additional to other vitamin supplements. He was successfully extubated. Subsequently was placed on CIWA scale with diazepam given active EtOH withdrawal symptoms. Post extubation, patient's mental status appeared to be at baseline. # Polysubstance abuse/Overdose. Unclear the intention of the OD this time. ECG without significant changes in QRS and QTc. Cardiac enzymes negative. In additional to the banana bag and vitamin supplements, he was also placed on CIWA scale upon extubation. Psychiatry was consulted for evaluation of this OD. SW was consulted. Patient was sectioned and placed on 1:1 sitter given his history of suicidal attempts. # Alcohol withdrawal. Patient required 10 mg diazepam every 4 hours consistently post extubation. His requirement for diazepam decreased over time. It was at 5 mg diazepam every 4 hours upon transfer to the floor. CIWA scale was discontinued [**2121-9-23**] as he was out the concerning withdrawal window and [**Doctor Last Name **] primarily for agitation, and he was placed on q4hr zyprexa for intermittent anxiety/agitation. # Leukocytosis. No clear source of infection. No antibiotics was given at arrival to the MICU. It resolved. Most likely from inflammatory process associated with overdose. # Left parietal scalp laceration. CT head and neck were negative. It was stapled prior to arrival to the MICU. Post extubation, patient states that he had the staples placed about 10 days prior to this admission. Staples were removed in the MICU. Wound has healed well. # Transaminitis. Noted upon arrival. Mild in nature. Viral hepatitis serology was sent given his history of drug use. RUQ ultrasound was benign except for splenomegaly. He was found to be hepatitis C positive. He was HBV and HIV negative. He should follow up with the liver center at [**Hospital1 18**], number provided in the discharge paperwork. # Acute renal failure. Crt improved while in house. Most likely a pre-renal etiology. # MRSA Screen Positive. Pending Tests: - Blood cultures x 2 [**2121-9-19**] no growth to date Transitional Care issues: - may need monitoring of QTc while titrating psychiatric drugs as it was elevated to 450s initially following overdose. Checked again at around 400 when titrating seroquel. Medications on Admission: Unable to verify on admission Per ED record - chlorpromazine 100 mg qHS - baclofen 20 mg 4 times a day - doxepin 75 mg qHS - propranolol 10 mg TID Discharge Medications: 1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: Please apply to the lower anterior right ribs. Discharge Disposition: Extended Care Facility: [**Hospital 1680**] Hospital - [**Location (un) 538**] Discharge Diagnosis: Primary -Polysubstance abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], It was a pleasure taking part in your care. We hope you continue to feel well. You were admitted because you were found on the street intoxicated. In the ED, you were intubated for your safety. Head and neck imaging was obtained which did not reveal any abnormalities. Your liver enzymes were elevated and we tested you for various infections that cause this. We found that you have an infection called Hepatitis C. We did an ultrasound of your liver which did not reveal evidence of cirrhosis. We recommended that you discuss this with your primary care physician and possibly speak with a hepatologist (liver doctor). We treated you for alcohol withdrawal, which can be a deadly complication of alcohol use. We suggest that you no longer drink alcohol as this can also cause a lot of damage to your liver. The following changes were made to your medications: - please stop propranolol, doxepin, and chlorpromazine - we started seroquel in the hospital, this may change depending on the opinions of your psychiatrists moving forward Please take care of yourself, [**Known firstname **], and please stop using drugs. Followup Instructions: Please see the physician at the extended care facility within one to two days of arrival Please see your primary care [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],RAFAY S. [**Telephone/Fax (1) 90556**] when you leave [**Hospital1 **] Please see a liver specialist here at [**Hospital1 18**] to tend to your serious liver infection, called hepatitis C. They can be reached at [**Telephone/Fax (1) 90557**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]

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icd9cm

[ [ [] ] ]

[ "86.59", "96.04", "96.71", "94.62" ]

icd9pcs

[ [ [] ] ]

