ChanBeDu/relevant_section_length · Datasets at Hugging Face

22,693

161,664

7451

Discharge summary

report

Admission Date: [**2192-12-19**] Discharge Date: [**2192-12-28**] Date of Birth: [**2123-4-8**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: Refractory ulcerative colitis. Major Surgical or Invasive Procedure: Laparoscopic proctocolectomy. History of Present Illness: 69M with refractory ulcerative colitis, on chronic prednisone with unremitting diarrhea. Past Medical History: PMH: COPD, UC, GERD, B/L calf claudication, high cholesterol, HTN, kidney stones, 30 pack-year smoker PSH: meningioma resection, TURP, tonsillectomy, Nissen fundoplication, laparoscopic left colectomy, endovascular AAA repair Social History: 30 pack-year smoker, quit 5 years ago. Family History: Father: aortic aneurysm Mother: CHF Physical Exam: No breath/heart sounds. No pupillary/gag reflexes. No response to painful stimuli. Brief Hospital Course: Admitted for laparoscopic proctocolectomy, for details see operative note. Post-operatively, diet was advanced as tolerated with good stomal output until POD #6, when he was noted to be nauseated and distended. X-ray confirmed significant ileus and gastric dilation. Bedside attempts to place NG tube were unsuccessful. Fluoroscopic placement was also unsuccessful. On POD #7, endoscopy was performed and found signficant tortuosity of the distal esophagus, 2 liters of bile were evacuated but NG placement was still unsuccessful. On POD #8, endoscopy was repeated and NG placement was successful. Ileostomy continued to put out between 500 and 1000 cc of bilious succus per day throughout. Beginning on POD #7, urine output declined and creatinine began to rise. FENa confirmed prerenal cause and aggressive IV hydration was instituted. On POD #8, WBC rose to 18.6 and patient continued to be oliguric with volume requirement. CT scan was obtained which showed ascites, minimal free air consistent with post-operative state and no abscess. The patient was moved to the ICU for monitoring, hydration and central line placement with central venous pressure monitoring. On the morning of POD #9, the patient was noted to be mentating, with a clinically unremarkable exam and normal stoma at 0630 AM. At approximately 0715, he had a witnessed respiratory arrest and ACLS protocol was instituted. Despite aggressive therapy, the patient was pronounced deceased at 0756. Discharge Disposition: Expired Discharge Diagnosis: Ulcerative colitis, s/p laparoscopic proctocolectomy. Ileus. Renal failure. Respiratory arrest. Discharge Condition: Deceased. Discharge Instructions: Deceased. Followup Instructions: Deceased. Completed by:[**0-0-0**]

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icd9cm

[ [ [] ] ]

[ "38.93", "46.23", "96.04", "45.13", "99.60", "45.8", "54.59", "99.15", "96.07", "48.69" ]

icd9pcs

[ [ [] ] ]

2484, 2493

977, 2461

346, 377

2634, 2645

2703, 2739

816, 853

2514, 2613

2669, 2680

868, 954

276, 308

405, 495

517, 744

760, 800

10,342

114,700

18083+18084

Discharge summary

report+report

Admission Date: [**2150-10-8**] Discharge Date: [**2150-10-25**] Date of Birth: [**2079-4-9**] Sex: M Service: CARDTHOR S DIAGNOSIS: Coronary artery disease for coronary artery bypass graft. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 71 year old gentleman with a history of stable mild exertional angina since the early [**2116**]. He has been medically managed through the years and has been tolerating management well. He describes his symptoms as mild pressure across the chest which resolved with rest. He walks approximately four miles each day as well. On [**2150-8-26**], he had a stress test and developed angina after four minutes, showing [**Street Address(2) 31707**] depressions in leads V4 through V6. Follow-up imaging revealed a mild to moderate sized reversible anteroseptal and antero-apical defect. His ejection fraction was noted to be 48% at the time. Subsequently he underwent cardiac catheterization at the [**Hospital1 1444**] on [**2150-10-6**], which revealed left ventricular ejection fraction of 55% with a mitral regurgitation. He was also shown to have 80% stenosis of the proximal right coronary artery, 100% stenosis of the distal right coronary artery, 50% stenosis of the left main artery, 100% stenosis of the mid left anterior descending, 80% stenosis of the proximal circumflex. He was admitted on the same day for a coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Coronary artery disease times 30 years. 2. Hypertension. 3. Hypercholesterolemia. 4. Noninsulin dependent diabetes mellitus. 5. Moderate chronic obstructive pulmonary disease. 6. Status post repair of triple aneurysm in [**2148-5-10**]. 7. Status post suprapubic prostatectomy. MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Diltiazem 180 mg p.o. q. day. 3. Lipitor 10 mg p.o. q. h.s. 4. Glucotrol XL 2.5 mg p.o. q. day. 5. Lisinopril 5 mg p.o. q. day. ALLERGIES: No known drug allergies. FAMILY HISTORY: His family history is unremarkable except for a small history of cerebrovascular accidents. SOCIAL HISTORY: He currently lives at home with his wife. [**Name (NI) **] had admitted to smoking heavily with a 90 pack year smoking history, but quit 14 years prior. He rarely drinks any alcohol. PHYSICAL EXAMINATION: On physical examination when he was admitted, he was afebrile with stable vital signs. He had full extraocular movements and his pupils were equal and reactive and he had no palpable cervical nodes. His neck was supple with no lymphadenopathy. His carotids were two plus bilaterally with no bruits. His lungs were clear to auscultation. He had an irregular pulse and normal heart sounds with no murmurs. His abdominal examination was benign. His abdomen was nontender to palpation with normal bowel sounds and no palpable masses. He had good peripheral pulses with warm extremities. He had no peripheral edema. HOSPITAL COURSE: He was admitted to the hospital on [**2150-10-6**], for a coronary artery bypass graft. On [**2150-10-8**], he was taken to the Operating Room for a coronary artery bypass graft times four. He had his left internal mammary artery grafted to the left anterior descending; saphenous vein graft to the diagonal and obtuse marginal, and the saphenous vein graft to the patent ductus arteriosus. He was placed under general anesthesia and intubated for the procedure. He tolerated the procedure well and recovered without complications. Postoperatively he did well. He remained neurologically intact and his Neo-Synephrine was weaned. On postoperative day four, he experienced an episode of atrial fibrillation. He was started on an amiodarone drip after a bolus and then converted to 400 mg p.o. twice a day. He converted back to sinus rhythm. He experienced some agitation while in the Intensive Care Unit and became suddenly confused and belligerent. He became paranoid and refused certain treatments. Psychiatry was called for consultation and the diagnosis of postoperative delirium was made. He was started on Haldol 2 mg p.o. three times a day p.r.n. and he continued to improve. On postoperative day six, he was started on Lopressor 25 mg p.o. twice a day. On postoperative day seven, he was noted to have some subcutaneous emphysema and air leak in the mediastinal tube was noted. The right chest tube was removed on postoperative day eight but he persisted in having an air leak. Ultimately, he had three chest tubes placed, one mediastinal and two additional chest tubes. He continued to have an air leak. Cardiology was consulted for his postoperative paroxysmal atrial fibrillation in which he developed significant pauses while on metoprolol, amiodarone and Haldol. They felt that his intrinsic sinus node function was okay. They suggested resuming his metoprolol 25 mg p.o. twice a day, holding the amiodarone, and then anti-coagulating him if atrial fibrillation persisted. If this was required, they would follow-up after the chest tubes were removed for replacement. He continued to have some episodes of supraventricular tachycardia which the Electrophysiology fellow thought was atrial flutter. During one of these episodes, a 12 lead EKG was obtained which was suggestive of atrial flutter. The plan from Cardiology was then to ablate him once the chest tubes were removed. He remained in the unit on postoperative day 15 with a persistent leak. Both chest tubes and his mediastinal tubes were clamped on postoperative day 15 and then one chest tube was removed on hospital day 15. His air leak has gradually been decreasing as well as the subcutaneous emphysema. On postoperative day 16, he was transferred to the floor. He was doing well with stable vital signs and in sinus rhythm. His remaining chest tube on the right was removed and his mediastinal tube was converted to a Heimlich valve with a Foley bag attachment. That evening, he had a short period of atrial fibrillation in which he spontaneously converted back to sinus rhythm. He has currently been more than 24 hours without an arrhythmia. He is stable with normal vital signs. He has been ambulating with assistance and tolerating his p.o. intake well. He has had bowel movements. His air leak has continuously been improving. He is finally stable for discharge home with follow-up Physical Therapy. He is to follow-up with Dr. [**Last Name (STitle) 1537**] in four weeks. He has been told to follow-up with his primary care physician and his Cardiologist in one to two weeks. He has been advised not to lift weights greater than ten pounds for three months. He was advised not to drive for one month or while on pain medications. DISCHARGE MEDICATIONS: 1. Metoprolol 12.5 mg p.o. twice a day. 2. Lasix 20 mg p.o. twice a day times seven days. 3. Potassium chloride 20 mEq p.o. twice a day times seven days. 4. Colace 100 mg p.o. twice a day. 5. Enteric-coated aspirin 325 mg p.o. q. day. 6. Percocet 5/325 mg one to two tablets p.o. q. four to six hours for pain p.r.n. 7. Glipizide 2.5 mg, one tablet p.o. q. day. 8. Lipitor 10 mg tablet p.o. q. day. 9. Haldol 1 mg p.o. three times a day p.r.n. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 50046**] MEDQUIST36 D: [**2150-10-24**] 18:09 T: [**2150-10-24**] 18:26 JOB#: [**Job Number 50047**] Admission Date: [**2150-10-8**] Discharge Date: [**2150-10-31**] Date of Birth: [**2079-4-9**] Sex: M Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 71 year old man who was admitted to [**Hospital1 69**] with stable mild exertional angina since the early [**2116**]'s. He has been medically managed throughout the years and has sone well. His symptoms include mild pressure across the chest wall which resolves with rest. He walks 4 miles every morning. He has had an exercise tolerance test done on [**8-26**] and developed angina after 4 minutes with [**Street Address(2) 11741**] depressions in V4 through 6. Imaging revealed a moderate sized reversible distal anteroseptal and anteroapical defect, his ejection fraction was estimated at 48%. Following the positive exercise tolerance he underwent cardiac catheterization on [**10-6**] which revealed an ejection fraction of 55%, mild mitral regurgitation, the left main was 50% stenosis, left anterior descending with 100% mid stenosis and left circumflex with an 80% mid stenosis right coronary artery with potential slit like lesion in the right coronary artery supplied with collaterals from the left anterior descending. Following cardiac catheterization CT Surgery was consulted and the patient was scheduled for coronary artery bypass grafting. PAST MEDICAL HISTORY: Significant for coronary artery disease times 30 years, hypertension, hypercholesterolemia, noninsulin dependent diabetes mellitus, chronic obstructive pulmonary disease, abdominal aortic aneurysm repaired in [**2148-6-9**], suprapubic prostatectomy in [**2146-8-10**]. MEDICATIONS: Prior to admission include aspirin 325 mg q.d., Diltiazem 180 mg q.d., Lipitor 10 mg q.d., Glucotrol XL 2.5 mg q.d. and Lisinopril 5 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Lives with his wife at home. Cigarettes 90 pack years, quit 14 years ago. Alcohol use is rare. PHYSICAL EXAMINATION: Elderly man in no acute distress. HEENT: Pupils equal and reactive to light, extraocular movements intact. Oropharynx is benign. Dentures upper and lower. Neck is supple, no adenopathy or thyromegaly, carotids are 2+ bilaterally without bruits. Lungs are clear bilaterally. Cardiovascular regular rate and rhythm, S1, S2. Abdomen is soft, nontender without masses, positive bowel sounds, no hepatosplenomegaly, well healed diagonal scar. Extremities without cyanosis, clubbing or edema, 2+ pulses throughout. Neurological examination is nonfocal. On [**10-9**] the patient was brought to the Operating Room where he had coronary artery bypass grafting, please see the OR report for full details. In summary the patient had coronary artery bypass graft times four to the left anterior descending, saphenous vein graft to the diagonal and to the OM sequentially and saphenous vein graft to the posterior descending artery. His bypass time was 88 minutes with a cross clamp time of 75 minutes. He tolerated the operation well and was transferred to the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer the patient had a mean arterial pressure of 80. He had a heart rate of 80, was A-paced. He had Neo-Synephrine at 1 mcg/kilo/min and Propofol at 15 mcg/kilo/min. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated. The patient's blood pressure remained labile throughout the night, he remained on a Neo-Synephrine drip and continued to be A-paced to maintain an adequate blood pressure. Postoperative day 1 the patient became confused and belligerent, at times combative. He was seen by the Psychiatry Service. Also on postoperative day one the patient developed rapid atrial fibrillation which was treated with Amiodarone following which the patient converted to normal sinus rhythm and over the next several days the patient continued to have episodes of rapid atrial fibrillation. His Amiodarone drip was continued intermittently, converting the patient to a normal sinus rhythm. Hemodynamically the patient began to require Neo-Synephrine infusion to maintain an adequate blood pressure during periods of atrial fibrillation and therefore he remained in the Intensive Care Unit. Additionally the patient did have periods of lucidity, however, a vast majority of the time he remained confused and at times combative. By postoperative day 4, the patient was able to be weaned off his Neo-Synephrine. He continued to have periods of atrial fibrillation. His Amiodarone had been converted to oral dosages. He did, however, remained in the Intensive Care Unit as he continued to be confused following consultation from Psychiatry the patient was begun on standard dose Haldol. Additionally, the patient continued to have a persistent air leak from his pleural chest tube with left sided subcutaneous emphysema. Postoperative day 8 it was decided the patient was stable and ready to be transferred to the floor for continuing postoperative care and cardiac rehabilitation. Following transfer to the floor the patient was re-admitted to the Intensive Care Unit because he had an episode of bradycardia with a heart rate in the 30's. Electrophysiology was consulted at that time and the patient's Amiodarone was discontinued per Electrophysiology's recommendation. Over the next several days the patient began to have symptoms of tachycardia as well as bradycardia. By postoperative day 13 the patient had gone for several days without any bradycardiac episodes although he did have periods of atrial fibrillation and on postoperative day 15 the patient was again transferred to the floor for continuing postoperative care. The patient did well over the next several days. However on postoperative day 17 he did have an additional episode of bradycardia that was felt to be isolated. Finally on postoperative day 19 the patient had a 6 second sinus pause. Electrophysiology Service was again consulted and the following day the patient went to Electrophysiology studies and ultimately A. flutter ablation, please see EP report for full details. Following the ablation the patient was transferred back for continuing care. He did well in the immediate period following his ablation and on postoperative day 22 it was decided the patient was stable and ready to be discharged to home. At time of discharge, the patient's condition is as follows; vital signs 98.4, heart rate 60 and sinus rhythm, blood pressure 90/49, respiratory rate 18, O2 sat 93% on room air. Weight preoperatively 84 kg at discharge, 76 kg. Laboratory data: Sodium 139, potassium 3.9, chloride 114, CO2 29, BUN 19, creatinine 0.8, glucose 81, PT 16.9, PTT 35.2, INR 1.9. PHYSICAL EXAMINATION: Alert and oriented times three, moves all extremities, follows commands. Respiratory clear to auscultation bilaterally. Cardiac regular rate and rhythm S1, S2. Sternum is stable. Incision with Steri-Strips open to air, clean, dry. Abdomen soft, nontender, nondistended. Extremities are warm and well perfused with no edema. DISCHARGE MEDICATIONS: Aspirin 325 mg q.d., Glipizide XL 2.5 mg q.d., Lovastatin 10 mg q.d., Metoprolol 25 mg b.i.d., Warfarin titrate to a goal INR of 2.0 to 2.5 last 3 doses 3 mg and 2 mg on Wednesday, Thursday and Friday. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post coronary artery bypass grafting times four with left internal mammary artery to the left anterior descending, saphenous vein graft to diagonal and OM sequentially and saphenous vein graft to the posterior descending artery. 2. Hypertension. 3. Hypercholesterolemia. 4. Noninsulin dependent diabetes mellitus. 5. Atrial fibrillation. 6. Chronic obstructive pulmonary disease. 7. Status post abdominal aortic aneurysm repair. 8. Status post suprapubic prostatectomy. The patient's condition is good. He is to be discharged to home with visiting nurses. He is to have follow-up in the wound clinic in two weeks, follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in [**2-10**] weeks, follow-up with Dr. [**Last Name (STitle) 1537**] in 4 weeks and follow-up with Dr. [**Last Name (STitle) 50048**] also in 4 weeks. The patient is to have an INR checked on Monday, [**11-2**] with the results to be called to Dr.[**Name (NI) 50049**] office at [**Telephone/Fax (1) 13266**]. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 49159**] MEDQUIST36 D: [**2150-10-30**] 20:03 T: [**2150-10-30**] 22:33 JOB#: [**Job Number 50050**]

[ "427.32", "427.31", "413.9", "E878.2", "272.0", "401.9", "496", "414.01", "998.81" ]

icd9cm

[ [ [] ] ]

[ "37.34", "37.22", "88.53", "39.61", "37.26", "88.55", "36.15", "36.13" ]

icd9pcs

[ [ [] ] ]

14868, 14875

1983, 2076

14643, 14846

14896, 16257

2943, 6695

14289, 14619

7633, 8828

8851, 9321

9338, 9436

13,563

110,011

30490

Discharge summary

report

Admission Date: [**2190-5-6**] Discharge Date: [**2190-5-11**] Date of Birth: [**2113-3-2**] Sex: M Service: CARDIOTHORACIC Allergies: Erythromycin Base Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2190-5-6**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to RCA, SVG to OM) and ASD Closure History of Present Illness: 77 y/o male with chest pain and shortness of breath. Found to have an abnormal EKG and positive stress test. Referred for cardiac cath which revealed severe three vessel disease and 70% left main disease. He was then referred for surgical revascularization. Past Medical History: Hypertension, Diabetes Mellitus, Gastroesophageal Reflux Disease, Peptic Ulcer Disease, Neuropathy, Benign Prostatic Hypertrophy, s/p Appendectomy, s/p Tonsillectomy Social History: Quit smoking 37 years ago. Rare ETOH use. Denies recreational drug use. Family History: Father died from MI at age 65 Physical Exam: VS: 56 132/63 5'7" 170# Gen: WD/WN male in NAD lying flat in bed Skin: w/d -lesions HEENT: PERRL, EOMI, anicteric, OP benign Neck: Supple, FROM, -JVD, -bruit Chest: CTAB -w/r/r Heart: RRR, soft SEM Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: Echo [**5-6**]: PRE-BYPASS: Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. A small secundum atrial septal defect is present with a left-to-right shunt across the interatrial septum is seen at rest. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. CXR [**5-10**]: The patient is status post median sternotomy, with sternal wires and clips. Within normal limits. The pulmonary vasculature is not engorged. There are small pleural effusions bilaterally. The lungs are otherwise clear. The surrounding soft tissue and osseous structures demonstrate mild degenerative changes along the thoracic spine. [**2190-5-10**] 10:00AM BLOOD WBC-10.0 RBC-3.74* Hgb-10.7* Hct-32.2* MCV-86 MCH-28.7 MCHC-33.4 RDW-14.3 Plt Ct-274# [**2190-5-10**] 10:00AM BLOOD Plt Ct-274# [**2190-5-10**] 10:00AM BLOOD Glucose-177* UreaN-24* Creat-1.1 Na-137 K-3.7 Cl-96 HCO3-33* AnGap-12 Brief Hospital Course: Mr. [**Known lastname 72434**] was a same day admit after undergoing all pre-operative work-up as an outpatient. On the day of admission he was brought to the operating room where he underwent a coronary artery bypass graft x 3 and an ASD closure. Please see operative report for details. Following surgery he was transferred to the CSRU in stable condition for invasive monitoring. He remain intubated overnight and post-op day one he was weaned from sedation, awoke neurologically intact and was extubated. He was started on beta blockers and diuretics and was gently diuresed towards his pre-op weight. Later on post-op day one he was transferred to the telemetry floor. On post-op day two his chest tubes were removed. On post-op day four his epicardial pacing wires were removed. He continued to make steady progress while working with physical therapy for strength and mobility. On POD #4 he spiked a fever and was pancultured. Sputum gram stain showed 4+ GPC and 3+ GNR for which he was started on cipro. On post-op day 5 he was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Metformin 500mg [**Hospital1 **], Aspirin 81mg qd, Zocor 20mg qd, Atenolol 50mg qd, Prilosec 20mg qd 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. 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. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 6. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. 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:*0* 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO BID (2 times a day) for 10 days. Disp:*20 Packet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Atrial Septal Defect s/p ASD Closure PMH: Hypertension, Diabetes Mellitus, Gastroesophageal Reflux Disease, Peptic Ulcer Disease, Neuropathy, Benign Prostatic Hypertrophy, s/p Appendectomy, s/p Tonsillectomy 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 greater than 10 pounds for 10 weeks. No driving for one month. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 26191**] in [**3-6**] weeks Dr. [**Last Name (STitle) **] in [**2-2**] weeks Completed by:[**2190-5-11**]

[ "401.9", "285.9", "745.5", "414.01", "530.81", "250.00", "411.1", "780.6" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.71", "36.15", "36.12" ]

icd9pcs

[ [ [] ] ]

5081, 5152

2540, 3655

293, 395

5464, 5470

1340, 2517

5771, 5945

976, 1007

3806, 5058

5173, 5443

3681, 3783

5494, 5748

1022, 1321

243, 255

423, 682

704, 871

887, 960

29,967

119,455

7548

Discharge summary

report

Admission Date: [**2146-1-3**] Discharge Date: [**2146-1-12**] Date of Birth: [**2071-5-31**] Sex: F Service: SURGERY Allergies: Iodine; Iodine Containing / Gadolinium-Containing Agents Attending:[**Last Name (NamePattern1) 4659**] Chief Complaint: Abdominal pain, distention, vomiting, transfer from NEB Major Surgical or Invasive Procedure: [**2146-1-7**] PICC placement. [**2146-1-10**] Colonoscopy History of Present Illness: Patient is a 74 year old female with extensive PMH including colonic neoplasm resection in [**2136**], who presented to the [**Hospital **] hospital on [**2145-12-28**] with nausea, vomiting, abdominal pain and distention for 3 days. She was treated conservatively, however not improving. The surgeon at [**Hospital **] hospital felt that she needed resection of the narrowed decending colon segment. However, the anesthesiologist felt that her post-operative course may well have exceded the ability of their ICU to handle and felt that she should be transfered out. She is now directly transferred to us for further managment. The presumptive diagnosis at the NEB was diverticulitis / constipation, patient was on sips of water, IVF with foley in place. At the time of presentation to NEB patient she was also hypokalemic. Her electrolytes were replaced as needed, her K this morning was 4.5. She was on a bowel regiment and had only 4 BMs yesterday. Per patient report her abdominal distention has improved. Her WBC this morning was 9.4. At NEB she was treated with zosyn from [**12-28**] until [**12-30**], when she was switched to ertapenem. Past Medical History: PMH: Afib, RA, CAD, h/o MI, OA, h/o Lung CA-chemo/XRT, GERD, HTN PSH: Left axillary artery angioplasty and jump graft from left ax-fem graft to SFA w/ PTFE ([**2143-10-2**]), Revision of left ax-fem graft w/ jump graft (PTFE) and left to right fem-fem bypass w/ PTFE ([**2143-4-17**]), Left ax to fem-fem bypass graft bypass w/ PTFE ([**2138-11-5**]), R CIA to bifemoral artery bypass w/ Dacron ([**2138-10-1**]), ballon angioplasty x 2 rle [**2129**], rul resection with xrt / chemo, TAH with b/l saplingoopherectomy, Appy, carpal tunnel release x 2 b/l, lipoma removal, [**Hospital Ward Name **] cyst b/l hands Social History: lives at home, uses wheel chair Family History: n/c Physical Exam: PE: VS: 99 52 157/52 18 95 on 2L/min gen: WA/WD, NAD CV: RRR, no murmur appreciated pulm: CTA b/l abd: + BS, distended, mildly tender to palpation, typmany throughout, no peritoneal signs, no guarding extremities: no edema Pertinent Results: [**2146-1-3**] 10:21PM BLOOD WBC-12.2*# RBC-3.52* Hgb-9.5* Hct-29.2* MCV-83 MCH-26.8* MCHC-32.3 RDW-15.9* Plt Ct-349 [**2146-1-6**] 02:13AM BLOOD WBC-13.7* RBC-3.01* Hgb-7.8* Hct-24.7* MCV-82 MCH-25.9* MCHC-31.5 RDW-16.7* Plt Ct-347 [**2146-1-7**] 02:09AM BLOOD WBC-14.3* RBC-3.92* Hgb-10.7* Hct-33.0* MCV-84 MCH-27.2 MCHC-32.4 RDW-16.5* Plt Ct-300 [**2146-1-9**] 04:15AM BLOOD WBC-8.5 RBC-3.85* Hgb-10.3* Hct-33.2* MCV-86 MCH-26.9* MCHC-31.2 RDW-15.9* Plt Ct-208 [**2146-1-10**] 06:00AM BLOOD WBC-6.5 RBC-3.71* Hgb-10.3* Hct-31.6* MCV-85 MCH-27.7 MCHC-32.5 RDW-15.9* Plt Ct-214 [**2146-1-11**] 04:09AM BLOOD WBC-6.3 RBC-3.47* Hgb-9.5* Hct-29.2* MCV-84 MCH-27.4 MCHC-32.5 RDW-16.0* Plt Ct-216 [**2146-1-9**] 04:15AM BLOOD PT-13.4 PTT-67.0* INR(PT)-1.1 [**2146-1-10**] 06:00AM BLOOD PT-14.1* PTT-150* INR(PT)-1.2* [**2146-1-12**] 05:30AM BLOOD PT-14.4* PTT-38.3* INR(PT)-1.2* [**2146-1-3**] 10:21PM BLOOD Glucose-82 UreaN-19 Creat-1.2* Na-137 K-4.7 Cl-101 HCO3-25 AnGap-16 [**2146-1-8**] 04:08AM BLOOD Glucose-125* UreaN-11 Creat-0.8 Na-142 K-3.7 Cl-102 HCO3-33* AnGap-11 [**2146-1-10**] 06:00AM BLOOD Glucose-128* UreaN-17 Creat-0.7 Na-136 K-3.8 Cl-98 HCO3-31 AnGap-11 [**2146-1-11**] 04:09AM BLOOD Glucose-90 UreaN-17 Creat-0.8 Na-138 K-3.8 Cl-102 HCO3-30 AnGap-10 [**2146-1-3**] 10:21PM BLOOD ALT-20 AST-41* AlkPhos-62 Amylase-107* TotBili-0.4 [**2146-1-8**] 04:08AM BLOOD ALT-20 AST-35 AlkPhos-57 TotBili-0.3 [**2146-1-3**] 10:21PM BLOOD Albumin-3.2* Calcium-8.6 Phos-2.5* Mg-2.4 [**2146-1-6**] 12:25PM BLOOD Calcium-7.2* Phos-2.3* Mg-1.9 [**2146-1-7**] 06:35PM BLOOD Calcium-8.6 Phos-8.6*# Mg-2.9* [**2146-1-9**] 04:15AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.6 [**2146-1-11**] 04:09AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.3 [**2146-1-3**] 11:56PM BLOOD Lactate-1.0 . [**2146-1-10**] Colonoscopy Multiple shallow ulcers in sigmoid colon (17-25 cm) c/w ischemia [**2146-1-5**] KUB massively dilated bowel, cecum less than 10cm in diameter. [**2146-1-5**] C. diff negative [**2146-1-4**] Urine cx no growth [**2146-1-4**] KUB prominent distention of large bowel Brief Hospital Course: Admitted to SICU from OSH for attempt to perform colonoscopy. Gastroenterology consulted. Bowel prep initiated. Unable to properly prep patient for procedure. Intubation (per patient request) for the colonoscopy. Colonoscopy was limited due to the poor prep, but they were able to get beyond a long narrowed segment (almost 10cm in length in decending colon. Just proximal to this long stricture was a stool covered ? mass vs impacted stool ball. The anastamosis was well proximal to this area and was widely patent. An attempt was made to decompress the colon proximal to the long stricture. Due to co-morbidities, patient was deemed a poor surgical candidate and we sought alternatives to a major operative procedure for this long stricture of uncertain etiology and possible mass vs impacted stool just proximal. [**Month/Day/Year **] consulted-patient well known to service for multiple [**Month/Day/Year 1106**] issues. She was started on a heparin drip. INR was elevated to 7 range, and reversed with FFP. Patient continued to exhibit obstructive symptoms. An attempt to insert a cecostomy tube via interventional radiology was not successful as the bowel had suprisingly significantly decompressed after the colonoscopy. We elected to wait on any further intervention and eventually the patient's obstructive symptoms subsided, and she began to pass stools with decrease in abdominal distention. She became medically & surgically stable, and was transferred from ICU to floor. . Admitted to [**Hospital Ward Name 1950**] 5 from SICU. Stable Vitals and labwork. Given Golylytely via NGT for multiple days in preparation for colonoscopy. Rectal tube inserted. Prep successful. Underwent colonoscopy under general anesthesia on [**2146-1-10**] which revealed Multiple shallow ulcers in sigmoid colon (17-25 cm) consistent with ischemia. No strictures identified in large colon and at previous anastamosis site. There were no masses or tumors found. . Patient returned to Stoneman5. Started on regular diet. Tolerated well. Swithced to oral medications. Started on more aggressive bowel regimen to prevent constipation-colace and Miralax. Continued with Heparin drip. Coumadin dosed daily, INR's checked daily. Started on Lovenox with planned bridge to Coumadin once INR therapeutic ([**1-19**]). Patient will continue Lovenox bridge at home. She has experience with self-injections in past. . She was evaluated per Physical Therapy during this admission, and was discharged home with [**Month/Day (3) 269**] for INR checks and Physical Therapy. Coumadin management will be continued per Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who was contact[**Name (NI) **] by phone by Dr. [**Last Name (STitle) **] prior to the patients discharge to co-ordinate her post-hospital management. Medications on Admission: ASA 81' Colace 100 qam, 200 qpm Pyridoxine 100', Coumadin 4' Omeprazole 20' Meclizine 12.5' Lidocaine 0.5% patch 11pm-11am Furosemide 20' Tue, Thr, Sat Compazine 1' PRN Albuterol nebs PRN Atorvastatin 40' Fentanyl 75 mcg/hr Q72 hrs Aldactizide 25/25' Discharge Medications: 1. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB, Wheeze. 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO TUE, THURS, SAT (). 6. Pyridoxine 100 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. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO BID (2 times a day). Disp:*qs * Refills:*2* 9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): For 12 hours - 11P-11A over right shoulder . 11. Acetaminophen 160 mg/5 mL Solution Sig: 15-30ml PO Q6H (every 6 hours) as needed for pain/fever for 2 weeks: Do not exceed 4gm in 24hrs. 12. Aldactazide 25-25 mg Tablet Sig: One (1) Tablet PO once a day. 13. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO at bedtime: Titrate dose to goal INR of [**1-19**]. 14. Enoxaparin 60 mg/0.6 mL Syringe Sig: 50mg Subcutaneous Q12H (every 12 hours): Please discard 10mg prior to injection. Disp:*60 * Refills:*3* 15. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] [**Location (un) 269**] Discharge Diagnosis: Large bowel obstruction Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * 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. . Lovenox to Coumadin bridge: -Please continue injecting yourself as prescribed. -Make sure you expel 10mg prior to injection. -The syringe is pre-filled 60mg. Your dose is 50mg. -Continue injections until INR is [**1-19**]. Dr.[**Last Name (STitle) **] will adjust your Coumadin dose accordingly. . Port-A-Cath: -Continue monthly flushes with heparin as indicated per your doctor. Followup Instructions: 1. Please follow-up with Dr.[**Last Name (STitle) **] [**Telephone/Fax (1) 8792**] in [**12-18**] weeks. . Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2146-3-21**] 10:30 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2146-3-21**] 11:10 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**] Completed by:[**2146-1-12**]

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icd9cm

[ [ [] ] ]

[ "99.15", "54.91", "45.24", "45.25", "96.71", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

9331, 9408

4668, 7488

380, 440

9475, 9475

2589, 4645

11009, 11548

2325, 2330

7790, 9308

9429, 9454

7514, 7767

9619, 10986

2345, 2570

284, 342

468, 1620

9489, 9595

1642, 2259

2275, 2309

48,533

171,629

38733

Discharge summary

report

Admission Date: [**2140-3-23**] Discharge Date: [**2140-3-24**] Date of Birth: [**2070-1-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: CDiff, ARF Major Surgical or Invasive Procedure: None History of Present Illness: 70yo M with h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-vesicular fistula s/p hemicolectomy complicated by wound dehiscence admitted to OSH with AMS and ARF and transferred tonight to [**Hospital1 18**] per family's request. His OSH course over the last few months has been collected through the OSH records and is as follows: In [**Month (only) 956**] he had a [**Last Name (un) **]-vesicular fistula which was treated with hemicolectomy. He was discharged but came back [**2140-3-7**] with wound dehiscence which was repaired on [**2140-3-7**]. Then he was readmitted on [**2140-3-19**] with respiratory distress and was treated with COPD flare/acute on chronic hypercarbic respiratory failure. He was then transferred to the floor where he evolved ARF (thought [**2-2**] prerenal) and got IVF which allowed his creatinine to improve to baseline(from 3). He was then receiving indomethacin, lisinopril, HCTZ and over the next few days he was then having slow elevation of his creatinine with decreasing UOP accompanied by abdominal discomfort and watery, non-bloody diarrhea (although dtr reports only one episode of diarrhea). Because of hypotension with BP 80s/60s he was transferred back to the CCU. There he was hypotensive (BP 80s-90s/50s) with low urine output and no response to multiple IVF boluses. He underwent CVL placement and then, because of abdominal distension on exam he underwent CT scan showed no free air but dilated large and small bowel (not surgical) and looked like ileus. He was started on IV flagyl empirically for C Diff. The toxin is pending. Creatinine now back up to 4.5. K 5.5. At 4pm he was started empirically on Vanc IV, Zosyn IV, levoquin IV. At this point family requested transfer [**Hospital1 18**]. . On the floor, patient was complaining of feeling uncomfortable and thirsty. His daughter reports that his MS is not at baseline however much improved from prior. He is still hallucinating, however, thinking rabbits are in the room, etc. She also notes he is complaining of pain and that the percocet they gave him at the OSH were helping. Past Medical History: COPD on home O2 (FEV1 reportedly <30) Gout Obesity [**Last Name (un) **]-vesilcular fistula s/p hemicolectomy with primary anastamosis [**2140-2-26**] complicated by wound dehiscence 2 weeks post-op s/p resuturing [**2140-3-7**] Hypercapneic respiratory failure [**3-20**] depression Diverticulitis HTN Social History: Lived alone before. Quit smoking two years ago. Quit drinking 19 years ago. Daughter works here at [**Hospital1 18**]. Family History: Two sisters died of lung-related illnesses and were both smokers. Physical Exam: Vitals: T:97 Ax BP:107/72 P:113 R: 18 O2:94% on 3LNC General: sleepy but arousable, orientedX1, mild distress [**2-2**] pain HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales, rhonchi CV: tachycardic, regular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, slightly tender, distended, bowel sounds present, no rebound tenderness or guarding, abdominal binder in place. [**Name8 (MD) **] RN who took down the dressing the bottom of the incision site with slight open wound not draining pus GU: foley Ext: cool, no clubbing, cyanosis or edema Pertinent Results: [**2140-3-23**] 11:13PM BLOOD WBC-36.8* RBC-4.27* Hgb-12.4* Hct-41.0 MCV-96 MCH-29.1 MCHC-30.2* RDW-13.7 Plt Ct-702* [**2140-3-24**] 04:39AM BLOOD Neuts-64 Bands-8* Lymphs-5* Monos-12* Eos-0 Baso-0 Atyps-0 Metas-7* Myelos-4* NRBC-4* [**2140-3-23**] 11:13PM BLOOD PT-15.2* PTT-25.1 INR(PT)-1.3* [**2140-3-23**] 11:13PM BLOOD Glucose-139* UreaN-92* Creat-5.0* Na-134 K-5.1 Cl-97 HCO3-20* AnGap-22* [**2140-3-23**] 11:13PM BLOOD ALT-19 AST-29 LD(LDH)-350* CK(CPK)-30* AlkPhos-73 Amylase-438* TotBili-0.2 [**2140-3-23**] 11:13PM BLOOD Lipase-53 [**2140-3-23**] 11:13PM BLOOD CK-MB-2 cTropnT-0.01 [**2140-3-23**] 11:13PM BLOOD Albumin-2.5* Calcium-9.4 Phos-4.4 Mg-2.4 UricAcd-9.1* Iron-21* Cholest-162 [**2140-3-23**] 11:13PM BLOOD calTIBC-114* Ferritn-1755* TRF-88* [**2140-3-23**] 11:13PM BLOOD TSH-3.8 [**2140-3-24**] 04:39AM BLOOD Vanco-14.8 [**2140-3-24**] 02:22AM BLOOD Type-[**Last Name (un) **] pO2-47* pCO2-43 pH-7.25* calTCO2-20* Base XS--8 [**2140-3-24**] 10:31AM BLOOD Lactate-4.9* Na-136 K-6.6* Cl-109 [**2140-3-24**] 10:31AM BLOOD freeCa-1.16 FINDINGS: No previous comparison ultrasound examinations. The right kidney is slightly small in size measuring 8 cm in its long axis. The left kidney measures 10.3 cm in its long axis. No renal calculi, hydronephrosis or mass lesions seen on either side. Ascites is noted. CONCLUSION: No hydronephrosis or renal calculi. Right kidney slightly smaller than the left. Findings are similar to the outside reference CT scan done on [**2140-3-23**] at Health Alliance. Brief Hospital Course: 70yo M with severe COPD, recent abdominal surgery c/by wound dehiscence admitted with likely CDiff colitis and ARF. . # C Diff Colitis: Patient was started on PO vancomycin and IV flagyl. Abdomen was grossly distended, with a bladder pressure of 40. General surgery was consulted for concern for toxic megacolon, and did not recommend surgical intervention. He became intermittently hypotensive responsive to fluid boluses. His leukocytosis increased to 44. On discussion with the family it was decided that the patient would be made comfort measures only, and supportive care would be withdrawn. He was treated with morphine IV drip for comfort and passed away several hours later. . # Acute Renal Failure/Anuria. Patient's creatinine at baseline per OSH was noted to be 1.2 [**Last Name (un) **] now 5.0. It was thought that this most likely represented ATN from hypotension, secondary to septic shock, possibly complicated by nephrotoxic medications (HCTZ/Lisinopril/indomethacin), or possibllt from post renal obstruction from abdominal compartment syndrome (initial bladder pressure was 40). Urology consulted regarding anuria, and believed it was likely fluid retention due to bladder spasm. Renal was consulted regarding the need for emergent dialysis. On discussion with the family it was decided that the patient would be made comfort measures only, and supportive care would be withdrawn. . # Anion gap metabolic acidosis: Likely from sepsis/lactic acidosis vs uremia. Serum electrolytes were followed throughout this hospitalization. . # Abdominal Wound: Per surgical consult from OSH there is no need for further surgery, however, wound may be site of infection based on exam and patient with considerable pain. On discussion with family regarding goals of care, he was treated for pain with morphine gtt. . # COPD Exacerbation: Patient was initially treated with steroids and nebulizer treatements, but these were stopped with change in code status. . # Anemia: Unclear if patient received a blood transfusion at OSH but hct increased over the last 4 days by ten points so this is likely. Hematocrit was monitored. Medications on Admission: Medications on transfer ([**Name8 (MD) **] RN note): Levaquin 500mg daily IV Flagyl 500mg Hydrocort 50mg IV Zosyn 2,25mg IV Insulin (regular) 10units X 1 Protonix 40mg IV Vancomycin 1gm IV NS@ 100mL/Hr . MEDS on transfer (per attending H+P from [**3-23**] ?meds he was getting on regular floor at OSH): Spiriva 18mcg INH Heparin 5000unit TID Zocor 10mg HS Humalog SS Celexa 20mg daily Asa 81mg daily MVI Advair 250/50 Q12H Discharge Disposition: Expired Discharge Diagnosis: - Discharge Condition: - Discharge Instructions: - Followup Instructions: -