10312, 10393

6834, 9302

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15609

Discharge summary

report

Admission Date: [**2114-1-5**] Discharge Date: [**2114-1-8**] Service: Medical Intensive Care Unit CHIEF COMPLAINT: Transferred from [**Hospital **] Rehabilitation for decreased oxygen saturation. HISTORY OF PRESENT ILLNESS: This is an 85-year-old white female with a history of coronary artery disease (status post coronary artery bypass graft with a complicated postoperative course) who was transferred from [**Hospital **] Rehabilitation for worsening oxygen dependence and respiratory distress. The patient initially underwent a coronary artery bypass graft on [**2113-10-27**] after cardiac catheterization showed a significant left main and 3-vessel disease. Her postoperative course was immediately complicated by hypotension and atrial fibrillation requiring an amiodarone drip and a long course of pressors. The pressors were continued until approximately postoperative days 15 to 16 for presumed septic shock. The course was further complicated by a gastrointestinal bleed with subsequent esophagogastroduodenoscopy on [**2113-12-3**] showing esophagitis and gastritis. The patient failed to wean from the ventilator and underwent an operative tracheostomy after failing a bedside attempt. The patient was subsequently transferred to [**Hospital **] Rehabilitation for ventilator weaning, but was transferred back several days later with maroon stools. The patient was transferred and hematocrit remained stable. A colonoscopy at an outside hospital prior to that had revealed diverticulosis, so no colonoscopy was performed at that time. The patient was transferred back to [**Hospital **] Rehabilitation. Over the last one month, the patient has been at [**Hospital **] Rehabilitation for chronic anemia apparently making minimal progress. A chest x-ray was performed one week ago for fever and leukocytosis, which reportedly revealed bilateral pneumonia. The patient appears to have been started on vancomycin, gentamicin, nebulizer, and Unasyn at that time with the sputum culture growing methicillin-resistant Staphylococcus aureus and Acetobactor. The white blood cell count trended down, but the sputum remained thick and had grown progressively bloody with suctioning. Over the last 24 hours, the patient has desaturated on multiple times requiring increasing FIO2 (from 0.4 to 1) progressively with arterial blood gas showing 7.47/47/53 while on 50% FIO2. The patient's sputum has grown purulent and more sanguinous. At the time of transfer, the patient was on intermittent mandatory ventilation, respiratory rate was 22 to 35, blood pressure was 140/70, oxygen saturation was 95% on 100% FIO2. The patient currently appears to deny chest pain, shortness of breath, and pain but was not very interactive. Prior to admission, outside notes suggestive of prior treatment for cellulitis around the gastrojejunostomy tube site. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post coronary artery bypass graft in [**2113-10-20**]. 2. Postoperative atrial fibrillation. 3. Echocardiogram on [**2113-11-4**] showed an ejection fraction of 40% to 50% with 2+ mitral regurgitation. 4. Congestive heart failure. 5. Status post tracheostomy for an inability to wean. 6. Status post endoscopic gastrojejunostomy tube placement. 7. Hypertension. 8. History of upper gastrointestinal bleed with an esophagogastroduodenoscopy on [**2113-11-22**] showing esophagitis and gastritis. 9. Lower gastrointestinal bleed in [**2113-11-19**]; transfusion and hematocrit remained stable. 10. Diverticulosis. 11. Chronic obstructive pulmonary disease (no pulmonary function tests on record). 12. Right total knee replacement. 13. Hypercholesterolemia. 14. A questionable history of ventricular tachycardia. ALLERGIES: SULFA. MEDICATIONS ON TRANSFER: 1. NPH 20 units subcutaneously q.h.s. 2. A regular insulin sliding-scale. 3. Prevacid 30 mg per gastrojejunostomy tube every day. 4. Trazodone 25 mg p.o. q.h.s. 5. Ferrous sulfate 300 mg p.o. q.d. 6. Multivitamin 5 mL p.o. q.d. 7. Amiodarone 200 mg p.o. q.d. 8. Atrovent nebulizer every 2 hours as needed. 9. Albuterol nebulizer every 2 hours as needed. 10. Lasix 40 mg p.o. q.d. to b.i.d. 11. Lopressor 12.5 mg p.o. b.i.d. 12. Vancomycin 1 g intravenously q.d. 13. Unasyn 3 g intravenously q.6h. 14. Gentamicin 80-mg nebulizer. SOCIAL HISTORY: The patient denies tobacco use. Denies alcohol use. Currently at [**Hospital **] Rehabilitation; was living at home prior to her transfer there status post coronary artery bypass graft. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 98.1, heart rate was 78, respiratory rate was 22, blood pressure was 153/57, oxygen saturation was 96% to 100%. Ventilator AC 16/500/0.6/5. Breathing at a rate of 19. Peak inspiratory pressure was 37 and plateau pressure was 31. In general, the patient was a diaphoretic, mildly tachypneic, an minimally interactive female. Head, eyes, ears, nose, and throat examination revealed no oropharyngeal lesions. Mucous membranes were moist. No icterus. Cardiovascular examination revealed a regular rate and rhythm. No rubs or gallops. A 2/6 systolic ejection murmur at the left lower sternal border without radiation. No jugular venous distention. Mild bilateral peripheral pitting edema. Pulmonary examination revealed decreased breath sounds at both bases (the left worse than right), coarse rales in the lower two thirds of the right lung field and lower one half of the left lung field. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Gastrojejunostomy tube located in left upper quadrant. Mild erythema around the site, no exudate. Neurologic examination revealed alert and oriented to name. The patient moved all extremities and voiced words; although she could not talk because she was on the ventilator. The patient could follow basic commands. PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent laboratory data on admission revealed sodium was 140, potassium was 3.7, chloride was 99, bicarbonate was 29, blood urea nitrogen was 33, creatinine was 1.2, and blood glucose was 174. White blood cell count was 12.2, platelets were 263, and hematocrit was 32.3. INR was 1.2 and partial thromboplastin time was 22.4. RADIOLOGY/IMAGING: A chest x-ray was suggestive of bilateral congestive heart failure with pleural effusions. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit and was diuresed with intravenous Lasix. Her ventilator was set at AC 10/500/40/5. She was briefly switched to pressure support but did not tolerate it and was placed back on assist control. She was diuresed with Lasix intravenously 40 mg every day to twice per day and initially put one liter out. Then her creatinine bumped to 1.4 and further diuresis was held. She was maintained on the above ventilator setting (AC 10/500/4/5) she did not desaturate and reported that she was comfortably breathing. After her creatinine dropped to 1.2, diuresis was attempted again with oral Lasix, and again her creatinine bumped to 1.4 (with a blood urea nitrogen of 33), and so further diuresis was held. On the day prior to discharge, the patient's urine output remained at 20 cc per hour, so she was gently hydrated with 250 cc of normal saline. This did not cause her any respiratory discomfort. Her course of vancomycin was due to be completed on [**2114-1-7**], and her Unasyn course was due to be complained on the day prior to her admission to [**Hospital1 190**]; however, both antibiotics were continued to the day of discharge. The patient did not appear clinically infected, did not have any leukocytosis or fever and was not coughing an excessive amount. Because some blood was removed from the tube with suctioning, the patient was offered a bronchoscopy but flatly refused. She was also offered thoracentesis for her bilateral pleural effusions, but she flatly refused this intervention also. She also refused to allow us to place a central venous triple lumen catheter as well as an arterial line. However, she did consent to allow a peripherally inserted central catheter line to be placed. A family meeting was held since the patient has her sister listed as her health care proxy to determine if the family felt that the patient was making requests consistent with her previously stated desires. The family spoke with the patient and with the primary team and agreed that the patient should make her medical decisions for herself for the time being and that she was capable of this. This meeting was held on [**2114-1-6**]. On the day of discharge, the patient's white blood cell count was 7.4, hematocrit was 27.6, and platelets were 226. Potassium was 4, magnesium 2.2, blood urea nitrogen was 36, creatinine was 1.4, and blood glucose was 116. Vancomycin level was 23. The patient's dose of vancomycin was 750 mg intravenously q.24h. whole in house. Her dose of Unasyn was 3 g intravenously q.6h. Her NPH was held, and she was covered a regular insulin sliding-scale. She was also started on Ultracal tube feeds. Her ventilator settings at the time of discharge were AC 10/500/40/5. She was achieving a peak inspiratory pressure of 29 on these settings. A sputum Gram stain was remarkable only for yeast, and culture was growing only yeast at the time of discharge. Urine culture was also positive for yeast. Blood cultures showed no growth at the time of discharge. DISCHARGE DISPOSITION: The patient was stable for discharge back to [**Hospital **] [**Hospital **] hospital to resume weaning from the ventilator. MEDICATIONS ON DISCHARGE: 1. Metoprolol 12.5 mg p.o. b.i.d. 2. Amiodarone 200 mg p.o. q.d. 3. Trazodone 25 mg p.o. q.h.s. 4. Multivitamin. 5. Iron sulfate 325 mg p.o. q.d. 6. Lansoprazole 30 mg p.o. b.i.d. 7. Senna 10 mL p.o. q.d. 8. Colace 30 mL p.o. t.i.d. 9. Atrovent meter-dosed inhaler 2 puffs inhaled q.i.d. as needed. 10. Albuterol meter-dosed inhaler 2 puffs inhaled q.6h. as needed. 11. Unasyn 3 g intravenously q.6h. 12. Heparin 5000 units subcutaneously q.12h. 13. Lasix 40 mg p.o. q.d. 14. Lactulose 20 mL p.o. q.d. as needed. 15. Kaopectate 30 mL p.o. q.d. as needed. 16. Chlorhexidine gluconate 5 mL p.o. b.i.d. as needed. 17. Xanax 0.5 mg p.o. t.i.d. as needed. 18. Ultracal FS tube feeds at goal of 55 cc per hour. 19. A regular insulin sliding-scale. DISCHARGE DIAGNOSES: 1. Congestive heart failure secondary to fluid overload. 2. Coronary artery disease; status post coronary artery bypass graft. 3. Chronic dependence on mechanical ventilator. 4. Status post tracheostomy for inability to wean. 5. Status post endoscopic gastrojejunostomy tube placement. 6. Hypertension. 7. History of upper gastrointestinal bleed with endoscopic findings of esophagitis and gastritis. 8. Lower gastrointestinal bleed; the patient was transfused and hematocrit remained stable. 9. Diverticulosis. 10. Chronic obstructive pulmonary disease. 11. Right total knee replacement. 12. Hypercholesterolemia. 13. A questionable history of ventricular tachycardia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**] Dictated By:[**Last Name (NamePattern1) 2582**] MEDQUIST36 D: [**2114-1-8**] 08:44 T: [**2114-1-8**] 08:48 JOB#: [**Job Number 45109**]