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7862, 7871

5250, 7387

326, 332

7917, 7921

3707, 5227

7971, 7976

2943, 3010

7892, 7896

7414, 7839

7945, 7948

3025, 3688

276, 288

360, 2464

2486, 2791

2807, 2927

31,029

160,574

52699

Discharge summary

report

Admission Date: [**2103-5-15**] Discharge Date: [**2103-5-23**] Date of Birth: [**2039-2-13**] Sex: F Service: MEDICINE Allergies: Morphine / Dilaudid Attending:[**First Name3 (LF) 2160**] Chief Complaint: right knee pain Major Surgical or Invasive Procedure: Right knee revision Central Line Placement Picc Placement History of Present Illness: 64 year old female with history of PUD, Crohn's, CAD s/p stent, CHF, RA and recent admission to MICU for hypotension and acute renal failure who presented to clinic yesterday for follow up complaining of right knee pain which had worsened over the past two days. Knee was not hot or erythematous and plan was for ortho follow up within the next 1-2 days. Pt also reported myalgias and fatigue. Creatinine was checked as follow up from d/c. Labs checked noted Cr 3.8 (from 1.4 on [**5-10**]), HCO3 18, Hct 33, WBC 14.2, K 5.3. Of note, pt was recently admitted for c/o R.leg heaviness, ?slurred speech on [**5-7**]. Code stroke was called and imaging showed "small infarct in L.IC of uncertain chronicity. However, this was not thought to be due to acute infarct. Mild ath dx in prox left ICA. Renal failure resolved with hydration. Hypotension resolved by holding anti-hypertensives. Pt also presented with R.sided back/leg pain which was attributed to radiculopathy. In ED, patient complaining of on-off substernal chest pain since yesterday evening. Also diffuse myalgias. T was found to be 102.3 rectally. Lactate WNL. CT abd, central access obtained. T 102.3 Rectal. Pt given doses of vanc/zosyn/flagyl. Ortho tapped R.knee and JFA was c/w septic joint. Pt found to be hypotensive, given 3L IVF and started on levophed. Upon arrival to the floor: Pt states that since discharge, her legs have felt "weak" and she has had pain in her R.leg. She otherwise denies fevers/chills, SOB/CP, abd pain/n/v/d/c/melena/brbpr, dysuria/hematuria, or joint pain other than her R.leg/knee. Past Medical History: Past Medical History (per notes,confirmed with pt): 1. CAD s/p RCA w/BMS on [**2102-2-2**] 2. Diastolic CHF (Recent EF~55%) 3. Crohn's Disease: h/o pancolitis w/o small bowel involvement; colonoscopy [**10-15**] showed no active disease 4. Chronic Renal Failure (Cr~1.4 at baseline). 5. DM Type II 6. Hypertension 7. h/o idiopathic dilated CMP now resolved 8. Peptic ulcer disease. 9. Alcoholic cirrhosis. 10. GERD. 11. Rheumatoid arthritis. 12. Pulmonary embolus in [**2098**]. 13. Total right knee replacement with subsequent chronic pain. 14. [**Doctor Last Name **] mal seizure in childhood. 15. Cervical disc disease. 16. L5/S1 radiculopathy with anterolisthesis of L4 on L5 on X- Ray with EMG consistent with mild radiculopathy. 17. Recent GIB in [**2-16**] of unclear etiology . Surgery: R knee replacement surgery PER ortho notes:RTKR '[**95**] ([**Doctor Last Name 7111**]) complicated by septic arthritis s/p irrigation and debridement, arthrotomy, revision of liner with Scorpio #5, 10 mm thickness liner in '[**01**] (KRod) Social History: Patient lives with a disabled son in [**Name (NI) 669**]. She has one other son who is currently incarcerated. She was married but divorced a long time ago. quit smoking 10 years ago. Drank ~1 pint alcohol/day x 10 years, quit 10 yrs ago. No illicit drugs. Family History: Mom died of [**Name (NI) 499**] cancer. Father with DM requiring bilateral below the knee amputation. One sister has had cervical cancer(cured) and rheumatoid arthritis. Most members of her family have trouble with hypertension. No one else with IBD. Grandmother with [**Name2 (NI) 499**] cancer. Physical Exam: vitals: T. 98.0, BP 114/85, HR 92, RR 17, sat 100% RA on 0.043 levo gen: obese female, NAD, somnolent but arousable to answer questions. HEENT: PERRLA, EOMI, anicteric, MMM neck: hard to access for JVD [**2-10**] body habitus, no LAD chest: b/l ae no audible w/c/r heart: s1s2 rrr no m/r/g abd: +bs, obese, soft, Nt,ND ext: R.leg/knee >L.leg, +mild erythema, +old healed surgical scar, TTP, otherwise 2+pulses. neuro:somnolent, but AAOx3 Pertinent Results: LABORATORY: [**2103-5-23**] 05:55AM BLOOD WBC-9.7 RBC-2.97* Hgb-8.4* Hct-25.6* MCV-86 MCH-28.4 MCHC-32.9 RDW-16.6* Plt Ct-372 [**2103-5-14**] 05:25PM BLOOD WBC-14.2* RBC-3.62* Hgb-10.7* Hct-33.3* MCV-92 MCH-29.7 MCHC-32.2 RDW-14.8 Plt Ct-360 [**2103-5-15**] 01:00PM BLOOD PT-13.4 PTT-29.3 INR(PT)-1.1 [**2103-5-20**] 02:58AM BLOOD D-Dimer-2605* [**2103-5-23**] 05:55AM BLOOD Glucose-91 UreaN-12 Creat-1.3* Na-139 K-4.1 Cl-110* HCO3-20* AnGap-13 [**2103-5-14**] 05:25PM BLOOD UreaN-36* Creat-3.8*# Na-133 K-5.3* Cl-102 HCO3-18* AnGap-18 [**2103-5-15**] 11:00PM BLOOD ALT-16 AST-25 LD(LDH)-185 AlkPhos-114 Amylase-113* TotBili-0.6 [**2103-5-15**] 11:00PM BLOOD Lipase-41 [**2103-5-16**] 06:10AM BLOOD CK-MB-10 MB Indx-1.4 cTropnT-0.03* [**2103-5-15**] 08:20PM BLOOD cTropnT-0.04* [**2103-5-15**] 08:20PM BLOOD CK-MB-12* MB Indx-1.5 [**2103-5-15**] 01:00PM BLOOD cTropnT-0.04* [**2103-5-15**] 01:00PM BLOOD CK-MB-18* MB Indx-1.9 [**2103-5-23**] 05:55AM BLOOD Calcium-8.5 Phos-4.4 Mg-1.8 [**2103-5-15**] 11:00PM BLOOD Albumin-3.2* Calcium-8.0* Phos-4.7*# Mg-1.6 [**2103-5-21**] 03:08AM BLOOD VitB12-393 [**2103-5-21**] 03:08AM BLOOD TSH-2.1 [**2103-5-14**] 05:25PM BLOOD TSH-5.4* [**2103-5-16**] 12:00PM BLOOD Cortsol-32.3* [**2103-5-16**] 11:30AM BLOOD Cortsol-30.1* [**2103-5-16**] 10:50AM BLOOD Cortsol-24.5* [**2103-5-16**] 06:10AM BLOOD RheuFac-20* CRP-251.5* [**2103-5-15**] 04:24PM BLOOD CRP-198.7* [**2103-5-15**] 11:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5.1 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2103-5-16**] 01:53PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008 [**2103-5-16**] 01:53PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2103-5-16**] 01:53PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0 [**2103-5-16**] 01:53PM URINE Hours-RANDOM UreaN-206 Creat-29 Na-141 [**2103-5-16**] 02:27AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2103-5-15**] 05:15PM JOINT FLUID WBC-[**Numeric Identifier 102558**]* RBC-4500* Polys-97* Lymphs-1 Monos-0 Macro-2 [**2103-5-15**] 05:15PM JOINT FLUID Crystal-NONE [**2103-5-15**] 05:15PM JOINT FLUID TotProt-4.2 Glucose-62 LD(LDH)-1338 MICROBIOLOGY: [**2103-5-15**] 3:05 pm URINE Site: CLEAN CATCH URINE CULTURE (Final [**2103-5-16**]): NO GROWTH. [**2103-5-15**] 1:00 pm BLOOD CULTURE #1. Blood Culture, Routine (Final [**2103-5-21**]): NO GROWTH. [**2103-5-15**] 5:15 pm JOINT FLUID **FINAL REPORT [**2103-5-18**]** GRAM STAIN (Final [**2103-5-15**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2103-5-18**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2103-5-17**]): SPECIMEN NOT TRANSPORTED ANAEROBICALLY. ANAEROBIC CULTURE NOT PERFORMED. TEST CANCELLED, PATIENT CREDITED. REPORTED BY PHONE TO DR [**Last Name (STitle) **] ([**Numeric Identifier 108725**]) [**2103-5-17**] AT 3:40PM. [**2103-5-18**] 5:28 am SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST (Final [**2103-5-21**]): NONREACTIVE. [**2103-5-18**] 8:40 am FOREIGN BODY RIGHT KNEE. WOUND CULTURE (Final [**2103-5-20**]): NO GROWTH. TISSUE Site: KNEE GRAM STAIN (Final [**2103-5-18**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2103-5-21**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2103-5-18**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2103-5-18**]): NO FUNGAL ELEMENTS SEEN. [**2103-5-18**] 10:15 pm BLOOD CULTURE Blood Culture, Routine (Pending): DIAGNOSTICS: [**2103-5-15**] CT ABDOMEN/PELVIS: CT ABDOMEN: Evaluation is limited by lack of intravenous contrast, small amount of oral contrast, and streak artifact from the patient's hands, which are overlying her midabdomen. Moderate dependent bibasilar atelectasis, and coronary artery calcifications are unchanged. Liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys remain grossly unremarkable. There is no hydronephrosis. Stomach and intra- abdominal loops of bowel are unremarkable. There is no sign of bowel obstruction, or fluid collection to suggest abscess formation. There is no free air, free fluid, or abnormal intra-abdominal lymphadenopathy. Note is made of small injection granulomas in the anterior lower abdominal wall, some of which contain small foci of air. CT PELVIS: Pelvic loops of large and small bowel, and genitourinary structures remain normal. Foley catheter balloon is seen within decompressed bladder. There is no free pelvic fluid or abnormal pelvic or inguinal lymphadenopathy. OSSEOUS STRUCTURES: No suspicious lesions are present. IMPRESSION: No acute intra-abdominal pathology. No significant change since [**2103-5-7**]. [**2103-5-15**] RIGHT KNEE XRAY: IMPRESSION: Small effusion. No evidence of loosening or acute fracture. [**2103-5-15**] CXR: SINGLE FRONTAL VIEW OF THE CHEST: Lung volumes are low. The cardiomediastinal silhouette is stable. A new right subclavian catheter is present with tip terminating over the lower SVC. There is no pneumothorax. [**2103-5-16**] MRI C-T-Lspine: FINDINGS: There are degenerative changes seen in the cervical region with posterior ridging from C3-4 to C5-6 level. There is no spinal stenosis or extrinsic spinal cord compression seen. At C6-7, mild degenerative changes noted. Small bilateral perineural cysts are visualized within the neural foramina. There is no evidence of discitis or osteomyelitis in the cervical region. Subtle increased signal is identified between the spinous processes of C5 and C6 of unclear etiology and could be degenerative in nature. Note is made of increased signal of scalenus medius and posterior muscles bilaterally at the level of C7-T1 which could indicate focal inflammation of the muscles. Further evaluation can be obtained with brachial plexus MRI if clinically indicated. IMPRESSION: 1. Degenerative changes in the cervical spine without spinal stenosis or spinal cord compression. 2. Increased signal within bilateral scalene muscles at C7-T1 level could be due to focal muscular inflammation. However, for better evaluation, brachial plexus MRI can help if clinically indicated. No evidence of discitis or osteomyelitis. THORACIC SPINE: TECHNIQUE: T1, T2 and inversion recovery sagittal images of the thoracic spine were acquired. FINDINGS: Mild multilevel degenerative changes are seen. No evidence of spinal cord compression seen. No evidence of marrow edema or compression fracture noted. IMPRESSION: Mild degenerative changes. No evidence of spinal cord compression, discitis or osteomyelitis. LUMBAR SPINE: TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the lumbar spine were acquired. FINDINGS: At L1-2, no abnormalities are seen. From L2-3 and L3-4, mild degenerative disc disease is seen. At L4-5, there is widening of facet joints noted with fluid within the facet joints secondary to degenerative change. There is mild spinal stenosis and moderate bilateral subarticular recess narrowing seen. There is mild right foraminal narrowing seen. There is a disc protrusion in the left foramen, which appears to be deforming the exiting left L4 nerve root. At L5-S1 level, degenerative disc disease and mild bulging seen. The distal spinal cord shows normal signal intensities. The paraspinal muscles are unremarkable. There is increased signal identified in the subcutaneous fat in the upper lumbar region, which could be due to mild edema. No definite fluid collection is seen. IMPRESSION: 1. Severe left foraminal narrowing at L4-5 level due to disc protrusion and facet degenerative changes which could result in irritation of left L4 nerve root. Mild spinal stenosis and moderate bilateral subarticular recess narrowing is also seen at L4-5 level. 2. Mild multilevel degenerative changes at other levels. 3. No evidence of bony metastasis or high-grade thecal sac compression. No evidence of discitis or osteomyelitis. [**2103-5-16**] ECHO: The left atrium and right atrium are normal in cavity size. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: No vegetation or abscess seen. Normal regional and global biventricular systolic function. Trace aortic and mitral regurgitation. [**2103-5-18**] CT HEAD: CONCLUSION: No change since [**2103-5-7**]. There is no evidence of hemorrhage or recent infarction. [**2103-5-20**] CTA CHEST: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Coronary artery calcifications. [**2103-5-21**] ECG: Sinus tachycardia. Old inferior myocardial infarction. Poor R wave progression across the anterior precordial leads. Consider prior anteroseptal myocardial infarction. Compared to the previous tracing of [**2103-5-20**] poor R wave progression is seen across the precordial leads and the other findings are similar. [**2103-5-22**]: RIGHT KNEE, THREE VIEWS There is a large amount of methyl methacrylate in the distal femur and proximal tibia. There is increased soft tissue density anterior to the knee joint. The patella abuts the anterior surface of the methyl methacrylate. A small locule of air is seen anterior to the distal femur and medial to the knee joint. Overlying skin staples are present. Relative lucency in the distal femur anteriorly likely reflects the former site of the femoral prosthesis. Allowing for background osteopenia and post-operative changes, no definite evidence of osteomyelitis is identified. Brief Hospital Course: A/P: Pt is a 64 y.o female with MMP including CAD, CHF, DM, CKD3, HTN, ETOH cirrhosis, h.o PE, s/p R.TKR who presents with R.septic knee, [**Last Name (un) **], and hypotension. #. Sepsis secondary septic R knee: Patient was admitted with fever, leukocytosis, hypotension (requiring IVF resuscitation and levophed for less than 24 hrs), and source of infection as septic R knee (positive tap in ED), s/p instrumentation in the past. She has signs of organ dysfunction, mainly ARF. Pt was started on vanco/zosyn. Ortho was consulted and took the patient to the OR for total knee revision on [**2103-5-18**]. Her instrumentation was removed and a temporary replacement was placed. The arthroplasty was sent for culture, which had no grown. Tissue from the surgery also had no growth, but all knee cultures were sent after recieving antibiotics. She had a TTE that did not visualize any vegetations though it was suboptimal. She also had an MRI of her entire spine to eval for other nidus of infection/abscess given BUE and RLE pain/weakness. The MRI showed no evidence of abscess, diskitis, or osteomyelitis. She was continued on vancomycin and ceftriaxone which she will continue for 6 weeks until she sees Dr. [**Last Name (STitle) **] in Infectious Disease clinic on [**2103-7-2**]. She will need weekly CBC with DIFF, Chem 7, LFTs, ESR, CRP, and vanco trough levels faxed to Infectious Disease Fax #[**Telephone/Fax (1) 432**]. The patient will followup in [**Hospital 5498**] clinic on [**2103-6-5**] for staple removal. She will have the hardware replaced in 6 weeks with orthopedics. # Hypotension: This was likely secondary to sepsis secondary to infected R knee joint and this was treated as above. She had a cortisol stimulation that was normal. She was not given steroids. Her antihypertensives were initially held, but restarted prior to discharge. #Acute Kidney Injury on CKD 3: Pt's baseline Cr is 1.3-1.6, and she presented this admission with Cr 3.4. Last admission she had also presented with Cr 3.4 that resolved to 1.4 after IVF. Her CKD is likely secondary to HTN/DM. Acute on chronic renal failure likely secondary to hypovolemia (pt given 3L in ED) plus septic physiology. At the time of discharge, her creatinine was back to her baseline of 1.3. # Cardiac: 1. CAD: Pt has h.o BMS to RCA in [**2102**]. Pt had presented with chest pressure that lasted a few minutes. EKG showed no acute ischemic changes. She was ruled out for MI by CEs x3. Asa/plavix were initially held given OR plans. BB, [**Last Name (un) **] were initially held for hypotension. Prior to discharge, she was restarted on her cardiac meds. 2. History of chronic diastolic CHF/CMP: She was initially volume resuscitated. She is followed by Dr. [**First Name (STitle) 437**] in heart failure clinic. She will be discharged on her Metoprolol Succinate, diovan, and her statin as was previously prescribed. Her lasix is to be used every other day as needed for weight greater than 195 lbs. # DM: Pt was continued on Lantus, HISS. Her glucose remained in the 100s with her lantus not requiring sliding scale insulin. # Pancreatic insufficiency: Pt was continued on creon TID with meals. # Crohn's Disease: The patient is on Asacol as an outpatient. She is also on Ciprofloxacin 250 mg [**Hospital1 **] chronically. During her hospitalization, ciprofloxacin was stopped since the patient is already on ceftriaxone. Her ciprofloxacin will be held until she completes her course of ceftriaxone, and Dr. [**Last Name (STitle) **] in [**Hospital **] clinic will discuss with the patient's Gastroenterologist whether this medication should be restarted. # Chronic neuropathic/radicular pain: Home long-acting narcotics were initially held given her somnolence. She was continued on topimax, gabapentin, duloxetine. At the time of discharge, she was restarted on her Oxycontin at a lower dose of 20 mg TID with oxycodone 5 mg for breakthrough pain. She is also on standing acetaminophen. Her Oxycontin can be uptitrated to 40 mg TID as an outpatient if needed. Initially, due to her mental status changes, it was thought that this was likely secondary to narcotics, especially post operatively. A head CT did not show any evidence of hemorrhage. It was felt that the likely cause of her altered mental status was the hydromorphone and her sepsis. Hydromorphone has been added to her allergy list. # h/o TIA symptoms: Neurology was not convinced presentation was consistent with acute stroke during last admission. She is on ASA/plavix for secondary prevention. The crohns disease and pancreatic insufficieny were stable. She is also on Ciprofloxacin 250 mg [**Hospital1 **] chronically. During her hospitalization, ciprofloxacin was stopped since the patient is already on ceftriaxone. Her ciprofloxacin will be held until she completes her course of ceftriaxone, and Dr. [**Last Name (STitle) **] in [**Hospital **] clinic will discuss with the patient's Gastroenterologist whether this medication should be restarted. Medications on Admission: -ASACOL 1600MG TID -ASPIRIN 325 mg QDay -TOPROL XL 100 mg QDay -CALCIUM 500 mg TID with meals -CIPRO 250 mg PO BID -CYMBALTA 60 mg QDay -DIOVAN 80 mg QDay -FOLIC ACID 1 MG Qam -HYDROXYZINE HCL 25 mg [**Hospital1 **] prn itching -LANTUS 68u at bedtime -LASIX 20 mg PO QOD prn weight >195 lbs. -LIDODERM 5%--Place patch on affected region for 12 hours at a time -LOMOTIL 2.5 mg-0.025 mg/5 mL--[**5-19**] ml PO QID prn diarrhea -NEURONTIN 1600 mg TID -NYSTATIN 100,000 unit/mL--10 ml suspension(s) PO QID -OXYCODONE 2.5 mg PO Q4-6h prn pain -OXYCONTIN 40 mg PO TID -PLAVIX 75 mg PO QDay -SIMVASTATIN 20 mg PO QDay -TOPAMAX 100 mg QDay -VITAMIN D 800 UNIT QDay -Creon 4 capsules TIDac Discharge Medications: 1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO twice a day as needed for itching. 9. Insulin Glargine 100 unit/mL Solution Sig: Sixty Eight (68) units Subcutaneous at bedtime. 10. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day as needed for pain: on for 12H off for 12H: apply to affected area. 11. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for diarrhea. 12. Neurontin 800 mg Tablet Sig: Two (2) Tablet PO three times a day. 13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 17. Topiramate 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous Q24H (every 24 hours). 20. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: Four (4) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 23. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 24. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 25. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 6 weeks: should continue until appointment with Dr. [**Last Name (STitle) **] on [**7-2**]. 26. Vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q 24H (Every 24 Hours) for 6 weeks: should continue until appointment with Dr. [**Last Name (STitle) **] on [**7-2**]. 27. Outpatient Lab Work Weekly Chem-7, CBC with DIFF, ESR, CRP, LFTs, Vancomycin Trough to be faxed to Infectious Disease Division, [**Hospital1 18**]- fax # ([**Telephone/Fax (1) 18871**]. Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital Discharge Diagnosis: Right Knee Septic arthritis Septic shock Acute renal failure Post op delirium - resolved Diabetes mellitus type 2 History of Hypertension Chronic Diastolic Heart Failure Crohn's Disease Anemia of Chronic Disease Chronic Kidney Disease stage 3 Discharge Condition: stable, afebrile Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet You were admitted for an infection. It was thought to be due to your infected knee. You were treated with IV antibiotics which you will need to continue for 6 weeks. You were evaluated by the orthopedics service, and you had to have your arthroplasty (knee hardware) removed. You had a temporary replacement in there which will need to be removed and new hardware placed in 6 weeks. In 2 weeks, you will need your staples removed. Physical therapy felt that you need inpatient physical therapy at a rehabilitation facility. Please take all medications as prescribed. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: chest pains, fevers, shortness of breath, worsening leg pain or swelling, diarrhea, inability to take food or fluids. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 457**] Date/Time: [**2103-7-2**] 10:30a Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6310**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2103-5-25**] 2:50 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2103-5-31**] 10:45 [**2103-6-5**] 01:40p [**Last Name (LF) **],[**First Name3 (LF) 2191**] A. [**Hospital6 29**], [**Location (un) **] [**Hospital **] CLINIC (SB) [**2103-6-5**] 01:20p X-RAY ORTHO SCC2 SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] X-RAY ORTHO SCC2 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2103-6-28**] 2:00

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icd9cm

[ [ [] ] ]

[ "84.56", "80.06", "38.93" ]

icd9pcs

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23095, 23169

14446, 19505

296, 356

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384, 1967

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7559, 7668

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3043, 3302

20,326

112,747

28502

Discharge summary

report

Admission Date: [**2142-5-2**] Discharge Date: [**2142-5-6**] Date of Birth: [**2075-12-7**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 922**] Chief Complaint: echocardiogram showed [**Location (un) 109**]=0.6 Major Surgical or Invasive Procedure: [**2142-5-2**] 1. Redo sternotomy. 2. Redo coronary artery bypass grafting x1 with a reverse saphenous vein graft from the aorta to the previously placed double sequential vein graft to the posterior descending coronary artery and second obtuse marginal coronary artery 3. Aortic valve replacement with a 25-mm [**Doctor Last Name **] Magna Ease aortic valve bioprosthesis model number 3300TFX, serial number [**Serial Number 69062**]. 4. Endoscopic vein harvesting. History of Present Illness: 66yo male s/p CABG in [**2137-9-15**]. He had known aortic stenosis at time of surgical revascularization but it was not significant enough to require aortic valve replacement. However since that time, serial echocardiograms have confirmed progression of aortic valve stenosis. Currently he denies chest pain, dyspnea, syncope, presyncope, palpitations, orthopnea, PND and pedal edema. He has been referred for surgical evaluation. Past Medical History: - Aortic Stenosis - Myocardial infarction - Coronary Disease - Dyslipidemia - Hypertension - History of postop PAF - Hypothyroid related to amiodarone Past Surgical History - Emergent coronary bypass grafting x5, on intra-aortic balloon pump with endoscopic left greater saphenous vein harvesting and endoscopic right greater saphenous vein harvesting on [**2137-9-19**] - Re-Exploration for bleeding following CABG Social History: Lives with: Wife in [**Name2 (NI) **] Occupation: Lithographer for [**Location (un) 86**] Globe Tobacco: Smoked infrequently between ages 16-21. ETOH:1 beer and 1 whiskey nip/day Family History: Non contributory Physical Exam: Pulse:59 Resp:16 O2 sat: 98/RA B/P Right:137/82 Left: 157/79 Height:5'9" Weight:200 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Sternotomy incision, sternum stable Heart: RRR [x] Irregular [] Murmur III/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Bilateral vein harvest sites Neuro: Grossly intact Pulses: Femoral Right: cath site Left: +2 DP Right:+2 Left:+2 PT [**Name (NI) 167**]:+2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit Right/Left:transmitted murmur Discharge Exam VS:T: 98.6 HR: 93 SR BP: 124/70 RR 18 Sats: 95% RA WT: 97 kg General: 66 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR Resp: bibasilar crackles otherwise clear GI: benign Extr: warm tr edema bilateral Incision: sternal clean dry intact no erythema. Neuro: awake, alert oriented Pertinent Results: [**2142-5-2**], Intraop TEE Conclusions Pre CPB (before first bypass run): 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 moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is low normal (LVEF 50-55%). Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to moderate ([**12-17**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Wire was seen in descending aorta during femoral artery cannulation. Femoral venous cannula seen entering SVC during placement by surgeon. Post CPB: The patient is being A-paced on phenylephrine and epinephrine infusions. The is a well seated bioprosthetic valve in the aortic position which has mean/peak gradients of 7/16mmHg with a cardiac output of 6/1L/minute. There is trivial mitral regurgitation. The visible contours of the thoracic aorta are intact. [**2142-5-6**] WBC-10.9 RBC-2.81* Hgb-9.3* Hct-27.1* MCV-96 MCH-33.3* MCHC-34.5 RDW-12.6 Plt Ct-179 [**2142-5-2**] WBC-20.5*# RBC-3.08* Hgb-10.2* Hct-29.4* MCV-96 MCH-33.1* MCHC-34.7 RDW-12.6 Plt Ct-132* [**2142-5-6**] Glucose-109* UreaN-17 Creat-0.9 Na-137 K-4.2 Cl-98 HCO3-29 [**2142-5-2**] UreaN-17 Creat-0.7 Na-139 K-3.9 Cl-112* HCO3-21* AnGap-10 [**2142-5-6**] Mg-2.3 Brief Hospital Course: The patient was brought to the operating room on [**2142-5-2**] where the patient underwent redo, AVR (tissue), revision of PDA/OM graft . Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. He developed urinary retention. Foley was re-inserted and Flomax started, he voided following 2nd foley removal. 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 POD4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home with Partners [**Name (NI) 269**] in good condition with appropriate follow up instructions. Medications on Admission: AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet - 1 Tablet(s) by mouth daily CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth daily LEVOTHYROXINE - (Prescribed by Other Provider) - 50 mcg Tablet - 1 Tablet(s) by mouth daily LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth twice a day METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth twice a day SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC ASPIRIN [ENTERIC COATED ASPIRIN] - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day CHLORHEXIDINE GLUCONATE - 4 % Liquid - apply topically daily Shower daily using chlorhexidine for 5 days prior to surgery and the day of surgery MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by Other Provider) - Tablet - Tablet(s) by mouth daily THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth once a day --------------- --------------- --------------- --------------- Discharge Medications: 1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 14. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 15. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day: take with furosemide. Disp:*5 Capsule, Extended Release(s)* Refills:*0* 16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: - Aortic Stenosis - Myocardial infarction - Coronary Disease - Dyslipidemia - Hypertension - History of postop PAF - Hypothyroid related to amiodarone Past Surgical History - Emergent coronary bypass grafting x5, on intra-aortic balloon pump with endoscopic left greater saphenous vein harvesting and endoscopic right greater saphenous vein harvesting on [**2137-9-19**] - Re-Exploration for bleeding following CABG Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2142-5-15**] 10:15 [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Location (un) 551**] [**Hospital Unit Name **] Surgeon Dr. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2142-5-29**] 1:00 [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Location (un) 551**] [**Hospital Unit Name **] Cardiologist Dr. [**Last Name (STitle) 4469**] [**5-30**] at 1:45pm Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 14328**] in [**3-20**] 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:[**2142-5-8**]

[ "424.1", "V45.81", "E942.0", "244.3", "414.01", "401.9", "V15.82", "788.20", "412", "272.4" ]

icd9cm

[ [ [] ] ]

[ "36.11", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

8870, 8941

4839, 6056

326, 811

9401, 9557

3067, 4120

10345, 11351

1927, 1945

7364, 8847

8962, 9380

6082, 7341

9581, 10322

1960, 3048

236, 288

839, 1274

1296, 1714

1730, 1911

4130, 4816

42,141

162,587

38853

Discharge summary

report

Admission Date: [**2128-3-29**] Discharge Date: [**2128-4-24**] Date of Birth: [**2066-11-19**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: Transfr for worsening liver failure, increasing Cr. Major Surgical or Invasive Procedure: Temporary dialysis catheter placement [**2128-4-9**] by IR History of Present Illness: This is a 61 yo M with history of diverticulitis s/p colectomy and colostomy placement in [**2115**], cryptogenic cirrhosis without past biopsy who presented to OSH on [**3-21**] with blood in his colostomy bag and an expanding hematoma on his right flank, now transferred to [**Hospital1 18**] for worsening liver failure and HRS. He has had a long history of bleeding from his ostomy site (states this has been an issue for years, unclear etiology but thought to be more of an ostomy site problem than a colonic problem). However he was recently admitted (around [**2128-3-7**]) to OSH for hematemasis; subsequent EGD showed 2 cords of non-bleeding grade 1 varicies. . He was readmitted to OSH on [**3-21**], and was sent to the ICU for a hct of 19. He was started on a PPI gtt, octreotide gtt and nadolol and transfused with PRBC and FFP (over hospital course recieved [**7-12**] PRBC and 8 FFP). Per the OSH records he does not seem to have been hemodynamically unstable. His bleed was thought to be lower GI (one description of "spurting" blood) and eventually resolved on its own. . He was transferred to the medical floor. There he developed a leukocytosis (13-15) and was started on levofloxacin. A infectious work up was done, blood and urine Cx from [**3-26**] were negative, A UA was reported at "slightly positive" (Nitrites and 1+ Leuk esterase) and CXR was done. Patient did not develop a fever. However on the medical floor he began to develop worsening liver failure. On admit his bili was 4.9 and increased to 14.7 on [**3-29**]; INR increased to 3.2. His creatinine also increased from 1.2 on [**3-26**] to 1.9 on day of transfer despide fluid resuscitation. The decision was made to transfer him to [**Hospital1 18**] for worsening liver failure, possible HRS and evaluation for transplant. . His vitals at the time of transfer were HR 80, BP 98/65, afebrile, 94%RA. BP at the OSH ranged from 84-110 / 48-72. Regarding his hypotension, he notes his usual BP was 120/80 and was on Diovan up through mid [**Month (only) 547**]. The first time his BP was noted to be low was during his first admission in early [**Month (only) 547**], and this continued through his second admission as well. . Currently, patient notes nausea with episode of vomiting earlier today. Notes having mild nausea with dry heaves on several mornings during his recent course. Endorses mild abdominal pain particularly with movement, though finds this difficult to distinguish from his back pain. Also with increasing abdominal distension. Endorses at least 50 pound weight gain since [**Month (only) 404**]. Massive edema in his legs has also developed. Endorses poor mobility at home with requirement of cane or walker due to leg edema. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, diarrhea, constipation, dysuria, hematuria. Endorses poor appetite over months. Endorses poor sleep and notes PCP concerned re: depression. Also endorses feeling that his thinking is not quite as sharp as usual. Past Medical History: - DM type II, diagnosed 10-12 years ago, now on insulin. - Diverticulitis s/p perforation and Hartmann procedure in [**2115**]. Attempted to take colostomy down at some point but unable second to adhesions. - Large parastomal hernia - cirrhosis and portal hypertension, (NASH?) no liver Bx performed, diagnosed within last few years. [**2128-3-8**] EGD with grade 1 varices, portal gastropathy. - anemia - mild chronic renal failure Cr 1.2 - COPD - HTN - history of B/l DVT Social History: Lives at home with wife. Three children in their 30s. Used to work as a chef. Smoked [**1-7**] PPD for about 18 years total, quit ~26 years ago. Also has smoked a pipe from time to time. EtOH intake: quit completely a couple years ago; "moderate" beer intake in early 20s and then [**1-7**] glasses wine nightly over the prior years. No IVDU ever. Family History: Significant for DM in sister as well as mother (also with retinopathy). Father also with DM very late in life (80s-90s). Brother also with pre-DM and history of MI. Mother and father both with CHF. No known liver disease. No hemochromotosis. Physical Exam: Exam on admission [**2128-3-29**]: Vitals - T: 97.8, BP: 87/58, HR: 78, RR: 16, 02 sat: 93% RA GENERAL: Pleasant male, good historian, jaundiced, in NAD. HEENT: + Scleral icterus. PERRL. MMM without OP lesions; OP notable for icterus. NECK: Supple, no adenopathy. JVD to ~3 cm ASA; notable EJ collapse with inspiration. CARDIAC: RRR, soft SM at RUSB. LUNG: CTA bilaterally, mildly decreased breath sounds at bases. ABDOMEN: large, obese. + RLQ Colostomy with brown stool - had blood mixed with stool in bag earlier. Parastomal hernia. +BS. Peripheral dullness but unable to check for shifting. Mild diffuse abdominal TTP, greatest at RUQ. + large ecchymosis over right flank. Abdominal wall also with large pitting edema. Small area of skin breakdown beneath pannus in RLQ. EXT: 3+ edema of bilateral LEs. RUE also with 1+ edema in upper arm; trace on L side. Mild venous stasis changes in LLE. NEURO: Appropriate, difficult to appreciate encephalopathy but patient endorses mild mental slowness. Very mild asterixis. Strength 5/5 in distal muscles of LE and UEs. Exam on transfer to SICU [**2128-4-10**]: GENERAL: Pleasant male, jaundiced, in NAD. HEENT: + Scleral icterus. MMM without OP lesions NECK: Supple CARDIAC: RRR, soft SM at RUSB. LUNG: Bibasilar crackles L>R. ABDOMEN: large, obese. + RLQ Colostomy with brown stool - no blood in ostomy bag. Parastomal hernia. +BS. Nontender. + large ecchymosis over right flank. Abdominal wall also with large pitting edema. Small area of skin breakdown beneath pannus in RLQ- improving per patient and RNs. EXT: 3+ edema of bilateral LEs. Venous stasis changes in LLE. NEURO: Appropriate, No asterixis. Exam on discharge *** Pertinent Results: Labs on admission [**2128-3-29**]: WBC-15.0* RBC-3.12* Hgb-9.7* Hct-28.6* MCV-92 MCH-31.2 MCHC-34.0 RDW-16.6* Plt Ct-158 Neuts-80.2* Lymphs-8.2* Monos-9.7 Eos-1.5 Baso-0.4 PT-27.5* PTT-54.0* INR(PT)-2.7* Glucose-169* UreaN-28* Creat-1.6* Na-131* K-4.6 Cl-100 HCO3-23 AnGap-13 ALT-32 AST-72* LD(LDH)-212 AlkPhos-93 TotBili-15.8* DirBili-8.9* IndBili-6.9 Lipase-357* Albumin-2.0* Calcium-7.3* Phos-3.7 Mg-1.5* Iron-98 calTIBC-99* Ferritn-935* TRF-76* Other labs: [**2128-4-3**] BLOOD Triglyc-67 HDL-10 CHOL/HD-4.4 LDLcalc-21 [**2128-3-29**] BLOOD TSH-1.8 [**2128-3-29**] BLOOD Free T4-1.3 [**2128-3-30**] BLOOD Cortsol-9.6 [**2128-4-4**] BLOOD IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2128-4-3**] BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2128-4-3**] BLOOD HCV Ab-NEGATIVE [**2128-4-3**] BLOOD AMA-NEGATIVE [**2128-4-3**] BLOOD [**Doctor First Name **]-NEGATIVE [**2128-4-3**] BLOOD CEA-5.6* PSA-0.7 AFP-3.2 [**2128-4-3**] BLOOD IgG-973 IgA-623* IgM-71 [**2128-3-29**] BLOOD IgG-1286 [**2128-4-3**] BLOOD HIV Ab-NEGATIVE [**2128-4-3**] Serum Tox screen negative [**4-3**] ALPHA-1-ANTITRYPSIN 47 (83-199 mg/dL) CA [**36**]-9 185 (<37) CERULOPLASMIN 10 (18-36 mg/dL) COPPER (SERUM) 43 (70-175 mcg/dL) Test Result Reference Range/Units VITAMIN D, 25 OH, TOTAL <4 L 20-100 ng/mL VITAMIN D, 25 OH, D3 <4 ng/mL VITAMIN D, 25 OH, D2 <4 ng/mL MICRO: BCx negative from [**Date range (1) 86243**]/10 Peritoneal fluids cultures negative as of [**2128-4-9**] C diff negative x3 as of [**2128-4-9**] RPR negative Rubella IgG/IgM positive VZV IgG positive POSITIVE FOR CMV IgG Positive 7 AU/ML (past exposure) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB: POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB: POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB: NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. STUDIES: [**3-30**] ECHO: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). There is no ventricular septal defect. The right ventricular cavity is dilated with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. [**3-30**] Abd US: 1. Nodular contour of the liver and splenomegaly, in keeping with cirrhotic liver. 2. Large amount of ascites, paracentesis site marked at the left flank area. 3. Reversed flow in main portal vein, right and left portal vein. Thrombosis of the right posterior portal vein. 4. Large right pleural effusion, small left pleural effusion. 5. No evidence of hydronephrosis. 6. Gallbladder distended, with wall edema, and sludge within the lumen. This is likely due to liver failure; however cholecystitis cannot be excluded. [**3-30**] MRCP/MRI Abdomen: 1. Cirrhotic liver with multiple sub-5-mm nodules, with evidence of portal hypertension with splenomegaly and ascites. The portal vein and its branches are widely patent with no evidence of thrombosis. 2. No large stones seen in the biliary tree or gallbladder; however, due to patient's large size, presence of motion artifact and presence of ascites secondary to patient's liver cirrhosis, we would not expect to see small biliary stones. No evidence of biliary obstruction. [**4-2**] Pre Op CXR (2 view): FINDINGS: Fluffy appearance of the pulmonary interstitium and bilateral pleural effusions are compatible with severe pulmonary edema. There is no pneumothorax. Heart is enlarged. Aorta is mildly tortuous. IMPRESSION: Severe pulmonary edema [**2128-4-5**] Stress: IMPRESSION: No anginal symptoms or ischemic ST segment changes. Appropriate blood pressure response. Flat heart rate response to Persantine infusion. Nuclear report sent separately [**2128-4-5**] Nuclear perfusion study: IMPRESSION: Left ventricular enlargement. Normal myocardial perfusion. [**4-8**] CXR for Dobhoff: Dobbhoff tube is coiled within the body of the stomach. Studies OSH per d/c summary [**2128-3-29**]: Ab U/S in [**2127-12-5**]: heterogeneous liver, mild splenomegaly CT [**Last Name (un) **]/pelvis [**2126**]- venous collaterals in the left upper quadrant suggestive of portal HTN. EGD [**2128-3-8**]: 2 columns of grade 1 varicies without evidence of bleeding, portal gastropathy. [**Last Name (un) **] in 09: diverticulosis; cecum not well visualized -CXR [**3-26**]: at OSH: Right basal opacity, possible PNA with parapneumonic pleural effusion or pleural effusion. Opacity is similar to CXR on [**3-21**]. -Ab U/S [**3-24**]: small to moderate amount of ascitites throughout the peritoneal cavity, largest pocket in RUQ. Gallbladder wall is diffusely thickened without ductal dilitation. limited view of kidneys without obstruction. Brief Hospital Course: Admission to [**2128-4-10**]. 61M with cryptogenic cirrhosis, history of diverticulitis s/p colostomy, presenting with acute on chronic liver dysfunction, GI bleeding, ARF, anasarca. . # Acute on chronic liver failure. Chronic thought due to NASH (has DM history, obesity) though never biopsy proven. Hep serologies negative. Etiology of acute component remains unclear, perhaps due to GI bleed that led to recent hospitalization. Pt had massive anasarca, coagulopathy, jaundice. Paracentesis negative for SBP. MRCP unremarkable with no evidence of portal vein thrombosis. a-1-antitripsin negative. [**Doctor First Name **] and AMA negative. Ceruloplasmin negative. Copper negative. CEA and Ca [**36**]-9 mildly elevated, likely due to liver disease. Vitamin 25(OH)D low. PPD negative (0 mm). He was started on rifaximin and lactulose. He began transplant evaluation which was suspended due to fluid overload. He was transferred to the SICU for CVVH on [**2128-4-11**]. ---pending transplant eval after CVVH: needs PFTs and repeat ECHO once diuresed with CVVH, Radiology to comment on liver volume, repeat 2 view CXR, dental eval; UGI (done [**2127**])/C-scope (done [**11/2127**]) results in chart. . # Hypotension. Pt with SBPs 80s-90s on admission, improved with midodrine. Likely distributive physiology from cirrhosis; cortisol normal making adrenal insufficiency unlikely. TSH normal. ECHO and EKG unremarkable. . # Acute on chronic renal failure. Concerning for HRS II as it worsened after albumin challenge. Creatinine slightly improved on [**Hospital1 **] albumin (stopped [**4-8**]), octreotide and midodrine 12.5mg TID. He did not have good response to lasix IV and per renal recommendations, required CVVH and was transferred to the SICU on [**2128-4-10**]. Started vitamin D qweek 50,000 units as pt has low serum vitamin 25 OH D levels (first dose Thurs [**2128-4-8**]). . # GI bleed/anemia. Hct remained stable requiring occassional transfusion. Pt had a few episodes of blood in ostomy bag. Pt has had occasional output of blood in ostomy in past and states this time was no worse and there is no 'spurting.' Source unclear, likely AVMs, that he treats with silver nitrate sticks at home. He had more acute bleeding recently leading to OSH hospital admission and need for 8 units of transfusion. Also coagulopathic from liver disease. Pt has large flank ecchymosis which he reports from 'internal bleeding.' Iron studies suggest anemia of chronic disease. He was started on [**Hospital1 **] PPI. Silver nitrate was applied to any obvious bleeding at stoma. Per transplant attending, repeat colonoscopy ([**Last Name (un) **] [**2126**] did not visualize cecum) was not needed for transplant. . # Anasarca. Pt was profoundly volume overloaded. Per OSH notes, he had acute renal failure with attempted volume repletion without much improvement. Per pt history, his anasarca had been developing over the past few months prior to admission as an outpatient. Pt was transferred to SICU for CVVH on [**2128-4-11**]. . # Leukocytosis. WBC remained between 13-16. He was afebrile. CXR without consolidation. Cultures NGTD. C diff negative x3. He was treated with levofloxacin at OSH then cipro at [**Hospital1 18**] for total 11 days (completed [**2128-4-5**]) for ?UTI given WBCs on OSH UA. Foley changed on [**4-5**] (pt unable to to void after foley d/c'd, so replaced) and given one dose of vanc given difficult placement. Follow up UCx was negative. . # DM type II - Held metformin for hospitalization. Started on glargine 7 units qHS and ISS with good control. As above, pt was transferred to SICU for CVVH on [**2128-4-11**]. Pt continued to have CVVH and in one week time he was down to his baseline weight. However, due to the liver decompensation and coagulopathy the patient continued to ooze from his ostomy site. On 5 /12 Successful direct percutaneous access and embolization of stomal varices. Coagulopathy has been treated supportively with multiple blood products and PRBCs daily without any improvement or stability. His INR and t bili remained high/labile. After extensive discussion with the family, he was made CMO on [**2128-4-22**]. He remained on fentanyl drip afterwards until 1:45 AM [**2128-4-24**] when he expired. Death was pronounced at 1:45 AM on [**2128-4-24**]. Medical examiner was contact[**Name (NI) **]. Autopsy was not indicated. Family did not request that either. Death report was submitted to the Medical records and admission office. Medications on Admission: MEDICATIONS AT HOME: lantus 30 units daily Byetta 10mg [**Hospital1 **] Metformin 1000mg [**Hospital1 **] Protonix 40mg daily Prinivil 10mg daily ProAir INH Diovan 80mg daily (stoppped prior to most recent OSH admission) Nadolol 60mg daily Ativan 1mg qHS Flovent INH. . MEDICATIONS ON TRANSFER from OSH [**2128-3-29**]: Morphine 1mg IV q4 prn pain Zofran 4mg IV prn N/V Insulin SS Levofloxacin 500mg daily magnesium oxide 400mg PO BID Nadolol 60mg daily Nystatin TP q8 Oxycodone 5mg qHS prn Pantoprazole 40mg [**Hospital1 **] Discharge Medications: Pt was diseased. Discharge Disposition: Expired Discharge Diagnosis: 1:45 AM [**2128-4-24**] Death cardiopulmonary arrest Hepato-renal failure Liver Cirrhosis Discharge Condition: Diseased Discharge Instructions: Family Funeral director. Completed by:[**2128-4-28**]

[ "458.9", "V45.72", "276.6", "571.5", "278.00", "572.3", "599.0", "285.1", "584.9", "285.29", "288.60", "V12.51", "572.2", "250.00", "427.5", "456.8", "570", "578.9", "572.4", "244.9", "459.81", "569.69", "456.21", "789.59", "V15.82", "403.90", "496", "287.5", "585.9", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "88.64", "87.66", "54.91", "38.95", "96.6", "39.95", "96.72", "38.91", "99.29" ]

icd9pcs

[ [ [] ] ]