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icd9cm

[ [ [] ] ]

[ "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

9511, 9637

10456, 11425

9664, 10434

6429, 9486

129, 211

240, 2877

3814, 4366

2900, 3788

4383, 6410

9,167

153,025

20963+20964

Discharge summary

report+report

Admission Date: [**2181-6-27**] Discharge Date: [**2181-8-8**] Date of Birth: [**2181-6-27**] Sex: M Service: NB THIS IS THE SECOND HALF OF THE DISCHARGE DICTATION PLEASE SEE THE FIRST HALF FOR DETAILS OF THE HOSPITALIZATION. IT ALSO HAS A DISCHARGE DATE OF [**2181-8-8**]. Neurologic: [**Known lastname **] has had a normal head ultrasound on [**7-10**]. Renal: A renal ultrasound was performed on [**7-10**] for presence of two vessel cord. This study was within normal limits. Infectious Disease: [**Known lastname **] received an initial course of ampicillin and gentamicin secondary to respiratory distress. These were discontinued after cultures remained negative at 48 hours. With the concerns for necrotizing enterocolitis he completed a 14- day course of ampicillin, gentamicin and clindamycin. Access: [**Known lastname **] required a Broviac line for access. This line was removed two days prior to discharge with the site healing well. Sensory: A hearing screen was performed on [**2181-8-3**], demonstrating normal results. Health Maintenance: [**Known lastname **] received his hepatitis B on [**8-2**]. In addition, his newborn screens were sent twice and found to be within normal limits. DISPOSITION: Home. PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **], [**Hospital **] Pediatrics. Phone number [**Telephone/Fax (1) 37259**]. RECOMMENDATIONS: Feeds at discharge: Breast milk 24 Kcal with Neosure until six to nine months' corrected age. Medications: Ferrous sulfate 0.4 cc p.o. daily, Vidalin 1 cc p.o. daily. Car seat screening: Normal. FOLLOW UP: Patient to be seen by primary care physician one to two days following discharge. Parents to schedule. Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: 1) born at less than 32 weeks; 2) born between 32 and 35 weeks with two of the following: daycare during RSV season, a smoker in the household, neuromuscular diseas, airway abnormalities, or school age sibiling; or 3) chronic lung disease. Influenza immunization is recommeneded annually in the fall for all infants once they reach six months of age. Before this age ( adn fro the first 24 months of the child's life), immunization against influenza is recommeneded fro household contacts and out- of-home caregivers. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 50655**] Dictated By:[**Last Name (NamePattern1) 52011**] MEDQUIST36 D: [**2181-8-7**] 12:32:05 T: [**2181-8-7**] 13:11:08 JOB#: [**Job Number 55723**] Admission Date: [**2181-6-27**] Discharge Date: [**2181-8-8**] Date of Birth: [**2181-6-27**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: [**Known lastname **] is a now 42-day-old ex-33- [**5-2**] week infant who was born by repeat cesarean section for concerns of intrauterine growth restriction and evolving pregnancy induced hypertension. [**Known lastname **] mother is a 35-year- old G2, P1, now 2, Asian woman who's estimated date of confinement was [**2181-8-11**]. Her prenatal screens were B positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis B surface antigen negative and GBS unknown. Her prior obstetrics history was notable for pregnancy induced hypertension with a prior infant delivered at 28-5/7 weeks gestation at [**Hospital1 69**]. That infant was in the Neonatal Intensive Care Unit for three months and is now two years old and doing well. Mom's blood pressure had remained elevated since the delivery of the first infant and consequently she was on atenolol. This current pregnancy was complicated by pregnancy induced hypertension superimposed on this chronic hypertension. Mom was subsequently treated with both labetalol and Procardia. Notable findings from prenatal ultrasound included two vessel cord and intrauterine growth restriction. With worsening hypertension, decision was made for repeat cesarean section. [**Known lastname **] was born from breech presentation with rupture of membranes at delivery. Mom did receive intravenous antibiotics prior to delivery. There were no concerns for maternal fever or sepsis risk factors. Resuscitation was notable for a difficult extraction with early apnea and heart rate less than 100. The patient was bulb suctioned with PPV times one minute with good response. Apgars were 4 and 8 with subsequent admission to the Neonatal Intensive Care Unit for respiratory distress. PHYSICAL EXAMINATION: Weight 1275 grams, 15th percentile. Length: 48.5 cm, 15th percentile. Head circumference: 27.25 cm, 10th percentile. General appearance: SGA preterm infant at 33-4/7 weeks, active and crying with extensive bruising over extremities. HEENT: Anterior fontanelle open and flat. Normocephalic. Bilateral red reflexes present. Palate intact. Chest: Sternal and intercostal retractions. Mild grunting and flaring. Fair aeration bilaterally. Clavicles intact. Heart regular rate and rhythm. Normal S1, S2. No murmur. Two plus pulses in extremities. Abdomen non- tender, non-distended. Two vessel cord, no abdominal masses. Genitourinary: Preterm male with testes in inguinal canal bilaterally. Anus patent, normally placed. Trunk straight. No dimple present. Extremities: Hips stable. Neurologic: Appropriate for gestational age. Normal motor and grasp. HOSPITAL COURSE BY SYSTEM: Respiratory: [**Known lastname **] course was consistent TTN requiring approximately 24 hours on CPAP. He did have occasional apnea and bradycardia events early in his hospitalization; however, he has been without additional events of apnea of prematurity and he was never treated with caffeine. Cardiovascular: [**Known lastname **] has been noted to have a soft 2/6 systolic murmur at the precordium radiating to both right and left. Clinically, the murmur is most consistent with DPS. No workup has been indicated. Fluids, Electrolytes and Nutrition: [**Known lastname **] was originally NPO with gradual advance of feeds per protocol. He had made it to 30 Kcal with ProMod nearly all orally when he developed 48 hours of grossly bloody stools. Three serial KUB's were performed during that time and showed a localized distended loop. However, there was no evidence of pneumatosis. In addition, [**Known lastname **] had reassuring labs with a normal CBC and electrolytes. [**Known lastname **] was treated presumptively for necrotizing enterocolitis. He received full 14 days of antibiotics with ten days of NPO. At present he has resumed oral feedings and is currently on 24 Kcal (breast mild supplemented with Neosure). He has intermittently had heme positive stools since re-feeding with most recent ones showing no evidence of blood. His weight at discharge 2.42 kg lenght 46.5 cm and head circumference 32 cm. Hematology: [**Known lastname **] had a mild course of hyperbilirubinemia with phototherapy. His max bilirubin was 9.4 on [**7-5**]. A rebound off of phototherapy was 5.4 on [**7-10**]. [**Known lastname **] is A positive, antibody negative with maternal blood type of B positive, also antibody negative. Initial hematocrit on admit CBC was 58.1. Most recent hematocrit on [**7-19**] was 34.1. [**Known lastname **] is on iron and will be discharged home on ferrous sulfate 0.4 cc daily. Please see the second part of this dictation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**] Dictated By:[**Last Name (NamePattern1) 55724**] MEDQUIST36 D: [**2181-8-7**] 12:24:56 T: [**2181-8-7**] 12:56:24 Job#: [**Job Number 55725**]