16799, 16808

11692, 16180

367, 428

16941, 16951

6382, 6832

4428, 4671

16757, 16776

16829, 16920

16206, 16206

16975, 17030

16227, 16734

4686, 6363

276, 329

456, 3548

3570, 4046

4062, 4412

6844, 11669

29,906

181,939

32424

Discharge summary

report

Admission Date: [**2134-10-1**] Discharge Date: [**2134-10-7**] Service: MEDICINE Allergies: Morphine / Azithromycin / Codeine / Sulfa (Sulfonamides) / Lipitor Attending:[**First Name3 (LF) 2704**] Chief Complaint: Cardiac Catheterization Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: This is an 87 y/o woman with a h/o CAD, s/p CABG (x4 details below) who presented to [**Hospital6 33**] on [**9-29**] c/o chest pain. Patient had been relatively symptom free since her CABG until she eas evaluated as an outpatient by Dr. [**Last Name (STitle) 32772**] for chest pain. She was given nitroglycerin. At that time, patient refused stress testing or further evaluation. On presentation she described a left sided chest pain lasting 10 minutes that was associated with L-arm tingling, rating [**7-2**]. Pain was worse with exertion and relieved with NTG. Patient took ASA 325mg at home, and then presented to [**Hospital3 **] after pain returned. She described no SOB, nausea, vomiting, lightheadedness, back pain, or abdominal pain. . On presentation to the ED, patient was pain free, VSS. EKG demonstrated 1mm ST elevations in III, aVF, and ST depressions in I and aVL. Patient was admitted at [**Hospital3 **] as ROMI, started on heparin, Aspirin, plavix and beta blocker. Cardiac enzymes were negative. She underwent diagnositc cath that showed multivessel CAD, totally occluded grafts except for patent SVG to RCA with stenosis (grade ). Patient was then transferred to [**Hospital1 18**] where she was scheduled to undergo cath. . Official Cath report from [**Hospital1 18**] pending at the time of this note, but patient had successful stenting of her vein graft with BMS x3. Patient was intermittently on phenylephrine during the procedure. A left femoral sheath was placed for possible insertion of IABP. Immediately following the procedure patient noted to be bleeding from this site, manual pressure was applied and patient was started on dopamine. Patient then bradycardic (HR 32) in setting of bleed, and CPR was started. She was given atropine/epi bolus. By report, patient then went in to VT arrest. Amio 300 given, and patient intubated by anesthesia. Patient was shocked and returned to [**Location 213**] rhythm. Reportedly down about 5 minutes. Pressures were labile on/off pressors, and she was transferred to the CCU on dopamine (7.5 ucg/kg/min) and neosynephrine (1.50 ucg/kg/min). In total she received 1.5L of fluid prior to arrival in CCU and was defibrillated x1. . ROS at OSH notable for unsteady gait w/ involuntary movement of her R-arm and R-leg. Followed by Neurology for these episodes of unclear etiology. Past Medical History: - CABG - 16 years ago at [**Hospital1 756**], SVG to PDA, SVG to RCA, SVG to Ramus, SVG to LAD. LIMA had low flow and was not used. - Hypothyroidism - Hypertension - Dyslipidemia - Previous TIA - s/p Appendectomy - s/p Mastectomy Social History: 25 pack year history of tobacco. No alcohol or illegal drug abuse. Patient is widowed with 2 children. Daughter is a nurse. Family History: non-contributory Physical Exam: VS: T , BP 107/48, HR 75, RR 20, O2 100 % on A/C Gen: Elderly woman, intubated, and in NAD, resp or otherwise. Does not follow commands, but occasionally grimaces and moves extremities. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pale, no cyanosis of the oral mucosa. Neck: Supple. CV: Distant heart sounds, PMI mid-clavicular. Chest: No scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. +wheezes, no rales or ronchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. R-femoral arterial and venous sheaths in place. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit, mild oozing, no hematoma; 2+ DP Pertinent Results: CXR: PA and lateral upright chest radiograph compared to [**2134-10-5**]. . The mild to moderate cardiomegaly is stable. Sternal wires are intact. Generalized increased interstitial markings are noted, grossly unchanged as well as there is no significant change in small bilateral pleural effusions, findings consistent with mild pulmonary edema. Stent in bypass graft most likely going to the RCA or PDA is again noted in unchanged location on both PA and lateral views. . There is no pneumothorax. . IMPRESSION: Unchanged appearance of mild pulmonary edema accompanied by small pleural effusion. Status post CABG. Stented bypass. LENI [**2134-10-6**]: FINDINGS: Grayscale, color, and Doppler son[**Name (NI) 1417**] of the right and left common femoral, superficial femoral, and popliteal veins demonstrate normal compression, color flow, waveforms, and augmentation. There is no evidence of deep vein thrombosis. . IMPRESSION: No deep vein thrombosis in the lower extremities. . [**2134-10-4**] TTE Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferior wall, distal septum and apex. The remaining segments contract normally (LVEF = 45-50 %). The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . IMPRESSION: Regional left ventricular systolic dysfunction suggestive of multivessel CAD. Mild mitral regurgitation. . [**2134-10-6**] TTE Conclusions The left atrium is normal in size. The estimated right atrial pressure is 0-10mmHg. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the distal half of the anterolateral wall and basal inferior wall. The remaiining segments contract normally (LVEF = 50 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2134-10-4**], the findings are similar. Brief Hospital Course: #V. Fib: Patient was transferred to the CCU for management. On arrival, patient was intubated and on pressor support with dopamine and neosynephrine. Impression on arrival was for a vagal episode in the setting of groin pressure for bleeding from the femoral sheath site, leading to atropine and then V. Fib arrest. In CCU, patient had bleeding from her groin site requiring firm pressure for 30 minutes, and in this setting became transiently hypotensive and bradycardic. Patient's dopamine was increased with good response. Ultimately, pressors were titrated to off over the next 24-48 hours. She had no recurrence of NSVT, VT, or V.Fib while in the CCU. Patient was transfered to floor for management and was discharged w/o events. . #CAD: Patient had BMSx3 placed to her vein graft. On arrival to CCU, she was continued on ASA/Plavix. Lipitor was held given the patient had been intolerant of statin therapy in the past (severe myalgias). Beta-blocker/ACE were held in setting of cardiogenic shock requiring pressor support. After patient had been transferred to the floor she was restarted on her acebutalol at 200mg daily, and later lisinopril 5mg daily. Creatinine was stable on discharge, and patient with a normal K+. She continued to have SOB however, requiring diuresis with lasix 20mg IV over 3 days with good UOP. Patient was discharged with PO lasix dose for 5 days and will likely not require lasix in the future. Recommend reevaluation by PCP on discharge (Patient has an appointment in 5 days time). On the day of discharge patient was able to ambulate 50 yards w/o difficulty and w/o oxygen (O2 Sat 93%RA w/ exertion). . #Anemia/Thrombocytopenia: Patient had a significant 11 point hematocrit drop during her CCU stay. CT scan of the chest and abdomen demonstrated a small hematoma at the site of her left-femoral sheath, a small hematoma in the rectus abdominus muscle, and a small hematoma at the site of her central line placement (R-IJ). Patient had a stable hematocrit therafter and did not require a transfusion. Her platelet count dropped and in the setting of her bleeding heparin products were held. Here HIT antibody was negative and platelets stabilized and heparin was restarted prior to discharge with stable hematocrit, platelets and no evidence of bleeding. As part of her work-up, the patient was noted to have trace guaiac positive stools, and was recommended for outpatient follow-up with colonoscopy. . #Hypothyroidism: patient was continued on at home dose of levothyroxine 75ucg daily. . #Activity: PT recommended discharge to home with outpatient physical therapy. . The remainder of her hospital stay was uneventful. Medications on Admission: MEDICATIONS ON TRANSFER: Aspirin 325 mg qd Acebutalol Synthroid Nitroglycerin PRN Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Acebutolol 200 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:*60 Tablet, Chewable(s)* Refills:*2* 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: V. Fib Arrest . Coronary Artery Disease s/p Bare Metal Stents x3 Hypertension Hypothyroidism Discharge Condition: Stable, 93% on room air with exertion (walking on flat ground). Discharge Instructions: You have been admitted to the hospital for evaluation of chest pain. It was determined that you had decreased blood supply to your heart and would benefit from a reopening of the blood vessels to your heart. A cardiac catheterization was peformed and three bare metal stents were placed into your artery to reopen the blood supply. Following the procedure you had a complication known as Ventricular Fibrillation where your heart stopped pumping properly. You received CPR and defibrillation and were admitted to the ICU for evaluation and treatment. . Your heart should continue to improve. Upon leaving the hospital please continue to take all medications as directed, and attend all follow-up appointments. The following changes have been made to your medications: . Please take: 1. Aspirin 325mg daily (EVERY day unless told by a Cardiologist) 2. Plavix 75 mg (EVERY day unless told by a Cardiologist) 3. Acebutalol 200mg daily 4. Lisinopril 5mg daily 5. Lasix 20mg daily (for 5 days only) 6. Calcium Carbonate 500mg twice per day (for your bones) 7. Vitamin D 400 units twice per day (for your bones) . Please discuss these changes with Dr. [**Last Name (STitle) 32772**] at your next appointment on [**10-12**]. Should you have any chest pain, sudden or new shortness of breath, or any other symptom concerning to you please call your PCP or return to the Emergency Department. . It is recommended that you discuss with your PCP having [**Name Initial (PRE) **] colonoscopy as you have evidence of mild bleeding in your stools. Followup Instructions: [**Last Name (LF) 75694**],[**First Name3 (LF) **] [**Telephone/Fax (1) 14967**], Friday [**10-22**] at 11AM. Please call with questions. [**Month (only) **],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 14967**], Tuesday, [**10-12**] at 1:15pm. Please call with any questions. Fax: [**Telephone/Fax (1) 75695**] . Please discuss having a colonoscopy with your PCP as you have mild evidence of bleeding in your stools.

[ "287.5", "244.9", "998.11", "272.4", "585.9", "427.41", "414.02", "998.12", "410.41", "427.1", "414.01", "785.51", "E879.0", "403.90", "285.1", "997.1", "427.5" ]

icd9cm

[ [ [] ] ]

[ "99.20", "00.40", "00.17", "88.55", "96.04", "37.22", "00.66", "36.06", "96.71", "99.60", "88.52", "00.47" ]

icd9pcs

[ [ [] ] ]

10388, 10447

6628, 9307

298, 323

10584, 10650

4013, 6605

12246, 12708

3138, 3156

9439, 10365

10468, 10563

9333, 9333

10674, 12223

3171, 3994

235, 260

351, 2724

9358, 9416

2746, 2978

2994, 3122

80,891

196,778

2198

Discharge summary

report

Admission Date: [**2131-10-7**] Discharge Date: [**2131-10-14**] Date of Birth: [**2075-6-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization, Stent placement, Intra-Aortic Balloon Pump placement and removal, swan placement and removal. History of Present Illness: 56 y/o female with a h/o hyperlipidemia who presented to an OSH on the AM of [**2131-10-7**] with 10/10 substernal and left-sided chest pain, radiating down the left arm. Per patient, she noted the onset of SSCP Friday AM at work. The pain lasted for about an hour and resolved without any intervention. Was not associated with any SOB or other symptoms. Subsequently, on Saturday afternoon, she again developed the same SSCP, this time radiating to her left arm, associated with nausea. Denied associated SOB. Pain persisted until Sunday AM when she finally presented to the OSH. EKG there revealed STE in V2-V4. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA, Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She was transferred to [**Hospital1 18**] urgently for cardiac catheterization. In the cath lab, she was found to have a totally occluded proximal LAD. She had two stents placed to her LAD. She then became hypotensive and was resuscitated with IVF. An IABP was placed along with a femoral Swan. Upon arrival to the CCU, she was hemodynamically stable and chest pain free. She had no complaints. Past Medical History: Tobacco abuse (12 py history) Depression Hyperlipidemia Social History: -Tobacco history: Smokes [**4-3**] cigarettes daily for the past 25 years -ETOH: None -Illicit drugs: None Daughter is nurse [**First Name (Titles) **] [**Last Name (Titles) 121**] 3 Family History: Mother with MI at age 74. Brother and sister with [**Name (NI) 10322**]. Physical Exam: General Appearance: Well nourished, NAD, Overweight, Anxious HEENT: PERRL, MMM, no JVD Cardiovascular: nl PMI, s1 s2 no m/r/g, no thrills Respiratory / Chest: Crackles @ Bases Abdominal: Soft, Obese, Non-tender, Non-distended, BS present, no HSM Groin: Extremities: 2+ distal pulses, warm well perfused, no edema. Initially had IABP placed in right femoral artery with a Swan Ganz catheter in right femoral vein. Neurologic: Attentive, Follows simple commands Pertinent Results: Cath [**2131-10-7**]: 1. Two vessel vessel coronary artery disease. 2. STEMI secondary to occluded LAD. 3. Cadiogenic shock. 4. Successful stenting of the LAD. 5. Insertion of IABP with improvement of cardiac output. ECHO [**2131-10-9**]: Mild regional left ventricular systolic dysfunction with severe hypokinesis of the anterior wall, anterior septum and apex and mild hypokinesis of the anterolateral wall. Overall left ventricular systolic function is mild to moderately depressed (LVEF= 40 %). The remaining left ventricular segments contract normally.Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. No AS, AI, trivial MR. [**First Name (Titles) 11718**] [**Last Name (Titles) 11719**] thickened but no stenosis. No MVP. [**2131-10-7**] 01:27PM BLOOD WBC-13.8* RBC-4.54 Hgb-13.2 Hct-39.3 MCV-87 MCH-29.2 MCHC-33.7 RDW-13.6 Plt Ct-192 [**2131-10-8**] 06:03AM BLOOD WBC-12.1* RBC-4.05* Hgb-11.8* Hct-34.6* MCV-85 MCH-29.1 MCHC-34.1 RDW-13.9 Plt Ct-159 [**2131-10-14**] 05:30AM BLOOD WBC-9.4 RBC-3.22* Hgb-9.4* Hct-26.8* MCV-83 MCH-29.3 MCHC-35.2* RDW-13.6 Plt Ct-236 [**2131-10-7**] 01:27PM BLOOD Neuts-86.8* Lymphs-9.9* Monos-3.1 Eos-0.1 Baso-0.1 [**2131-10-14**] 05:30AM BLOOD PT-23.2* PTT-28.9 INR(PT)-2.2* [**2131-10-14**] 05:30AM BLOOD Glucose-97 UreaN-21* Creat-0.8 Na-137 K-4.2 Cl-100 HCO3-24 AnGap-17 [**2131-10-7**] 01:27PM BLOOD ALT-113* AST-480* CK(CPK)-6137* AlkPhos-129* TotBili-0.5 [**2131-10-11**] 06:20AM BLOOD CK(CPK)-167* [**2131-10-7**] 01:27PM BLOOD CK-MB-GREATER TH cTropnT-7.95* [**2131-10-11**] 06:20AM BLOOD CK-MB-4 cTropnT-6.29* [**2131-10-14**] 05:30AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0 [**2131-10-7**] 10:47AM BLOOD Type-ART FiO2-100 pO2-80* pCO2-39 pH-7.41 calTCO2-26 Base XS-0 AADO2-610 REQ O2-97 Intubat-NOT INTUBA [**2131-10-7**] 10:47AM BLOOD Glucose-123* Lactate-1.5 K-3.9 [**2131-10-10**] 03:36PM BLOOD Hgb-10.9* calcHCT-33 O2 Sat-65 [**10-8**] - BCx, UCx neg Brief Hospital Course: 56 y/o female with hyperlipidemia who presented with chest pain and found to have a STEMI [**12-30**] to an occluded LAD. STEMI: Pt presented with chest pain and found on cath to have occluded LAD. Occlusion was stented but pt required IABP placement for cardiogenic shock (cardiac index of 1.3) indicative of cardiogenic shock and requiring IABP. ECHO confirmed large anterior infarction and severe LV dysfunction. Pt required IABP for several days, at which point she was weaned and IABP and swan removed. Pt did not have any furthur complications including mechanical or arrhythmic. She did have 2 episodes of chest pain thought to be either noncardiac or secondary to reperfusion which responded to NTG and were not associated with EKG changes or further enzyme leak. She tolerated the addition of ASA, plavix, high dose statin, lasix, ACE inhibitor and beta-blocker, titrated up as tolerated by MAP and pt's symptoms. On discharge pt's SBP were consistently in the 80s, without any symptoms of lightheadedness or dizziness and this was deemed acceptable as pt will be unlikely to mount higher BPs given her large MI. Pt was also started on anticoagulation with coumadin given the large area of infarct and akinetic/hypokinetic anterior/apical wall. She will need close monitoring of her INR. TOBACCO ABUSE ?????? Pt counseled extensively by team and social work about smoking cessation. ANEMIA - Pt's hematocrit dropped from admission (39) to discharge (26). This was thought to be initially due to some blood loss from cath, and frequent blood draws. There was no sign of active bleeding and pt remained asymptomatic. Pt was not transfused and stool guaiac was not checked as pt did not have any bowel movements. Pt was asked to follow up with her PCP for [**Name Initial (PRE) **] Hct check. HYPERLIPIDEMIA - Pt was switched to high dose statin. Medications on Admission: Lipitor 20 mg PO daily Ibuprofen PRN Cod liver oil Geritol Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: Inferior STEMI Secondary: Hyperlipidemia Tobacco use Discharge Condition: Vital signs stable Discharge Instructions: You were admitted to the hospital with a heart attack. You had a drug-eluting stent placed in your coronary artery (left anterior descending) to open up the blockage in your heart. You were started on several new medications including aspirin and plavix. You must take these medications daily because they keep your stent open. Do not stop this medication unless directed by your cardiologist only. You were also started on a medication called warfarin. This medication is a blood thinner to prevent blood clots. You will need to have blood test to monitor your warfarin level. You were started on the following medications: Aspirin 325 mg daily (prevent future heart attacks) Plavix 75mg daily (Keeps stent open) Lipitor 80mg daily (Stops plaque formation and reduces cholesterol) Lasix 20mg daily (Water pill) Lisinopril 10mg daily (blood pressure) Toprol XL 75mg daily (Blood pressure and heart rate) Warfarin (blood thinner) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please stop smoking. This can reduce your risk of future heart attacks and strokes!! Information was reviewed with you on admission regarding smoking cessation. Please contact your doctor or return to the emergency room with any worrisome symptoms such as chest pain, shortness of breath, lightheadedness, weakness or numbness, difficulty with speech, bleeding, etc. Followup Instructions: Follow up with Dr.[**Doctor Last Name 3733**] in cardiology. Please call ([**Telephone/Fax (1) 3942**] to make an appointment in [**12-31**] weeks. Follow up with your primary care provider, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**], ([**Telephone/Fax (1) 11720**] to make a follow up appointment in [**11-29**] weeks. You need to have your INR checked on Tuesday [**2131-10-16**]. Please have VNA services fax results to Dr. [**Last Name (STitle) 1683**] at [**Telephone/Fax (1) 6443**] Completed by:[**2131-10-14**]

[ "272.4", "785.51", "428.0", "305.1", "410.01", "414.01", "311", "458.29", "287.5" ]

icd9cm

[ [ [] ] ]

[ "37.61", "88.56", "37.23", "00.40", "88.50", "00.66", "88.72", "97.44", "36.07", "00.46" ]

icd9pcs

[ [ [] ] ]

7289, 7346

4512, 6373

327, 447

7473, 7494

2477, 4489

8941, 9490

1908, 1982

6482, 7266

7367, 7367

6399, 6459

7518, 8918

1997, 2458

277, 289

475, 1612

7386, 7452

1634, 1691

1707, 1892

48,340

100,820

9140

Discharge summary

report

Admission Date: [**2131-9-30**] Discharge Date: [**2131-10-5**] Date of Birth: [**2071-10-10**] Sex: M Service: TRANSPLANT SURGERY CHIEF COMPLAINT: Cadaveric kidney transplant. HISTORY OF THE PRESENT ILLNESS: This is a 59-year-old male with end-stage renal disease on peritoneal dialysis from type 2 diabetes (20 years), who presents for a cadaveric kidney transplant. The patient was last seen in the hospital on [**2131-4-27**] where he was admitted for bacterial peritonitis. Since that time, he has had no medical problems or complaints. The patient denied any headache, fever, chest pain, shortness of breath, abdominal pain. ALLERGIES: Diazepam, Prinivil. ADMISSION MEDICATIONS: 1. Metoprolol 25 mg p.o. b.i.d. 2. Pravachol 40 mg p.o. q.d. 3. Aspirin 81 mg p.o. q.d. 4. Imdur 60 mg p.o. q.d. 5. Zantac 150 mg p.o. b.i.d. 6. Lasix 80 mg p.o. q.d. 7. Calcium acetate 667 mg p.o. t.i.d. 8. Iron 325 mg q.d. 9. Epogen. 10. NPH insulin q.a.m. 30 units. 11. Regular insulin. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.6, blood pressure 128/68, heart rate 61, respirations 20, saturation 100% on room air. General: The patient was in no acute distress, alert and oriented times three. Cardiovascular: Regular rate and rhythm with a II/VI systolic ejection murmur. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended. Extremities: Bilateral lower extremity edema. HOSPITAL COURSE: The patient went to the OR the same day, [**2131-9-30**], and underwent a kidney transplant (cadaveric). The patient underwent the procedure without any complications. He was transferred to the floor the same day and was started on perioperative antibiotics (Cephazolin). He was on IV PCA, morphine, for pain control. The patient was able to tolerate liquids on postoperative day number one. On postoperative day number two, his pain medication, IV PCA, morphine, was changed to Percocet with good pain control. The patient was followed by the Renal Service for his end-stage renal disease and by Endocrinology ([**Last Name (un) **]) for control of his blood sugar. On postoperative day number two, the patient was started on half NPH of his usual home dose, 15 units q.a.m. along with a regular insulin sliding scale. The patient's urine output has been satisfactory throughout the [**Hospital 228**] hospital stay. The patient was also started on his immunosuppressant medications; specifically, the patient was started on CellCept 1 gram b.i.d. and Tacrolimus was adjusted according to daily levels. The patient's blood pressure was controlled throughout his stay with his home medications (antihypertensives). On postoperative day number three, the patient received 2 units of packed RBCs (red blood cells) for a low hematocrit of 25. The patient has shown significant improvement over the following days. His central line was discontinued on postoperative day number four. He was placed on a renal diet. His Foley was discontinued. He was ambulatory without any fever and stable with blood glucose under sufficient control. The patient was discharged home on postoperative day number five, [**2131-10-5**] with instructions to follow-up with Dr. [**Last Name (STitle) **] at the Transplant Center on [**2131-10-11**] and Dr. [**Last Name (STitle) **] at the Transplant Center on [**2131-10-15**]. DISCHARGE MEDICATIONS: 1. Bactrim. 2. Pantoprazole. 3. Docusate. 4. Metoprolol. 5. Isosorbide mononitrate. 6. Percocet. 7. Nystatin. 8. Valgancyclovir. 9. Mycophenolate. 10. Tums. 11. Prednisone. 12. Insulin (regular). 13. Tacrolimus 5 mg p.o. b.i.d. 14. Aspirin 81 mg. The patient was provided with all the information necessary. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**Last Name (NamePattern1) 23784**] MEDQUIST36 D: [**2131-10-5**] 12:44 T: [**2131-10-6**] 07:46 JOB#: [**Job Number 31482**]

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54640

Discharge summary

report

Admission Date: [**2191-9-7**] Discharge Date: [**2191-9-23**] Date of Birth: [**2159-2-2**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 618**] Chief Complaint: CODE STROKE: left arm weakness, left facial droop, inability to speak Major Surgical or Invasive Procedure: Trans-esophageal echocardiogram History of Present Illness: Mr [**Known lastname 111763**] is a 32 year old man with no significant PMH who presented with left sided weakness and the inability to speak. History is aided from his family friend [**Name (NI) 335**] at bedside and over the phone while patient was being transported from [**Hospital1 34585**]. . Patient was in a normal state of health at 11 am this morning and was speaking with his friend. [**Name (NI) **] night and this morning he also felt well, and was playing basketball with his friends. . At some point between 12-1pm today patient emerged from his room and he was not able to speak yet he was still walking. He wrote on a piece of paper that he needed help and to go to the hospital. He was then taken to [**Hospital6 **] where he had an NIHSS of 13. Initial vitals were 167/79, HR 115, Temp 97.7, 99% on RA. Decision was made to give IV t-PA. tPA was given at 14:21 PM (6.8 mg IV push and 61 mg/hour). Patient was then transferred to [**Hospital1 18**] for potential neuro-interventional procedure. . On arrival to [**Hospital1 18**] ED patient was able to communicate only by writing and was stating he had an [**9-9**] headache. Repeat NIHSS was done and was given a 14. A repeat NCHCT was significant for extensive cerebral edema and decision was made to not persue an intervention. . On general review of systems (obtained through his friends), the pt had not complainted of reecent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: -none -no history of sickle cell, cardiac disease, or any medical problems this is his first time to a hospital ever. Social History: Patient is originally from [**Country **] but has lived in the US for the past 6 years. Was there several weeks back for a wedding. Was living in [**Location (un) **] and was planing on moving back to [**Country **]. He is currently staying with a family friend here in [**Name (NI) 86**]. Recently graduated from a masters in architecture program. Social etoh, no smoking, or illicit drug use. Family History: Sister: 2 miscarriages Father: possible stroke in his 20s with some paralysis--unclear history Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals: T: 98 P:117 R: 25 BP:139/103 SaO2:97% General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: sinus Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities:warm and well perfused Skin: no rashes or lesions noted. . Neurologic: -Mental Status: done by patient writing, he was alert, oriented x 3. Attentive following midline and appendicular commands. Language is fluent to writing but he remains mute with no attempt to speak. Pt. was able to name both high frequency objects from stroke card by writing them out. The pt. had good knowledge of current events. He appears to be neglecting the left. Calculation was intact (answers ("4+3 = 7" for seven quarters in $1.75) . -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. left field cut vs heavy neglect on the left, but extingushes to DSS. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: left facial droop VIII: Hearing intact to voice . -Motor: Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 3 0 0 0 0 0 0 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 . -Sensory: he writes only "slight feeling on the left" -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was mute . -Coordination: No intention tremor,on FNF on the right =========================== PHYSICAL EXAM ON DISCHARGE: Vitals: 98.2 110/75 62 18 100% RA Neuro: Severe aphonia (difficulty producing speech) but preserved comprehension and ability to communicate via written language. +distal left arm weakness (3+/5 in left wrist and finger extensors). Full strength in bilateral lower extremities and right arm. Pertinent Results: LABS ON ADMISSION: -WBC-6.4 RBC-5.43 Hgb-15.1 Hct-44.2 MCV-81* MCH-27.8 MCHC-34.2 RDW-13.5 Plt Ct-260 -PT-11.9 PTT-22.4* INR(PT)-1.1 -Glucose-170* UreaN-10 Creat-1.1 Na-139 K-3.9 Cl-100 HCO3-26 AnGap-17 -CK(CPK)-836* -ALT-24 AST-23 LD(LDH)-198 AlkPhos-80 TotBili-0.4 Lipase-31 . CARDIAC ENZYMES: -[**2191-9-7**] 4PM: CK-MB-2 cTropnT-<0.01 CK(CPK)-836* -[**2191-9-7**] 11:40PM: CK-MB-1 cTropnT-<0.01 CK(CPK)-706* -[**2191-9-8**] 8:47AM: CK-MB-1 cTropnT-<0.01 CK(CPK)-574* . MODIFIABLE STROKE RISK FACTOR LABS: -Cholest-218* Triglyc-68 HDL-78 CHOL/HD-2.8 LDLcalc-126 -%HbA1c-7.3* eAG-163* . HYPERCOAGULABILITY WORKUP LABS: -Lupus-NEG -ProtCFn-136 -ProtSFn-228* (high, normal is 50-150%) -ACA IgG-1.6 ACA IgM-6.3 -AT-120 -ALPHA 2 ANTIPLASMIN-69% (low, normal is 80-150) -PLASMINOGEN ACTIVITY-90% (normal) -BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-<9% (normal) -[**Doctor First Name **]-NEGATIVE -HIV Ab-NEGATIVE . LABS ON DISCHARGE: -WBC-3.7* RBC-4.79 Hgb-13.0* Hct-39.1* MCV-82 MCH-27.2 MCHC-33.2 RDW-13.8 Plt Ct-281 -PT-23.9* INR(PT)-2.3* . IMAGING: . NONCONTRAST HEAD CT ([**2191-9-7**]): There is a large region of transcortical hypoattenuation in the right temporal lobe, with some superior extension into the parietal lobe, consistent with a right MCA distribution acute ischemic infarct, likely predominantly involving its inferior division. No definite "hyperdense" right MCA is appreciated. There is no intracranial hemorrhage, mass effect, or shift of normally midline structures. Apart from the site of infarction, the [**Doctor Last Name 352**]-white matter differentiation is preserved. Ventricles are normal in size and configuration. Mild sulcal effacement is seen in the right temporal region. Suprasellar and basilar cisterns are patent. Paranasal sinuses and mastoid air cells are well aerated. Globes and orbits are preserved. IMPRESSION: Large acute right MCA distribution ischemic infarct without significant mass effect or intracranial hemorrhage. . NONCONTRAST MRI HEAD ([**2191-9-8**]): 1. Large acute-to-subacute right MCA stroke, with expected parenchymal edema, but no midline shift. 2. No evidence of large amount of intracranial hemorrhage. Small hypointense foci in the gradient echo images could represent either flow voids or a small amount of hemorrhage. . TTE ([**2191-9-8**]): The left atrium and right atrium are normal in cavity size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). 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) 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 pericardial effusion. IMPRESSION: No ASD/PFO or cardiac source of embolism. Normal global and regional biventricular systolic function. . TEE ([**2191-9-12**]): No cardiac source of embolism seen. Negative bubble study. However, there was quite vigorous inflow from the inferior vena cava which was baffled towards the septum by the Eustachian valve. As a result the upper part of the right atrium does not opacify well with bubbles, making less bubbles available for potential shunting. . MRI brain w/o contrast ([**2191-9-12**]): Evolving right MCA territory subacute infarct with hemorrhage. . BILATERAL LOWER EXTREMITY DOPPLERS ([**2191-9-13**]): No evidence of deep vein thrombosis of either right or left lower extremity. . Brief Hospital Course: Mr [**Known lastname 111763**] is a 32 year old man with no significant PMH who presented with left sided weakness and the inability to speak. . # CRYPTOGENIC RIGHT MCA STROKE: Per HPI, patient received IV tPA at OSH prior to transfer to [**Hospital1 18**]. On arrival to the ED, a repeat NCHCT showed extensive cerebral edema so decision was made not to pursue neuro-interventional procedure. Patient was admitted to Neuro-ICU for close monitoring. On arrival to the Neuro-ICU, strength had improved in the left lower extremity, but patient remained plegic in left upper extremity and left lower face and was neglecting the left side. He also had a severe headache not responsive to toradol, dilaudid, fentanyl or Tylenol. Repeat head CT 24 hours post tPA was stable compared to prior. CTA showed right MCA superior division cut-off, and MRI confirmed large right MCA stroke. For first 2 days of hospitalization he was quite lethargic and remained in ICU for close neurologic monitoring given risk for herniation [**3-3**] cerebral edema. His lethargy improved after this and he was transferred to the regular neurology floor for further monitoring. Given presence of right MCA superior division cut-off on CTA head, etiology of patient's stroke was felt most likely embolic. Extensive workup for embolic stroke was pursued, none of which was revealing. He had TTE which showed no PFO/ASD/atrial thrombi. Follow-up TEE showed Eustachian valve (fetal remnant) which caused artifact on study, but no clear PFO/ASD etc were seen. Routine LENIs showed no DVT. Given family history of early stroke (father) and sister with h/o 2 miscarriages, hypercoagulable state was also considered so extensive lab panel was sent including [**Doctor First Name **], lupus anticoagulant, Protein C/S activity, anticardiolipin IgG/IgM, alpha 2 antiplasmin, plasminogen antibody, and beta 2 migroglobulin IgA/IgG/IgM. All of these studies were negative. HIV [**1-31**] antibody was also sent (as HIV can cause increased propensity for thrombosis, presence of anti-phospholipid antibodies, clotting factor abnormalities and TTP-HUS). This too was negative. However, of note ultra-sensitive HIV PCR was not sent. Ultimately, . Patient also had routine modifiable stroke risk factor labs sent (A1C, full lipid panel) sent which revealed elevated A1C (7.3%) and elevated LDL (126). He was started on atorvastatin 40mg daily for secondary stroke prevention. Metformin 500mg PO BID was initially started, then stopped as small vessel disease was clearly not likely etiology of this stroke and diet/exercise seemed more appropriate intervention. . For directed stroke treatment, patient was initially started on ASA 325mg daily. However, as it was felt that etiology of this stroke was likely embolic, the decision was made to empirically start lifelong Coumadin for secondary stroke prophylaxis (day 1 = [**2191-9-13**]). Patient's INR remained stable between [**3-4**] on Coumadin 2.5mg daily during hospitalization. He will follow up with [**Hospital 191**] [**Hospital 197**] clinic for monitoring. . Clinically, patient's symptoms improved slowly during hospitalization with the aid of extensive PT, OT and speech therapy. His LLE strength quickly improved to full. His LUE strength improved to full in the proximal extremity, although he still has weakness in his distal LUE particularly in the wrist and finger extensors. His difficulty speaking was of particular interest to the neurology team, as aphemia (inability to vocalize, with preserved comprehension and written language) is almost always a left-sided brain lesion in right-handed patients. Ultimately it was felt that he is probably genetically co-dominant in terms of handedness. . For insurance reasons, patient was unable to be discharged to rehab. With extensive help from PT, OT, speech therapy and case management teams, plan was made for patient to be discharged to friend's home in [**State 350**] with free care for outpatient PT/OT/ST. He will follow up with Neurology (Dr. [**Last Name (STitle) **] in 2 months, at which point he will likely have repeat functional MRI for prognostic purposes. He will also have new PCP appointment within the next month: would advise rechecking HIV at this point. . ===================== TRANSITIONS OF CARE: - Contact info: mother [**Name (NI) **] ([**Telephone/Fax (1) 111764**]), [**Name2 (NI) **] (friend he will be staying with upon discharge: [**Telephone/Fax (1) 111765**]). Patient's cell phone # is [**Telephone/Fax (1) 111766**] but he is unable to speak. - Should consider repeat HIV test in future - Will follow up as outpatient with Dr. [**Last Name (STitle) **] in [**Hospital 878**] clinic ==================== ============================================================ 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 = 126 ) - () No 5. Intensive statin therapy administered? (for LDL > 100) () Yes - () No (if LDL >100, Reason Not Given: ) 6. Smoking cessation counseling given? () Yes - () 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? () Yes - () No (if LDL >100, Reason Not Given: ) 10. Discharged on antithrombotic therapy? (x) Yes (Type: () Antiplatelet - () Anticoagulation) - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A Medications on Admission: None Discharge Medications: 1. Outpatient Physical Therapy 2. Outpatient Occupational Therapy 3. Outpatient Speech/Swallowing Therapy 4. Warfarin 2.5 mg PO DAILY16 Start [**9-19**] in am RX *warfarin [Coumadin] 1 mg 2.5 tablet(s) by mouth once a day Disp #*100 Tablet Refills:*2 5. Atorvastatin 40 mg PO DAILY RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: 1. Right MCA stroke (likely embolic) 2. High cholesterol Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro exam: severe aphonia (difficulty producing speech) but preserved comprehension and ability to communicate via written language. +distal left arm weakness (3+/5 in left wrist and finger extensors). Full strength in bilateral lower extremities and right arm. Discharge Instructions: Dear Mr. [**Known lastname 111763**], You were admitted to the hospital after developing sudden-onset inability to speak and weakness in your left arm. You first went to an outside hospital where you were found to have a stroke and received IV tPA, a clot-busting medication. You were then transferred to [**Hospital3 **] where you were initially monitored closely in the ICU for brain swelling. We did an MRI which showed that you had a large stroke on the right side of your brain, likely caused by a blood clot (embolus). We searched extensively for the cause of this clot, but could not find any particular reason why you developed it. To prevent you from having more strokes in the future, we started you on Coumadin, a blood thinning medication to prevent clots from forming. We also found you have high cholesterol, so we started you on a cholesterol-lowering medication (atorvastatin) to help prevent future strokes. During hospitalization you worked closely with speech therapy, occupational therapy and physical therapy to regain some of your speech and strength. You will continue doing this as an outpatient. . Now that you are on Coumadin, you will need to have your blood tested periodically to make sure the level (a.k.a. INR) stays normal. You will be called by the [**Hospital3 **] [**Hospital 197**] Clinic on [**Hospital 766**] to arrange your lab tests. . Please attend the outpatient appointments listed below with your new Primary Care doctor ([**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **]), your Neurologist ([**Doctor First Name **] [**Doctor Last Name **]), and physical therapy. . We made the following changes to your medications: 1. STARTED Coumadin (Warfarin) 2.5mg by mouth daily 2. STARTED atorvastatin 40mg by mouth daily Followup Instructions: Department: NEUROLOGY When: Tuesday, [**11-15**] at 5:30 pm With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. ([**Telephone/Fax (1) 2574**]) Building: [**Hospital6 29**], [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: THURSDAY [**2191-10-13**] at 3:15 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 75863**], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage OCCUPATIONAL THERAPY APPOINTMENTS: Department: REHABILITATION SERVICES When: THURSDAY [**2191-10-13**] at 11:20 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24924**], OTR/L [**Telephone/Fax (1) 44928**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: REHABILITATION SERVICES When: TUESDAY [**2191-10-18**] at 1:20 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24924**], OTR/L [**Telephone/Fax (1) 44928**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: Speech Therapy When: [**Last Name (LF) 766**], [**9-26**] at 8:30-9:90 am When: Thursday, [**9-29**] at 2:00-3:00 pm When: Thursday, [**10-6**] at 3:30-4:30 pm Where: Span 106 (off enterance to [**Hospital Ward Name 121**] Building, [**Location (un) 453**]) Department: Rehabilitation Services - Physical Therapy When: Thursday, [**10-6**] at 2:15pm With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 111767**] Where: Span 106 (off enterance to [**Hospital Ward Name 121**] Building, [**Location (un) 453**]) Telephone: [**Telephone/Fax (1) 44928**] [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

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icd9pcs

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Discharge summary

report

Admission Date: [**2194-6-24**] Discharge Date: [**2194-7-10**] Date of Birth: [**2162-6-13**] Sex: M Service: MEDICINE Allergies: Bactrim / Penicillins Attending:[**First Name3 (LF) 6701**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Bronchealveolar Lavage on [**2194-6-27**] History of Present Illness: This is a 32 yo gentleman with PMH significant for newly diagnosed AIDS one month prior with most recent CD4 < 20, who presented with fatigue, cough, and fever for the last 5 days. . Patient was in his usual state of health until 5 days prior, when he developed a fatigue and a dry cough that appeared to be brought on by speaking. Of note, he had experienced dyspnea on exertion several weeks earlier upon initiation of HAART therapy which improved with the initiation of mepron. These symptoms persisted for the next four days. This morning, patient developed fever to 101.3 at home, chills, intermittent headache, facial flushing. Denies any nuchal rigidity or photophobia op rashes. Also endorses intermittent nausea. Denies CP, dysuria. Has had intermittent nightsweats over the last several weeks with 8 pound weight loss in last month. Reports that he was on a prednisone taper for the last three weeks, with last dose planned for today. . Of note, patient with history of longstanding loose stools, cramping initially attributed to IBS but found to have CMV on biopsy s/p colonoscopy in 6/[**2193**]. Patient is on prophylactic doses of mepron and azithromycin. . In the ED initial VS were T: 99.2, BP: 135/99, HR: 105, RR: 18, O2sat: 100% RA. Patient found to desat to 90% with ambulation and to the 80s with speaking. Chest radiograph demonstrated no acute process with improvement of faint left lung opacity. Patient was given zosyn 2.25mg IV, pentamidine 300mg IV, levofloxacin 750mg IV, prednisone 40mg PO X 1, tylenol 1gram X 1. . ROS: (+) Per HPI (-) Denies sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies vomiting, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rashes. No numbness/tingling in extremities. All other review of systems negative. Past Medical History: - AIDS diagnosed [**5-31**], reportedly CD4<20 with high viral load - CMV colitis diagnosed by colonoscopic bx in [**5-1**] - history of molluscum contagiosum - history of giardia infection in spring [**2193**] - seasonal allergies - GERD Social History: Works in real estate. Smoked [**11-23**] ppd from age 18-25. Denies ETOH or illicit use. MSM. Family unaware of his diagnosis and current hospitalization. Family History: Father with CAD, currently being evaluated at [**Hospital3 2358**] for CABG. Physical Exam: VS: T: 99, BP: 135/90, P: 109, R: 18, 100% RA Gen: NAD, pleasant HEENT: MMM Neck: supple, no JVD CV: RRR S1 S2 no R/G/M Pulm: good air movement, CTA B with no w/r/r. Abd: soft, nontender, nondistended, normoactive bowel sounds Ext: no edema, pulses 2+ bilaterally, no pedal edema Neuro: CNII-XII intact, moving all extremities, 5/5 strength, intact sensation in extremities. Pertinent Results: ADMISSION LABS: [**2194-6-24**] 08:33PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2194-6-24**] 08:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2194-6-24**] 06:17PM LACTATE-1.2 [**2194-6-24**] 06:10PM GLUCOSE-106* UREA N-11 CREAT-0.9 SODIUM-137 POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-30 ANION GAP-13 [**2194-6-24**] 06:10PM ALT(SGPT)-73* AST(SGOT)-42* LD(LDH)-191 TOT BILI-1.8* [**2194-6-24**] 06:10PM LIPASE-36 [**2194-6-24**] 06:10PM ALBUMIN-4.3 CALCIUM-9.6 PHOSPHATE-3.4 MAGNESIUM-2.3 [**2194-6-24**] 06:10PM WBC-4.6# RBC-4.20* HGB-12.8* HCT-37.0* MCV-88 MCH-30.4 MCHC-34.5 RDW-14.2 [**2194-6-24**] 06:10PM NEUTS-89.0* LYMPHS-7.0* MONOS-3.4 EOS-0.3 BASOS-0.3 [**2194-6-24**] 06:10PM PLT COUNT-147* URINE LABS: [**2194-7-7**] 05:50AM URINE pH-6 Hours-24 Volume-[**2108**] Creat-55 TotProt-8 Prot/Cr-0.1 [**2194-7-5**] 07:13AM URINE Hours-RANDOM UreaN-418 Creat-79 Na-80 K-17 Cl-51 TotProt-17 Calcium-5.7 Phos-85.5 Prot/Cr-0.2 DISCHARGE LABS: [**2194-7-10**] 05:27AM BLOOD WBC-3.9* RBC-3.33* Hgb-10.5* Hct-29.0* MCV-87 MCH-31.4 MCHC-36.1* RDW-14.6 Plt Ct-270 [**2194-7-10**] 05:27AM BLOOD Glucose-87 UreaN-9 Creat-1.2 Na-134 K-3.8 Cl-98 HCO3-27 AnGap-13 [**2194-7-10**] 05:27AM BLOOD ALT-71* AST-22 LD(LDH)-139 AlkPhos-100 TotBili-0.7 [**2194-7-10**] 05:27AM BLOOD Calcium-9.3 Phos-4.6* Mg-2.1 MICRO: [**2194-6-24**] Blood cx: Negative [**2194-6-25**] Urine cx: Negative [**2194-6-26**] RPR: Nonreactive [**2194-6-26**] Toxoplasma: negative serum IgM and IgG [**2194-6-26**] STOOL: Negative for Microspora, Cryptosporidium, Giardia, Cyclospora, C. diff, ova & parasites [**2194-6-26**] Urine Legionella: Negative [**2194-6-26**] Respiratory Viral Culture: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus. [**2194-6-26**] Cryptococcal Serum Ag: Negative [**2194-6-26**] Urine cx: negative [**2194-6-26**]: Blood cx: negative [**2194-6-27**] Blood fungal/mycoplasma cx: negative [**2194-6-27**] blood culture: negative [**2194-6-27**] 2:52 pm BRONCHOALVEOLAR LAVAGE : Positive for PCP [**2194-6-28**] CMV viral load 72,500 [**2194-6-30**] stool cx negative [**2194-7-1**] urine cx negative [**2194-7-2**] sputum cx negative for AFB [**2194-7-1**] blood cx negative [**2194-7-2**] blood cx negative [**2194-7-7**] blood cx and fungal cx pending [**2194-7-9**] CMV viral load pending Imaging: [**2194-6-24**] CXR: No acute intrathoracic abnormality. Faint left lung opacity is improved. As before, a non-urgent CT may clarify the underlying etiology of that opacity. [**2194-6-25**] CT Head: There are prominent sulci and ventricles consistent with cerebral atrophy. No acute intracranial process or large mass identified. If continued concern for occult intracranial process causing visual field deficit, enhanced MR (if feasible) would be more sensitive. [**2194-6-25**] CTA Chest: 1. Assessment for subsegmental PE is limited due to respiratory motion particularly in lung bases. Otherwise no evidence of pulmonary embolism to segmental levels. 2. Peribronchiolar nodules with adjacent ground glass opacities are suggestive of an acute infectious etiology but are not specific for a particular organism and may be due to viral, mycoplasma, MAC or bacterial etiology. However nodular opacities are not typical for PCP. 3. Probable anemia [**2194-6-27**] MRI Head w/ and w/o contrast: No acute intracranial hemorrhage, edema, or large mass identified. [**2194-7-1**] CXR: As compared to the previous radiograph, there is a slight progression of disease. The opacities at the bases of the right upper lobe and the periphery of the left upper lobe are slightly more extensive than on the previous radiograph. Otherwise, there are no changes. Unchanged size of the cardiac silhouette. [**2194-7-5**] abd US: Unremarkable renal and hepatic son[**Name (NI) **]. [**Name2 (NI) **] findings to explain elevated creatinine or LFTs. [**2194-7-7**] CXR: Unchanged multifocal opacities, worst in the left upper lobe, no significant interval changes. [**2194-7-9**] CXR: In comparison with the study of [**7-7**], there has been placement of a right subclavian PICC line that extends to the upper to mid portion of the SVC. The area of patchy opacification in the left mid and upper zone laterally is again seen. This is consistent with an area of consolidation. The suspected area of opacification in the right mid zone is not seen at the present time. Brief Hospital Course: #PCP: [**Name10 (NameIs) **] presented with 5 days of dry cough and fever of 101.3 the night before admission. Patient came to the hospital on atovaquone and prednisone for about 3 weeks for suspected PCP after recent outpatient visit for similar symptoms and SOB. On admission, patient was stable, and CXR showed improving lung opacity. CT chest on admission showed non-specific peribronchiolar nodules with adjacent ground glass opacities that were suggestive of an acute infectious etiology. At this point, given clinical suspicion for PCP, [**Name10 (NameIs) **] atovaquone was d/c'd and he was started on a course of pentamidine for treatment of suspected PCP (he had a bactrim allergy which precluded him from 1st line treatment of bactrim for PCP). Throughout the admission, he had occasional fevers but clinically remained stable with the exception of dry cough and blood/urine cultures were all negative on multiple occasions. Both ID and pulmonary were consulted who recommended a bronchealveolar lavagefor further diagnostic workup of cough. This was done on [**6-27**] and did not show macroscopic changes, but immunoflourescence test for PCP was positive. The infectious disease team felt strongly that he should be on bactrim despite his allergy, and an allergy/immunology consult was obtained to guide in bactrim desensitization. On [**6-30**] he was admitted for a rapid PO bactrim desensitization in the MICU. He tolerated this well, and was subsequently put on a 21 day course of 2 DS bactrim tabs TID, with an ongoing prophylactic dose of 1 DS tab daily after the course. He was sent out with prescriptions for these. His prednisone was also tapered down during admission, and he was put on a 10 day course of fluconazole for possible fungal infection which he completed in-house. . #CMV Retinitis: On admission patient was endorsing visual changes in his left eye; specifically black floaters. Given recent diagnosis of CMV colitis in [**Month (only) **], there was strong suspicion for CMV retinitis. An ophthalmology consult was obtained on [**6-25**] who did a bedside dilated fundoscopic exam which was significant for CMV retinitis of the inferior left retina. He was started on ganciclovir 5mg/kg IV BID for what will be a 21 day course. His vision remained stable throughout admission. He still endorsed the floaters, but they did not seem to worsen. He was set up with outpatient ophthalmology follow-up for [**7-11**]. On [**7-9**] a PICC line was placed so that he could continue his IV ganciclovir course as an outpatient. . #CMV Colitis: Patient diagnosed in [**Month (only) **] which prompted his HIV workup. Throughout admission patient would often have diarrhea sometimes multiple times/day. This began to improve toward the end of admission, and we suspect this is due to the effect of the IV ganciclovir that he was receiving for his retinitis. GI recommended a 3 weeks course of IV ganciclovir for the CMV colitis. Of note, his CMV viral load from [**6-28**] was 72,500. His repeat value is still pending at discharge. . #HIV/AIDS: We continued his HAART per his outpatient regimen. We also continued his q-weekly azithromycin for MAC prophylaxis. . #Transaminitis: On admission, pt had elevated LFTs with ALT of 73, AST of 42 and TBilli of 1.8. RUQ u/s showed nothing to suggest etiology. We suspected that this may have been [**12-24**] his HAART therapy, or perhaps the pentamidine or CMV in the liver. His LFTs continued to rise (ALT as high as 225, AST of 106, and AP of 135), and eventually they trended down to normal (with exception of ALT of 71 on discharge). . # ARF: Patient's creatinine bumped from 0.7-1.6 over 7 days. Differential included pre-renal given patient's nausea and poor PO intake vs medication induced. Renal was consulted who felt that this was likely pre-renal, and urine electrolytes 24-hour urine were obtained which suggested a pre-renal etiology. He was given large amounts of maintenance fluids over 3 days and his creatinine improved. He was written for prescription for IV boluses if necessary as an outpatient when his IV infusion therapists visit. Medications on Admission: - norvir 100mg PO daily - reyataz 300mg PO daily - truvada 200mg-300mg PO daily - atovaquone 1500mg (10 mL) oral suspension daily - prednisone 20mg PO daily taper started [**2194-6-5**] - fexofenadine 180 mcg PO daily - hyoscyamine 1-2 tabs PO BID prn - lorazepam 1mg PO prn - azithromycin 1200mg PO q weekly (wednesday) Discharge Medications: 1. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (WE). 3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 4. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO Q4PM (). 5. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO Q4PM (). 6. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO Q4PM (). 7. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) for 5 days: Continue until [**7-14**]. You may crush the tabs. Disp:*30 Tablet(s)* Refills:*0* 8. Ganciclovir Sodium 500 mg Recon Soln Sig: One (1) Intravenous twice a day for 6 days: weight dosed to 300mg [**Hospital1 **]. Disp:*qs * Refills:*0* 9. Zofran 8 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*90 Tablet(s)* Refills:*0* 10. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO once a day: Start this after completing your treatment dose on [**7-14**]. You may crush the tabs. Disp:*30 Tablet(s)* Refills:*2* 11. Infusion therapy Patient may receive 1 liter of normal saline with infusions if he has been vomitting or not taking PO 12. Hyoscyamine Sulfate 0.125 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for diarrhea. 13. Outpatient Lab Work Weekly lab draws through PICC until [**2194-8-22**]: CBC with differential, AST, ALT, Chem-10, CMV Viral load. Please have results faxed to your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 6420**] at [**Telephone/Fax (1) 34420**] Discharge Disposition: Home Discharge Diagnosis: Primary: Pneumocystis pneumonia Human Immunodeficiency Virus Acquired Immunodeficiency Syndrome cytomegalovirus retinitis cytomegalovirus colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 69730**], You were admitted to the hospital for cough and fever, and after a thorough workup, you were found to be positive for PCP (an infection of the lungs). We initially treated this with a medication called Pentamidine, because you were allergic to bactrim (the ideal treatment for PCP). However we desensitized you to bactrim(eliminated the allergy) during the hospitalization allowing us to treat you with it. You also have a condition called CMV colitis (a viral infection of your gastrointestinal tract), as well as CMV retinitis (an infection in your eye caused by the same virus). We have started you on an intravenous medication called ganciclovir, which should be continued twice per day until [**7-15**]. You will take this medication through your PICC line and will have services to help you do this. This will help to treat the virus in both your gastrointestinal tract and your left eye. Additionally, it very is important that you continue your Bactrim for the PCP infection, as missing doses may reactivate your allergy. You should continue to take 2 double strength tablets 3 times per day through [**7-14**]. Once you have completed this course, you should continue to take 1 double strength tablet daily. In addition to the above changes, we have stopped your prednisone and atovaqone. You should continue to take all other medications as previously prescribed. The details of all of your medications are listed below. We have also sent you home with zofran for nasusea. Please take one 8mg pill every 6 hours as needed for nausea. Please note the follow-up appointments which have been set up for you below. You will also need weekly labs drawn until [**2194-8-22**] by your visiting nurse. These include: CBC with differential, AST, ALT, BUN, Creatinine, electrolytes, and CMV viral load. Followup Instructions: Name: NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6420**] Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 6422**] Phone: [**Telephone/Fax (1) 5723**] Appointment: Wednesday [**2194-7-16**] 11:30am Department: [**Hospital3 1935**] CENTER When: FRIDAY [**2194-7-11**] at 1:55 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GASTROENTEROLOGY When: TUESDAY [**2194-7-22**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Weekly lab draws by your visiting nurse through your PICC line until [**2194-8-22**] which include: CBC with differential, AST, ALT, Chem-10, CMV Viral load. Please have results faxed to your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 6420**] at [**Telephone/Fax (1) 34420**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]