[ "765.26", "770.6", "779.3", "774.2", "785.2", "V30.01", "557.0", "770.81", "765.15" ]

icd9cm

[ [ [] ] ]

[ "93.90", "38.93", "96.6", "96.71", "99.55", "99.83", "96.04" ]

icd9pcs

[ [ [] ] ]

5510, 7764

1616, 2817

4610, 5482

1424, 1604

2846, 4587

60,733

143,438

40390

Discharge summary

report

Admission Date: [**2107-9-22**] Discharge Date: [**2107-9-28**] Date of Birth: [**2026-7-1**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2107-9-23**] Emergent coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the right coronary artery and the ramus intermedius artery. [**2107-9-23**] Cath History of Present Illness: 81M w h/o htn, transferred from OSH. Recently developed chest pain and was found to have abnormal stress test. He is transferred for cardiac cath which revealed left main CAD. He is brought emergently to the OR for CABG. Past Medical History: Hypertension Prostate cancer s/p XRT and TURP [**4-/2107**] Radiation cystitis & prostatitis Diverticulitis Psoriasis Social History: Race: Caucasian Lives with: wife and nephew Occupation: retired contractor Tobacco:Quit 40 years ago. Smoked for 10-15 years. ETOH: Denies Illicit drugs: Denies Family History: Brothers with CAD/1 s/p CABG neither at early age Physical Exam: Pulse: 59 Resp: 16 O2 sat: 100%2L B/P 154/78 Height: Weight: 78.1kg General: NAD, WGWN, appears stated age, en route to OR Skin: Dry [x] intact [x] numerous psoriatic plaques, especially of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 4459**]: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema- no Varicosities: None [x] Neuro: Grossly intact [x] Pertinent Results: [**2107-9-23**] Echo: Pre CPB: 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. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%) with borderline normal free wall function. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are three mildly thickened aortic valve leaflets. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. There is no mitral valve prolapse. No mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. Post CPB: The patient is AV-Paced, on no inotropes. [**2107-9-23**] 12:10AM BLOOD WBC-6.7 RBC-4.85 Hgb-13.9* Hct-39.9* MCV-82 MCH-28.7 MCHC-34.8 RDW-15.0 Plt Ct-180 [**2107-9-27**] 04:43AM BLOOD WBC-8.6 RBC-3.44* Hgb-9.8* Hct-29.3* MCV-85 MCH-28.6 MCHC-33.6 RDW-15.5 Plt Ct-197 [**2107-9-23**] 12:10AM BLOOD PT-12.8 PTT-28.7 INR(PT)-1.1 [**2107-9-23**] 08:28PM BLOOD PT-15.6* PTT-39.6* INR(PT)-1.4* [**2107-9-23**] 12:10AM BLOOD Glucose-142* UreaN-24* Creat-1.4* Na-138 K-3.6 Cl-103 HCO3-30 AnGap-9 [**2107-9-28**] 05:15AM BLOOD Glucose-111* UreaN-28* Creat-1.6* Na-139 K-3.9 Cl-104 HCO3-27 AnGap-12 [**2107-9-23**] 03:40PM BLOOD ALT-13 AST-21 TotBili-0.2 Brief Hospital Course: Mr [**Known lastname **] was transferred from [**Hospital3 24768**] with new onset angina for cardiac catheterization. The catheterization revealed Left Main disease and he was referred to cardiac surgery for emergent coronary bypass surgery. Please see operative report for details. In summary he had: emergent coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the right coronary artery and the ramus intermedius artery. His bypass time was 86 minutes, with a crossclamp of 76 minutes. He tolerated the operation well and was transferred post-operatively to the cardiac suregry ICU in stable condition. In the immediate post-op period he remained hemodynamically stable, woke neurologically intact, weaned from the ventilator and was extubated. On post-op day one he continued to be hemodynamically stable and was transferred to the cardiac surgery stepdown floor. The remainder of his hospital course was uneventful. All tubes, lines and drains were removed per cardiac surgery protocol. The patient did have several episodes of post-operative atrial fibrillation which were treated with Beta blockers and ultimately Amiodarone following which he converted to sinus rhythm. Once on the stepdown floor the patient worked with physical therapy and the nursing staff to increase his activities of daily living and improve his endurance. On POD five he was discharged home with visiting nurses. He is to follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 3 weeks. Medications on Admission: Atenolol 50mg PO daily Finasteride 5mg PO daily Discharge Disposition: Home With Service Facility: vna southeastern ct Discharge Diagnosis: Coronary artery disease s/p Coronary Artery Bypass Graft x 3 Past medical history: Hypertension Prostate cancer s/p XRT and TURP [**4-/2107**] Radiation cystitis & prostatitis Diverticulitis Psoriasis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema - none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2107-10-19**] 1:45 Cardiologist: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time: [**2107-10-20**] 3:00 Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 24717**] Phone:[**Telephone/Fax (1) 24721**] in [**2-21**] 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:[**2107-9-28**]