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Discharge summary

report

Admission Date: [**2136-4-27**] Discharge Date: [**2136-5-4**] Date of Birth: [**2101-9-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: Shoulder pain, insomnia, agitation Major Surgical or Invasive Procedure: None. History of Present Illness: 34 yoF w/ h/o OCD and chronic neck/shoulder pain who presented to the ED today c/o neck/shoulder pain and insomnia. Pt was recently admitted [**Date range (3) 45433**] w/ the same complaints. Given extensive prior negative w/u (see below), this was believed to be functional. She was initially on a morphine PCA, which was transitioned to oral meds. The pain service was consulted who recommended neurontin/ralofin/ambien/vicodin. Psych was also consulted, and the patient was started on anafranil and ambien. The patient did receive lorazepam 0.5 - 1 mg q4h, which was tapered to q6h prior to discharge. Since disharge, the patient's pain has continued unabated. She describes "hot, burning" pain [**11-12**] in her right arm, right scapula, down the back of her neck, and an "aching" [**3-15**] pain in her left scapula. (+) intermittent numbness/subjective weakness of RUE. She has only slept for ~ 4 hrs in the last 4 days. She denies headache, fever, chills, stiff neck, heat/cold intolerance, nausea, vomiting, abdominal pain, chest pain, shortness of breath, or dysuria. (+) 2 episodes of loose stools/day for the last 2 days. When she presented to the ED, T 99.7, HR 110s-150s, bp 170/112. Given agitation and concerning for benzodiazepine withdrawl, the patient received a total of 8 mg of IV lorazepam, 30 mg IV diazepam, 2 mg IV hydromorphone, 10 mg IV morphine within a 10 hr period. Psychiatry was also consulted, who recommended d/c ambien, start standing valium 10 mg POdaily, haldol 5 mg PO daily avoid anafranil and ultram Past Medical History: 1) OCD 2) Chronic neck/shoulder pain - [**10-6**] EMT: mild slowing of right median conduction across carpal tunnel - [**12-7**] C-spine MRI: disc protrusions C4-7 w/ indent on spinal canal, most severe right C6-7 - 1/05 L-spine MRI: disc dessication L4-5 and L5-S1; L4-5 disc dz w/ ?neural canal narrowing - [**3-10**] T-spine MRI mild disc bulging and disk degenerative changes T11-12 and T12-L1 - followed by pain clinic; receiving TENS/steroid injections 3) history of thyroiditis 4) R breast implant Social History: Shx: married, no ETOH or tobacco use. Family History: Family hx: Her mother has hypertension. There is no family history of arthritis or autoimmune diseases Physical Exam: PE: Tc 99.7, pc 110, resp 20, 97% RA Gen: young female, initially sleeping comfortably. When awoken, becomes agitated, wiggling in bed and arching back. A&OX3. HEENT: Pupils ~ 6 mm and sluggishly reactive to light, EOMI, anicteric, nl conjunctiva, OMM dry, OP clear, neck supple, no LAD, no JVD, no thyromegaly Cardiac: tachycardic, regular, no M/R/G appreciated Pulm: CTA bilaterally Abd: NABS, soft, NT/ND Ext: No C/E/E, warm w/ 2+ DP bilaterally. Full passive ROM in shoulders/elbows/wrists bilaterally. Active ROM right shoulder limited by pain. Skin: Cheeks and upper chest mildy flushed. Erythematous birthmark over right upper extremity Back: No point tenderness over spine. No CVA tenderness. Diffuse tenderness to palpation over right scapula. Neuro: CN II-XII grossly intact and symmetric bilaterally, [**6-7**] strength througout. 5/5 strength throughout, 1+ UE and LE reflexes, symmetric bilaterally, toes equivocal bilaterally. No tremor, no asterixis. * Pertinent Results: [**2136-4-27**] 04:56AM PLT COUNT-364 [**2136-4-27**] 04:56AM NEUTS-83.5* LYMPHS-11.0* MONOS-4.9 EOS-0.3 BASOS-0.2 [**2136-4-27**] 04:56AM WBC-12.4* RBC-4.55 HGB-14.3 HCT-39.2 MCV-86 MCH-31.4 MCHC-36.5* RDW-12.9 [**2136-4-27**] 04:56AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2136-4-27**] 04:56AM TSH-0.77 [**2136-4-27**] 04:56AM ALBUMIN-5.0* CALCIUM-10.0 PHOSPHATE-3.1 MAGNESIUM-2.0 [**2136-4-27**] 04:56AM LIPASE-43 [**2136-4-27**] 04:56AM ALT(SGPT)-28 AST(SGOT)-44* LD(LDH)-274* AMYLASE-43 TOT BILI-0.9 [**2136-4-27**] 04:56AM GLUCOSE-109* UREA N-4* CREAT-0.6 SODIUM-134 POTASSIUM-2.9* CHLORIDE-94* TOTAL CO2-28 ANION GAP-15 [**2136-4-27**] 11:30AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2136-4-27**] 11:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2136-4-27**] 11:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004 [**2136-4-27**] 01:05PM D-DIMER-126 [**2136-4-27**] 01:16PM LACTATE-2.4* K+-3.8 [**2136-4-27**] 04:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Brief Hospital Course: Mrs [**Known lastname 45434**] is a 34 year old lady with cervical disc protrusions, long-standing obsessive-compulsive disorder, anxiety, and trichotillomania, who came to the hospital with acute on chronic severe neck and shoulder pain. Previous [**Hospital1 18**] MRI showed cervical disc protrusion on MRI and previous shoulder films were not remarkable. On admission, she was extremely anxious with persistent marked sinus tachycardia. Because of a concern for benzodiazepine withdrawal, she was admitted to the [**Hospital Unit Name 153**]. Again, her symptoms were initially presumed secondary to a benzo withdrawl, but this was reconsidered because she was taking only low doses at home. Over her [**Hospital Unit Name 153**] course, she had persistent tachycardia (up to 180s) accompanied by extreme anxiety and pain. All ECGs showed sinus rhythm. Her TSH was normal and she had no obvious signs of infection, hypoxia (i.e. pulmonary embolism), or intoxication. Her clinical picture was not consistent with a pheochromocytoma or another exogenous adrenergia. Her SBPs initially were in the 150s, but subsequently normalized. She was seen by Pain and Psych. A major psychiatric component of her pain syndrome was recognized. Further details by problem: 1. Neck/Shoulder Pain: this is likely from a combination of right rotator cuff tendonitis and cervical disc disease. We contact[**Name (NI) **] the pt's Orthopedist, Dr. [**Last Name (STitle) 7808**], who recommended that her rotator cuff tendonitis may benefit from anti-inflammatory therapy, but that he would offer no further intervention until the pt's Psychiatric disease was stablized, as he believes there is a large Psychiatric component to the pt's pain. Dr. [**Last Name (STitle) 7808**] did NOT recommend repeat imaging of the shoulder. The pt's Neurosurgeon at [**Hospital1 2025**] had not recommended surgery for her cervical disc disease at the time of admission. Chronic pain service was consulted, and recommended standing ibuprofen w/ MS contin for long-acting analgesia, and MSIR for breakthrough pain. The pt's pain was much improved w/ morphine, allowing for greater mobility and functionality. However, she had persistent pain, prompting consultation of Neurology service to evaluate need for further imaging or surgery. The Neurology consultants believed that the pt did not require imaging or surgical intervention, and recommended continuing the current treatment w/ addition of a soft cervical collar. A multi-disciplinary team meeting including Internal Medicine, Psychiatry, and Chronic Pain Medicine agreed that it is ultimately important that this pt have consistent care from a consistent set of providers, w/ medication to be prescribed by 1 provider [**Name Initial (PRE) 19007**] (preferrably the pt's PCP,) and recommendations to be made to the PCP by specialist services. The pt agreed w/ this plan; however, she is not happy w/ her current PCP and wishes to establish a new PCP at the [**Name9 (PRE) 2025**] primary care clinic. She plans to pursue this after d/c. The pt was screened for the [**Hospital1 **] Pain Rehab program, but no beds were available for the inpt program and the screener recommended that the pt pursue the outpt program until an inpt bed became available. She was d/c with prescription for MS Contin and MSIR, and was instructed to f/u w/ her Neurologist, Orthopedist, and new PCP. 2. Sinus Tachycardia: This was likely secondary to pain and anxiety as her HR was normal during sleep. Her HR reached rates of 180s during her admission, but assurance and treatment of anxiety were successful at reducing rates. There were no signs of hypovolemia, hypoxia, or endocrine dysfunction during her admission. TSH was normal. At d/c, she has occasional sinus tachycardia when she is in pain or anxious, which resolves w/ sleep. 3. OCD/Anxiety: Psychiatry service was consulted and initially believed that the pt's symptoms were all [**3-7**] pain. However, as her anxiety and complaints persisted despite pain control w/ morphine, Psychiatry consultants believed that the pt was having a flair of her OCD and would benefit from inpt Psychiatric admission to stabilize her symptoms and sleep. Seroquel was added to aid in sleep, with good effect. Her clomipramine dose was increased to 50mcg daily during her admission, as recommended by her outpt Psychiatrist. When the pt was medically stabilized, Psychiatry consultants offered inpt Psych admission to the pt, who refused any further inpt care. The pt was thus d/c to home to f/u with her oupt Psychiatrist. At d/c, she has significant anxiety surrounding her neck/shoulder pain and uncertainty about the future of her symptoms and treatment. Medications on Admission: Gabapentin 300 mg PO TID Hydrocodone-Acetaminophen 2.5-500 mg qhs prn Clomipramine 25 mg PO daily Prilosec 20 mg PO daily Nabumetone 500 mg PO BID Ambien 10 mg PO daily (took 20 mg yesterday) Seroquel Ativan 1-1.5 mg/day (last dose 2 days ago) Discharge Medications: 1. Cervical soft collar 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take daily while using morphine. Disp:*60 Capsule(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take daily while using morphine. Disp:*60 Tablet(s)* Refills:*2* 5. Morphine Sulfate 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*58 Tablet Sustained Release(s)* Refills:*0* 6. Morphine Sulfate 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours): apply to affected area once each day, change patch daily . Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0* 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation: take if constipated while using morphine. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* 10. Clomipramine HCl 25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 12. Ibuprofen 400 mg Tablet Sig: 0.5-1 Tablet PO Q4-6H (every 4 to 6 hours). Discharge Disposition: Home Discharge Diagnosis: Primary: 1. cervical stenosis with back and neck pain 2. right rotator cuff tendonitis 3. obsessive compulsive disorder Discharge Condition: Stable to go home with follow-up. Eating, walking, no signs of infection, no signs of cord compression. Discharge Instructions: You are being discharged after treatment for neck, back, and shoulder pain secondary to cervical stenosis. Please call your doctor or present to the ED for eval if you have pain unrelieved by medication, fever, shortness of breath, bleeding, inability to urinate, or other concerning symptoms. Followup Instructions: 1. Follow-up with Dr. [**Last Name (STitle) 45435**] at [**Hospital1 2025**] Neuro clinic on [**2136-5-9**] at 2PM, # [**Telephone/Fax (1) 45436**] 2. Provider: [**Name10 (NameIs) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ORTHOPEDIC PRACTICE Where: [**Doctor Last Name **] ORTHOPEDIC PRACTICE Date/Time:[**2136-5-22**] 1:15 3. Follow-up with Dr. [**Last Name (STitle) 5730**] in Psychiatry clinic on [**2136-5-25**] at 2:30 PM 4. Follow-up with Dr. [**Last Name (STitle) **], [**Apartment Address(1) 9394**] PAIN MANAGEMENT CENTER Where: PAIN MANAGEMENT CENTER Date/Time:[**2136-6-1**] 11:40 5. Expect a letter from [**Hospital1 **] Pain Rehab with an appointment date and time for your initial evaluation. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "530.81", "300.3", "782.0", "312.39", "300.00", "722.0", "276.5", "704.00", "427.89", "401.9", "781.0", "780.52" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11439, 11445