[ "403.90", "414.01", "511.0", "997.1", "V10.46", "427.31", "585.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4998, 5048

3311, 4900

288, 535

5292, 5509

1762, 2630

6349, 7121

1123, 1174

5069, 5130

4926, 4975

5533, 6326

1189, 1743

238, 250

563, 788

5152, 5271

945, 1107

2640, 3288

32,020

159,828

2917

Discharge summary

report

Admission Date: [**2172-2-3**] Discharge Date: [**2172-2-8**] Date of Birth: [**2122-3-14**] Sex: M Service: MEDICINE Allergies: Vancomycin / Lisinopril / Banana Attending:[**First Name3 (LF) 5037**] Chief Complaint: RV collapse on echo Major Surgical or Invasive Procedure: pericardiocentesis [**2172-2-3**] History of Present Illness: This is a 49 yo man with Hep C, cryoglobulinemia, and MPGN s/p renal transplant in [**2169**] w/ recurrent MPGN in transplanted kidney, and known pericardial effusion who presents with RV collapse on echo. He went to get rituximab today for his cryoglobins, but this was cancelled due to abnormal echo results from Friday. He was directly admitted to [**Hospital Ward Name 121**] 10. . He was recently admitted from [**1-20**] - [**1-24**] for dyspnea, treated with diuresis. He was also recently hospitalized for 2 months of worsening SOB, cough, and chest pain thought to be rapamycin-induced lung toxicity. During that admission, his immunosuppression was switched from rapamycin to tacrolimus and symptoms quickly resolved. He had had a fever during that hospital course. Infectious workup, including BCx, UCx, and CXR, was unrevealing. He was not started on antibiotics as the patient appeared non-toxic and had a normal WBC count. . He c/o DOE as well as pain in his feet [**3-15**] edema and cryoglobulin rash. The rash recurred on [**1-30**]. He denies chest pain, SOB at rest, palpitations. He does reports worsening LE edema since discharge, with 2 pillow orthopnea. . ROS: Pt denies fever or chills. Feels that he has lost weight. Reports dry cough, no rhinorrhea or nasal congestion. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No melena or BRBPR. No dysuria. Reports tremulousness with myoclonic jerks occurring frequently. Past Medical History: HCV type 1a - Grade 1 Stage 1 on bx [**2168**] (VL 1460K on [**2171-12-6**]) HBV (VL none detected [**2171-11-7**]) Cryoglobulinemia s/p rituximab and plasmapheresis; last [**Month/Day/Year **] was on [**2172-1-22**] as an inpatient. s/p renal transplant [**2169-6-9**] [**3-15**] MPGN BOOP on biopsy from [**2172-1-17**], may be from rapamycin toxicity, on 1-2L home O2 HTN Depression/PTSD h/o pericarditis h/o tunneled line bacteremia w/ enterococcus, MSSA, coag neg staph h/o thrombocytopenia h/o anemia +CMV Social History: He is married with 2 children. He is a former carpenter/roofer, now on permanent disability. He smoked [**2-12**] ppd but quit over 9 months ago. He denied EOTH or drugs in past 20 yrs. Family History: Non-contributory Physical Exam: VS: BP 119/73 P 69 RR 24 SpO2 86% RA and 95% 2L NC. General: mildly SOB with talking, alert, slightly tremulous HEENT: EOMI, MMM Neck: supple, no LAD CV: RRR, nl S1/S2. [**3-19**] holosystolic murmur at USB. no rub appreciated. Pulm: bilateral basal crackles, L>R, decreased breath sounds to left base. occ anterior wheezes. Abd: soft, NT/ND, graft to RLQ non-tender. Ext: Rash worst at ankles B, small (2-4mm) macules, 3+pitting edema bilaterally to thighs. LUE with AV fistula and palpable thrill. Neuro: -mental status: Alert & Oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: 4/5 strength to LE, [**6-15**] to UE, slightly decreased bulk. -sensory: No deficits to light touch throughout. -cerebellar: No dysarthria. Action tremor present, no resting tremor. no asterixis. -DTRs: 2+ biceps and 1+ ankle reflexes bilaterally. No clonus. Pertinent Results: [**2172-2-3**] 08:45AM BLOOD WBC-6.5 RBC-3.04* Hgb-7.6* Hct-25.0* MCV-82 MCH-25.1* MCHC-30.4* RDW-17.9* Plt Ct-744* [**2172-2-8**] 06:25AM BLOOD WBC-5.9 RBC-3.42* Hgb-9.0* Hct-28.6* MCV-84 MCH-26.2* MCHC-31.3 RDW-17.6* Plt Ct-441* [**2172-2-3**] 08:30PM BLOOD PT-14.0* PTT-27.3 INR(PT)-1.2* [**2172-2-3**] 08:45AM BLOOD CD19-0.6 CD20-0.06 [**2172-2-3**] 08:45AM BLOOD Glucose-106* UreaN-92* Creat-5.2*# Na-137 K-4.8 Cl-96 HCO3-26 AnGap-20 [**2172-2-8**] 06:25AM BLOOD Glucose-100 UreaN-55* Creat-3.8* Na-144 K-5.1 Cl-106 HCO3-30 AnGap-13 [**2172-2-8**] 06:25AM BLOOD ALT-14 AST-27 LD(LDH)-212 AlkPhos-59 TotBili-0.8 [**2172-2-3**] 08:30PM BLOOD TotProt-5.0* Albumin-3.3* Globuln-1.7* Calcium-8.9 Phos-5.9* Mg-2.3 [**2172-2-6**] 05:50AM BLOOD calTIBC-130* Ferritn-879* TRF-100* [**2172-2-5**] 07:05AM BLOOD VitB12-413 Folate-10.7 [**2172-2-3**] 08:30PM BLOOD TSH-7.2* [**2172-2-6**] 05:50AM BLOOD T4-4.3* Free T4-0.91* [**2172-2-3**] 08:34PM BLOOD C3-90 C4-LESS THAN [**2172-2-3**] 08:45AM BLOOD FK506-15.7 [**2172-2-6**] 05:50AM BLOOD FK506-6.6 . [**2172-2-3**] 3:40 pm SWAB PERICARDIAL. GRAM STAIN (Final [**2172-2-3**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2172-2-5**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2172-2-9**]): NO GROWTH. ACID FAST SMEAR (Final [**2172-2-4**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. [**Month/Day/Year **] CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. [**2-6**] Pericardial fluid: Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS. Predominantly small lymphocytes. No mesothelial cells present. Note: . [**2-3**] Pericardiocentesis: 1. Resting hemodynamics revealed severe pulmonary arterial hypertension and elevation of PCW, RA and RVED pressures at baseline, with 35 mmHg pulsus paradoxus. Pericardial pressure was elevated at 23 mmHg, but not tracking with RA pressure. There was left-to-right shunting with Qp/Qs of 1.3. 2. Pericardiocentesis from the subxiphoid approach was performed, yielding 800 ml of dark (red-wine colored) fluid, which was kept warm in hot-water bath, given patient's cryoglobulinemia, before being taken to laboratory. After pericardiocentesis, pulsus paradoxus was reduced to 13 mmHg, and pericardial pressure fell to 11 mmHg, with respiratory variation noted. Qp/Qs remained 1.2 without significant increase in Qs (using assumed oxygen consumption). There was mild improvement in PA pressures with diminution, but not normalization, of all filling pressures. Post-tap echocardiogram performed in cath lab showed only minimal pockets of fluid/thickening. The pericardial catheter was sutured in place and patient sent to CCU after removal of LFA and LFV sheaths and manual compression. 3. There was residual effusoconstrictive physiology with elevation of pericardial pressure despite removal of 800 cc fluid and minimal residual fluid seen on transthoracic echocardiography. FINAL DIAGNOSIS: 1. Large pericardial effusion, with drainage of 800 cc dark red fluid. 2. Pericardial effusive constrictive disease. 3. Small left to right intracardiac shunt at the atrial level. . Echo [**1-31**]: The left atrium is mildly dilated. A left-to-right shunt across the interatrial septum is seen at rest c/w a small secundum atrial septal defect (clip #[**Clip Number (Radiology) **]). The estimated right atrial pressure is 0-5 mmHg. 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. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a moderate to large circumferential pericardial effusion with evidence of stranding c/w organization. Intermittent right ventricular invagination is seen. . Echo [**2-3**] Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small circumferential, partially echofilled pericardial effusion without evidence for hemodynamic compromise. Compared with the prior study (images reviewed) of [**2172-1-31**], the effusion is much smaller and the right ventricular cavity is slightly larger (but not dilated). . [**2-5**] The left atrium is mildly dilated. A small left-to-right shunt across the interatrial septum is seen at rest c/w a small secundum atrial septal defect. The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is a small, relatively echodense pericardial effusion without evidence for tamponade or constrictive physiology. Compared with the prior (post-tap) study (images reviewed) of [**2172-2-3**], the findings are similar. . [**2-7**] Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. There is a small echodense inferior and inferolateral pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2172-2-5**], findings are similar. . ECG Study Date of [**2172-2-6**] 12:57:26 PM Sinus rhythm. Low limb lead QRS voltage. Delayed R wave progression. Diffuse ST-T wave changes. Findings are non-specific. Clinical correlation is suggested. Since previous tracing of [**2172-2-4**] atrial ectopy is absent. . UNILAT LOWER EXT VEINS RIGHT PORT [**2172-2-4**] 10:55 AM UNILAT LOWER EXT VEINS RIGHT P Reason: LEG PAIN [**Hospital 93**] MEDICAL CONDITION: 49 year old man with RLE swelling REASON FOR THIS EXAMINATION: ? DVT INDICATION: 49-year-old male with right leg swelling. [**Doctor Last Name **]-SCALE AND DOPPLER ULTRASOUND OF THE RIGHT LOWER EXTREMITY: There is no comparison. Normal flow, compressibility, and augmentations are seen in right common femoral, superficial femoral, and popliteal veins. No evidence of DVT. IMPRESSION: No evidence of DVT. Brief Hospital Course: This is a 49 yo M with Hep C, cryoglobulinemia, and MPGN s/p renal transplant in [**2169**] w/ recurrent MPGN in transplanted kidney, and known pericardial effusion who presented with RV collapse on echo. Hospital course by problem below: . # Pericardial effusion with RV collapse on echo: Differential included cryoglobulin vasculitis vs malignancy vs uremia vs infectious vs medication effect vs hypo/hyperthyroidism. He underwent pericardiocentesis on [**2-3**] with 880 cc serosanguinous fluid removed. Fluid studies showed elevated LDH consistent with exudative effusion, but no organisms were seen on gram stain. Cultures were negative. Pulsus was measured daily and ranged between [**7-19**]. He was also monitored on telemetry. Plasmapheresis was initiated to address cryoglobulins. Pain was controlled with percocet. Repeat echo on [**2-7**] showed a small pericardial effusion without tamponade physiology (unchanged from [**2-5**]). He was scheduled for repeat echo next week and cardiology follow-up as an outpatient. . # Cryoglobulinemia: Believed to be secondary to hepatitis C infection. He had a positive cryocrit on [**2-3**]. He underwent plasmapheresis on [**1-16**], and [**2-7**], with rituxan administration. His petechial rash resolved after [**Month/Year (2) **] on [**2-3**]. Rheumatology was consulted and recommended continuing current therapy. . # ARF: s/p renal transplant with recurrent MPGN. He was given cellcept and tacrolimus; levels were checked daily. His diuretics were held for several days following pericardiocentesis and restarted on [**2-7**]. He was discharged on lasix 40mg PO QD. By day of discharge his creatinine had improved to 3.3 from 5.2. . # DOE/SOB: Patient was continued on combivent and maintained on supplemental oxygen throughout his admission. Etiology of his hypoxia is unknown, but thought possibly secondary to rapamune-induced lung toxicity. . # Tremor: This was attributed to uremia and dissipated with improvement in renal function. . # Anemia of chronic disease: He was transfused 2 U PRBC with an appropriate response in hct. He was continued on Epogen. . # HTN: His BP was stable, even in the setting of large pericardial effusion. He was continued on his outpatient regimen of metoprolol and amlodipine. Medications on Admission: Citalopram 40 mg QDay Cholecalciferol (Vitamin D3) 400 unit PO DAILY Metoprolol Tartrate 50 mg PO BID Mycophenolate Mofetil 500 mg [**Hospital1 **] Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY Tacrolimus 1mg Qam 0.5 mg Qpm Epoetin Alfa 10,000 QWeek. Furosemide 80 mg PO BID Calcium Carbonate [**2164**] mg Tablet TID W/MEALS Ipratropium-Albuterol 18-103 mcg 1-2 puffs IH Q6H prn Oxycodone-Acetaminophen 5-325 mg PO Q4H prn Docusate Sodium 100 mg Capsule PO BID Amlodipine 5 mg PO BID Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H prn Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO q4h:prn as needed for pain. 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 5. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QPM (once a day (in the evening)). 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 10. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-12**] Puffs Inhalation Q6H (every 6 hours) as needed. 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: cryoglobulinemia pericardial effusion Discharge Condition: stable 98.0 112/67 63 18 97% 2L Discharge Instructions: You came to the hospital for shortness of breath and an abnormal echocardiogram. You had the fluid around your heart drained. You also restarted plasmapheresis. You should seek immediate medical attention if you experience chest pain, shortness of breath, worsened leg swelling, dizziness, or any other worrisome symptoms. . You will need a repeat cardiac echo next week some time. Please call [**Telephone/Fax (1) 128**] to schedule. . Please call Dr. [**First Name (STitle) **] [**Name (STitle) **], from cardiology, to schedule follow-up for your pericardial effusion. [**Telephone/Fax (1) 4022**] Your lasix dosing was switched to 40mg PO once daily, from 80mg PO twice daily. Please take all medications as directed. Followup Instructions: Echocardiogram. Call [**Telephone/Fax (1) 128**] Provider: [**Name10 (NameIs) 1248**],BED ONE [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2172-2-10**] 8:15 Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2172-2-10**] 3:40 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2172-2-10**] 4:00 Provider: [**Name10 (NameIs) **], [**2172-2-21**] 8:20am. [**Hospital Unit Name **] [**Location (un) 436**]. [**Telephone/Fax (1) 673**] [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]

[ "273.2", "423.9", "285.29", "745.5", "584.9", "070.70", "401.9", "244.9", "781.0", "311", "996.81" ]

icd9cm

[ [ [] ] ]

[ "99.71", "99.04", "37.0" ]

icd9pcs

[ [ [] ] ]

14946, 15004

10820, 13112

311, 347

15086, 15121

3558, 4977

15895, 16556

2607, 2625

13707, 14923

10387, 10421

15025, 15065

13138, 13684

7049, 10350

15145, 15872

3252, 3539

2640, 3155

5016, 7032

252, 273

10450, 10797

375, 1851

3170, 3235

1873, 2386

2402, 2591