4827, 9562

348, 356

11609, 11715

3634, 4804

12058, 12926

2525, 2630

9857, 11416

11466, 11588

9588, 9834

11739, 12035

2645, 3615

274, 310

384, 1925

1947, 2454

2470, 2509

31,730

174,225

12256

Discharge summary

report

Admission Date: [**2150-11-11**] Discharge Date: [**2150-11-21**] Service: MEDICINE Allergies: Diltiazem / Demerol Attending:[**First Name3 (LF) 7055**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: EVENTS / HISTORY OF PRESENTING ILLNESS: (per HPI) "84 year old woman with known CAD (s/p BMS to RCA x 2 in '[**44**], DES to LAD [**2-11**]), systolic HF (EF 45%), PVD (s/p bilateral LE bypass,) HTN, RAS, PAF, who presented to an outside hospital w/ sudden onset of SOB. Patient awoke in middle of night w/ difficulty breathing. When EMS arrived, she was found to be hypoxic to 84%. She was initially admitted to the ICU for CPAP, but with a significant symptomatic improvement to lasix, she was able to have oxygen titrated down to NC. She denies any ensuing CP prior to the episode and had no palpitations. She denies any recent LE swelling, premonitory SOB, or lightheadedness. Patient had a recent hospitalization 2 weeks prior to presentation. At that time she ruled out for MI, and was discharged following adjustments to medication. Patient underwent a pharm neuclear stress test, which was nondiagnostic on EKG, with failure to show changes in baseline sinus bradycardia. There is no report in the transfer records of elevated cardiac enzymes. Per report, nuclear imaging showed nuclear mixed inferior defect. Patient was transfered to [**Hospital1 18**] for cardiac catheterization." . Oon [**2150-11-11**], pt underwent a cardiac catheterization which showed ISRS and she had 2 DES to the LAD placed. She did well post-cath and received renal protection via bicarb and mucomyst. Her volume status remained tenuous and she was aggressively diuresed. However, her renal function also began to decline, raising concern for overdiuresis. Her room air sats remained low, though, so her outpatient lasix dose was resumed. Today, she was given her AM dose of lasix, but her afternoon dose was held because of her rising creatinine and her euvolemic status. However, in the evening, the patient began to complain of respiratory distress. Her SBP were found to be in the 160s-170s. She was given: 60mg IV lasix (with minimal UOP), 4mg IV morphine total, and nitroglycerin gtt at 1.4mcg/kg/min. Sats were 78% on 3-4L -> improved only to 90-92% on NRB. She was given an additional dose of 120mg lasix IV with minimal UOP. An ABG showed pH 7.18, pCO2 95, and pO2 94. Decision was made to attempt BiPAP but that was unable to be performed on the floor. The patient was minimally responsive and was using accessory muscles of respiration. The decision was made to intubate her for airway protection and control. She was intubated easily (with etom/succ) and brought to the CCU for further management. EKG performed on arrival to the SICU were concerning for ST elevations in the precordial leads, but they resolved somewhat with time so the decision was made to follow her enzymes and not go to cath urgently. She remained on heparin IV overnight for possible ACS as her troponins were elevated (but her CK was flat). Past Medical History: -CAD -> multivessel s/p 2 complex angioplasties of RCA; [**2-6**] she underwent PTCA/stenting of the mid/distal RCA; [**9-8**] LMCA had a mild proximal stenosis, LAD had a 60% proximal stenosis at D1. The remainder of the vessel had mild-moderate diffuse disease. . -The circumflex system was small with a 40% focal OM1 lesion. The RCA had a 20% proximal stenosis. There were serial 90% and 80% focal in-stent restenotic lesions of the mid and distal vessel. The PDA filled via collaterals from the left. Successful PTCA of the RCA was performed using a 3.0x15 mm cutting balloon proximally and a 2.5x15 mm cutting balloon distally. There was 20% residual stenosis in the mid-RCA and 10% distally with normal flow and no apparent dissection. . -DES to LAD in [**2-11**] --CHF - h/o recurrent admissions for CHF exacerbations; cath [**2144**] showed elevated filling pressures but normal EF. Recent ETT with anterior apical ischemia. LVEF 45-50% . --h/o pseudoaneurysm of brachial artery h/o difficult access due to -- --DM --HTN --PVD s/p Aortobifemoral bypass --hypercholesterolemia --anemia (baseline Hct 31-34) --PAF . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Cardiac History: as above . Percutaneous coronary intervention, in [**2144**] anatomy as follows: as above . Pacemaker/ICD: n/a Social History: Lives with daughter, non [**Name2 (NI) 1818**], no etoh. Family History: + DM, Physical Exam: EXAM: VS: T 97.3, BP 116/42, HR 62, RR 19, sats 100% on AC 450x18, Fi02 100%, PEEP 5 I/O -1130 since arrival to unit Gen: Elderly female, sedated and intubated. HEENT: Sclera anicteric, NCAT. Pupils are small, minimially reactive to light. ETT in place. Neck: Supple, JVP ~9cm. CV: NL S1 S2, RRR, II/VI systolic murmur at LUSB. Lungs: Coarse, crackles anteriorly and at bases bilaterally. + wheezes. Abd: Soft, NTND. + BS throughout. No masses. Ext: Unable to palpate femoral pulses, DP or PT bilaterally, but are warm to touch w/o evidence of pitting edema. No c/c. Has erythematous area on L second toe. Pertinent Results: . ADMISSION LABS . [**2150-11-12**] 07:10AM BLOOD WBC-5.5 RBC-4.37# Hgb-12.1# Hct-37.3# MCV-85 MCH-27.7 MCHC-32.4 RDW-16.8* Plt Ct-314 [**2150-11-11**] 11:00PM BLOOD Plt Ct-290 [**2150-11-12**] 07:10AM BLOOD Glucose-224* UreaN-32* Creat-1.3* Na-140 K-4.0 Cl-98 HCO3-30 AnGap-16 [**2150-11-11**] 11:00PM BLOOD CK(CPK)-22* [**2150-11-12**] 07:10AM BLOOD Mg-2.5 Cholest-128 [**2150-11-18**] 08:19PM BLOOD %HbA1c-5.7 [**2150-11-12**] 07:10AM BLOOD Triglyc-122 HDL-41 CHOL/HD-3.1 LDLcalc-63 . . CARDIAC ENZYMES [**2150-11-11**] 11:00PM BLOOD CK(CPK)-22* [**2150-11-15**] 06:26AM BLOOD CK(CPK)-64 [**2150-11-15**] 12:21PM BLOOD CK(CPK)-251* [**2150-11-15**] 08:58PM BLOOD CK(CPK)-351* [**2150-11-16**] 10:48AM BLOOD CK(CPK)-563* [**2150-11-17**] 11:16AM BLOOD CK(CPK)-337* [**2150-11-18**] 12:10AM BLOOD CK(CPK)-162* [**2150-11-19**] 03:00PM BLOOD CK(CPK)-48 . [**2150-11-15**] 01:13AM BLOOD CK-MB-NotDone cTropnT-0.27* [**2150-11-15**] 06:26AM BLOOD CK-MB-NotDone cTropnT-0.24* [**2150-11-15**] 12:21PM BLOOD CK-MB-28* MB Indx-11.2* cTropnT-0.62* [**2150-11-16**] 04:11AM BLOOD CK-MB-42* MB Indx-9.9* cTropnT-1.20* [**2150-11-16**] 10:48AM BLOOD CK-MB-52* MB Indx-9.2* cTropnT-1.52* [**2150-11-17**] 11:16AM BLOOD CK-MB-20* MB Indx-5.9 cTropnT-2.64* [**2150-11-18**] 12:10AM BLOOD CK-MB-10 MB Indx-6.2* cTropnT-2.58* [**2150-11-19**] 03:00PM BLOOD CK-MB-NotDone cTropnT-3.77* . . LABS BEFORE DEATH . [**2150-11-20**] 05:00AM BLOOD WBC-7.1 RBC-3.40* Hgb-9.8* Hct-28.9* MCV-85 MCH-28.8 MCHC-33.9 RDW-17.7* Plt Ct-388 [**2150-11-20**] 05:00AM BLOOD Neuts-90.2* Lymphs-7.0* Monos-2.3 Eos-0.4 Baso-0 [**2150-11-20**] 05:00AM BLOOD Plt Ct-388 [**2150-11-20**] 05:00AM BLOOD PT-13.8* PTT-32.0 INR(PT)-1.2* [**2150-11-20**] 05:00PM BLOOD Glucose-132* UreaN-103* Creat-4.1* Na-133 K-3.6 Cl-90* HCO3-28 AnGap-19 [**2150-11-20**] 05:00PM BLOOD Calcium-8.8 Phos-5.4* Mg-2.9* [**2150-11-20**] 05:00AM BLOOD Calcium-8.5 Phos-5.9* Mg-3.0* [**2150-11-20**] 05:00AM BLOOD Osmolal-311* [**2150-11-19**] 04:43PM BLOOD Osmolal-315* [**2150-11-19**] 04:44PM URINE Hours-RANDOM UreaN-408 Creat-43 Na-34 [**2150-11-19**] 04:44PM URINE Osmolal-347 . LAST ECG Cardiology Report ECG Study Date of [**2150-11-21**] 2:01:08 AM . Sinus rhythm. Diffuse low voltage. Intraventricular conduction delay. Probable prior lateral myocardial infarction. Compared to the prior tracing of [**2150-11-20**] the rate has increased. Otherwise, no diagnostic interim change. . Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] . LAST CXR CHEST (PORTABLE AP) [**2150-11-20**] 7:45 AM Reason: monitoring pulm edema and L pleural effusion [**Hospital 93**] MEDICAL CONDITION: 84 year old woman with fluid overload, thoracentesis on [**11-18**], ARF, stent thrombosis, s/p PCI. REASON FOR THIS EXAMINATION: monitoring pulm edema and L pleural effusion REASON FOR EXAMINATION: Fluid overload and pleural effusion monitoring. . Portable AP chest radiograph compared to [**2150-11-19**]. . There is no significant change in bilateral perihilar haziness suggesting pulmonary edema. In contrary, there is significant increase in right pleural effusion. The left pleural effusion remains unchanged. The bilateral atelectases are noted left more than right with no significant interval change. . IMPRESSION: Interval increase in moderate-to-large right pleural effusion. Unchanged mild-to-moderate pulmonary edema. . . CARDIAC CATH [**2151-11-17**] . BRIEF HISTORY: Patient is a 84 year old woman with CAD, CRI, DM, PVD with stenting to LAD 5 days ago for in-stent restenosis in the setting of pulmonary edema which is her anginal equivalent. She had two Taxus stents 2.5x24 and 2.75x12 overlapping placed into the LAD. She now presents again with CHF and had to be briefly intubated. Her troponin rose and was thought to initially be demand but when CK rose to 500's and echo showed anterior wall motion abnormality today, stent thrombosis in the LAD became a concern. EKG with LBBB which had been present intermittently in past. Patient was taken emergently to cath lab to exclude sub-acute stent thrombosis. . PTCA COMMENTS: Initial angiography revealed an occlusion of the mid LAD at the distal edge of the recently placed Taxus stent consistent with stent thrombosis. We planned to treat this lesion with PTCA and stenting. Heparin and integrelin were started in addition to asa and plavix. A 6F XBLAD guide provided good support for the procedure. A PT graphix wire crossed the lesion without difficulty. We Dottered through the lesion and re-established flow. A Voyager 2x15mm balloon was inflated at 8 atm and the lesion was stented with a 2.5x12 mm Vision stent at 18atm. The stent was post-dilated with a Highsail 2.75x8mm balloon at 26atm. Final angiography revealed no angiographically apparent dissection and TIMI 2 flow. Patient left the cath lab in stable condition. . COMMENTS: 1. Selective coronary angiography of the left system revealed occlusion of the recently stented LAD. The LMCA, LCX and their branches were unchanged from cath 5 days ago. The RCA was not engaged. 2. Limited hemodynamics revealed systemic blood pressure of 125/49 with HR of 56. 3. Successful treatment of mid LAD stent thrombosis with Vision 2.5x12mm stent. Final angiography revealed TIMI 2 flow. . FINAL DIAGNOSIS: 1. Single vessel CAD with stent thrombosis of the LAD 2. Successful recanalization of LAD and stenting with Vision bare metal stent. . ATTENDING PHYSICIAN: [**Last Name (LF) **],[**First Name3 (LF) **] M. REFERRING PHYSICIAN: [**Last Name (LF) 38289**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 275**] CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] M. [**Last Name (LF) 38290**],[**First Name3 (LF) **] M. ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] A. . . CARDIAC ECHO [**2151-11-17**] . This study was compared to the prior study of [**2150-2-24**]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. No LV mass/thrombus. Severely depressed LVEF. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC [**Year (4 digits) **]: Mildly thickened aortic [**Year (4 digits) **] leaflets (3). No AS. No AR. MITRAL [**Year (4 digits) **]: Mildly thickened mitral [**Year (4 digits) **] leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral [**Year (4 digits) **] chordae. Calcified tips of papillary muscles. Moderate (2+) MR. [**First Name (Titles) 24998**] [**Last Name (Titles) **]: Mildly thickened [**Last Name (Titles) **] [**Last Name (Titles) **] leaflets. Mild to moderate [[**12-9**]+] TR. Moderate PA systolic hypertension. PULMONIC [**Month/Day (2) **]/PULMONARY ARTERY: No PS. PERICARDIUM: No pericardial effusion. . Conclusions The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed (LVEF= 25%) with global hypokinesis and regional akinesis of the mid to distal septum and apex. There is no ventricular septal defect. Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. The aortic [**Month/Day (2) **] leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral [**Month/Day (2) **] leaflets are mildly thickened. There is no mitral [**Month/Day (2) **] prolapse. Moderate (2+) mitral regurgitation is seen. The [**Month/Day (2) **] [**Month/Day (2) **] leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2150-2-24**], the LVEF is now significantly depressed. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2150-11-16**] 16:06 . . CARDIAC CATH [**2151-11-12**] . BRIEF HISTORY: 84 year old female with a past medical history of CAD, diabetes, hypertension, and hypercholesterolemia. Presented [**2150-11-8**] to an outside hospital with pulmonary edema which was thought to be her anginal equivalent. History of severe PVD (multiple bypass surgeries) as well as multiple coronary PCIs. . INDICATIONS FOR CATHETERIZATION: Coronary artery disease, Canadian Heart Class IV, stable. . HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.65 m2 HEMOGLOBIN: 11.9 gms % FICK **PRESSURES RIGHT ATRIUM {a/v/m} 12/12/8 RIGHT VENTRICLE {s/ed} 53/12 PULMONARY ARTERY {s/d/m} 53/16/31 PULMONARY WEDGE {a/v/m} 18/18/16 LEFT VENTRICLE {s/ed} 138/16 AORTA {s/d/m} 138/40/60 . PTCA COMMENTS: Initial angiography revealed a 90% mid LAD ISR and 70% disease just distal to the prior stent. We planned to treat this lesion with ptca and stenting. Heparin was started prophylactically for the procedure. An xblad guiding catheter provided adequate support for the procedure. The lesion was crossed with a prowater wire with minimal difficulty. The lesion was dilated with a 2.0x15mm voyager balloon at 10 atm and then at 12 atm. A 2.5x24mm taxus stent was ythen deployed in the distal stenosis at 6 atm., A 2.75x12mm taxus stent was then deployed overlapping the proximal edge of the just-placed stent and within the previously stented region at 18 atm. The stents were postdilated with a 2.5x20mm nc [**Male First Name (un) **] balloon at 18 atm, 22 and then at 24 atm sequentially. Final angiography revealed o% residual stenosis, no angiographically apparent dissection and timi 3 flow. The patient left the lab free of angina and in stable condition. . COMMENTS: 1. Selective coronary angiography in this right dominant system demonstrated two vessel coronary artery disease. The LMCA had moderate diffuse disease, was moderately calcified, and had a distal taper of 40%. The LAD had a 40% stenosis at its origin. The previously placed stent had 90% in-stent restenosis. There was distal LAD had a 90% stenosis. The LCx was a nondominant vessel without critical lesions. There is a mid-segment 40% lesion unchanged from the previous angiograpm. The RCA was the dominant vessel with a previously placed and widely patent stent. The previous 60% stenosis in now 40%. There is diffuse PLB disease that was unchanged from previous angiography. 2. Resting hemodynamics demonstrated normal right sided filling pressures. The RVEDP wa 12 mmHg. There was pulmonary arterial hypertension with a pulmonary artery pressure of 53/16/31 (systolic/diastolic/mean in mmHg). LVEDP was 16 mmHg. There were no gradients across the [**Male First Name (un) **], pulmonary, mitral, or aortic valves. 3. Successful PTCA and stenting of the mid LAD with overlapping 2.5x24mm taxus and 2.75x12mm taxus both post dilated to 2.5mm. Final angiography revealed o% resiudal stenosis, no angiographically apparent dissection and timi 3 flow (see ptca comments). . FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. . ATTENDING PHYSICIAN: [**Last Name (LF) **],[**First Name3 (LF) **] A. REFERRING PHYSICIAN: [**Last Name (LF) **],[**First Name3 (LF) 1569**] W. CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] T. [**Last Name (LF) **],[**First Name3 (LF) **] A. ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] A. . Brief Hospital Course: Mrs. [**Known lastname 38291**] was an 84 y/o woman admitted for a CHF exacerbation, anginal equivalent. She went to cardiac cath on [**11-11**], was found to have 90% instent restenosis of her LAD and 90% stenosis just distal to the end of the stent. Two overlapping Taxus stents were placed at this time. Patient returned to the floor. She was noted to have a creatinine rise at this time. She developed volume overload and went into flash pulmonary edema on the floor. She was emergently intubated on [**2151-11-15**]. She at this time had no urine output to 60mg IV lasix. She then put out to 120mg IV lasix and diuril. Patient was noted to have a new LBBB at this time. Pt was noted to have an enzyme leak at this time, but her troponins were flat for the next day. The following day [**11-15**] she was extubated. She at that time developed shortness of breath and her enzymes trended up. She was taken back to the cardiac cath lab where she was noted to have an sub-acute thrombosus of at the distal margin of her recently placed LAD taxus stent. PTCA was done and a bare metal stent was placed. A repeat transthoracic echo was showed a LVEF of 25%, with global hypokinesis, a change from patients [**2-11**] echo. . At this time patient was noted to be in fluid overload. She had a left sided pleural effusion and an increasing oxygen requirement. On [**11-18**] a thoracentesis was done to help reduce oxygen requirement. . Patient had received two dye loads in one week. She at this time was making urine, but not putting out substantially to her lasix. A lasix drip was started. At this time the patient developed acute renal failure. Her Cr had climbed from 2.0 (1.3 on admit) to Cr 4.0. Patient was not responding well to diuril or lasix. The renal service was consulted to evaluate for CVVH. CVVH was considered and on the day prior to death, it was felt that clinically the patient could wait another day before starting dialysis. . Around this time metoprolol was stopped as patient was considered to be in an acute systolic CHF exacerbation. She was also started on Milrinone to help forward flow, in the hopes that it would aide in kidney perfusion and lead to better diuresis. . In the early morning of [**11-21**]. Patient reported sudden onset of shortness of breath. An ECG was done which showed no change from prior. Patients vitals were stable. She was slightly tachycardic, but normotensive. Patients oxygen requirements had not changed and on physical exam her lungs sounded clearer than earlier in the day. She was given IV morphine, started on a nitro drip and her milrinone was discontinued. Patients shortness of breath was relieved by this regimen. . Starting 4 hours prior to this the patient stopped making urine. She was not responding to lasix at this time. The patient's vitals were at this time stable. Normal heart rate, normotensive, normal RR, above 90% oxygen saturations. She was breathing with out distress and denied any more sensation of chest pain or dyspnea. The team felt that there was no need to consult for urgent dialysis. Renal had evaluated the patient only 7 hours prior and felt CVVH was not needed. Plans were in place for renal to reevaluate for CVVH first thing in the morning. . At 3AM, the housestaff was notified by nursing that the patient had passed away. There was no change in vitals or further complaints by patient prior to passing. Telemetry showed the patient went from normal sinus rhythm straight into asystole. The patient had been made DNR/DNI two days prior to this episode, so no code was called. . The attending physician and next of [**Doctor First Name **] were notified. PCP was later notified. Patient's daughter who was the healthcare proxy was offered and refused an autopsy. The primary cause of death was considered to be coronary artery disease. The immediate cause was unknown as there was no post-mortem. It was hypothesized that the cause of death was from a very sudden etiology such as acute thrombosus of her LAD, pulmonary embolism or another condition leading to a possible PEA cardiopulmonary arrest. This is however only speculation. Pt was never witnessed to be in PEA. . [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8952**] MD Medications on Admission: lasix 60mg [**Hospital1 **] amiodarone 200mg daily atenolol 50mg daily plavix 75mg daily imdur 60mg daily folate 1mg daily simvastatin 40mg daily hydralazine 25mg qid iron sulfate 325 mg [**Hospital1 **] calcium/vit D alendronate 70mg q wed ASA 325 mg daily NPH insulin 21 Units qam 14u in hs and RISS Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Cardiopulmonary Arrest Primary Cause of death was coronary artery disease, over years. Discharge Condition: Expired Discharge Instructions: No instructions. Pt expired. Followup Instructions: No follow up patient expired from unknown etiology. Post-mortem analysis was refused by patient's next of [**Doctor First Name **].

[ "414.01", "405.91", "584.9", "996.72", "599.0", "V45.82", "V17.3", "410.71", "428.23", "440.23", "272.0", "428.0", "518.81" ]

icd9cm

[ [ [] ] ]

[ "36.07", "38.93", "00.40", "37.22", "00.66", "00.46", "96.71", "34.91", "00.45", "37.23", "88.56", "36.06", "96.04" ]

icd9pcs

[ [ [] ] ]

21617, 21676

17021, 21265

250, 276

21807, 21816

5193, 7838

21893, 22027

4545, 4552

7875, 7976

21697, 21786

21291, 21594

16625, 16998

21840, 21870

4567, 5174

13976, 16608

190, 212

8005, 10507

304, 3119

3141, 4454

4470, 4529

6,156

126,231

50934

Discharge summary

report

Admission Date: [**2107-2-17**] Discharge Date: [**2107-2-28**] Date of Birth: [**2047-2-3**] Sex: F Service: CARDIOTHORACIC Allergies: Ambien / Percocet Attending:[**First Name3 (LF) 1283**] Chief Complaint: Daily angina and increasing SOB Major Surgical or Invasive Procedure: [**2107-2-20**] Dental extractions [**2107-2-21**] Cardiac cath (stenting of the left subclavian artery) [**2107-2-22**] Redo-Sternotomy, Aortic Valve Replacement, ASD closure ([**Street Address(2) 17167**].[**Male First Name (un) 923**] mechanical valve) History of Present Illness: 60 yo female with long-standing history of CAD with CABG x3 in [**2097**], and subsequent DES to CX [**8-30**], complicated by CX dissection. Vein grafts are known to be occluded since [**2103**]. She was recently hospitalized at OSH for RUQ pain. Seen by Dr. [**First Name (STitle) 2819**] of general surgery for gallbladder eval/HIDA scanning. This showed cholecystitis, and recent echo revealed severe AS. She now presents with increasing angina, sometimes at rest, and significant SOB with minimal exertion. Admitted to complete pre-op evaluation and repeat cath. Past Medical History: Coronary Artery Disease s/p Coronary Artery Bypass Graft [**2097**] and CX stents [**8-30**], Rheumatoid arthritis, Osteoarthritis, Fibromyalgia, Hypertension, Elev. cholesterol, Depression Cholelithiasis/cystic duct stenosis, Diabetes Mellitus, Hypothyroidism, Iron deficiency anemia, s/p Total Abd. hysterectomy, s/p Appendectomy Social History: single, has 3 children, denies ETOH or tobacco Family History: Mother had CABG at age 48, died of CAD at age 68 Father had DM, CAD, died of MI Physical Exam: 98% RA sat. 142/72 HR 72 RR 20 T 99.1 63" 97.2 kg no c/c/e NCAT, PERRL, anicteric sclera, OP benign neck supple, full ROM, no JVD CTAB well-healed sternotomy RRR 3/6 SEM mild RUQ/periumbilical tenderness extrems warm, well-perfused, no edema well-healed left leg SVG harvest site neuro grossly intact, slow but steady gait, strengths [**4-30**] and equal 2+ bil. fem/radials 1+ bil. DPs/ 1+ right DP, left non-palp. ? carotid bruits bil. versus transmitted murmur Pertinent Results: [**2107-2-18**] CNIS: Bilateral less than 40% carotid stenosis. [**2107-2-21**] Cath: Initial diagnostic angiography revealed a proximal 70% left subclavian artery stenosis with a 40 mmHg gradient across the lesion. The stenosis was proximal to the widely patent LIMA-LAD graft, and thus the decision was made to stent the lesion to improve flow to the LIMA. Heparin was used for IV anticoagulation. A 6F Shuttle sheath was used to engage the L subclavian artery. The lesion was crossed with a Magic Torque wire that was then exchange out thru a catheter for a Supracore wire. A 7.0x29 mm Genesis bare metal stent was deployed across the lesion at 12 ATM. The stent was postdilated with an 8.0x20 mm baloon at 20 ATM. Final angiography revealed 0% residual stenosis, no gradient, no dissection, and normal flow. [**2107-2-22**] Echo: Pre Bypass: There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with basal inferior hypokinesis. LVEF 45-50%. The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild to moderate ([**12-28**]+) aortic regurgitation is seen. The regurgitation is central with a vena contracta between 3 and 5 mm. With provacative manuvers and elevation of blood pressure and heart rate, mitral regurgitation becomes at worst, moderate. There is blunting of the pulmonary vein flow pattern. The mitral annulus meausres, on average, 3.3 cm. The leaflets are structurally normal. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are structurally normal. Mild to moderate ([**12-28**]+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Post Bypass: Preserved biventricular function. LVEF 45-50%. No change in wall motion. Aortic contours intact. Mitral regurgitation is now trace. There is a prostethic valve in the aortic position which appears well seated without preivavlvular leaks. Peak gradient 31, mean 13 mm Hg. No AI. Post bypass cardiac output calculated at 5.9 L/min. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [**2107-2-26**] Abd U/S: 1. Cholelithiasis without son[**Name (NI) 493**] evidence of cholecystitis. 2. Prominent common bile duct with no intrahepatic ductal dilation. 3. No ascites. [**2107-2-27**] CXR: Increased size of small right pleural effusion. Associated opacity in right lower lobe most likely atelectasis. Continued mild CHF. [**2107-2-17**] 11:30PM BLOOD WBC-4.7 RBC-4.69 Hgb-10.3* Hct-31.4* MCV-67* MCH-22.0* MCHC-32.9 RDW-16.6* Plt Ct-254 [**2107-2-23**] 02:39AM BLOOD WBC-11.6*# RBC-3.84* Hgb-9.3* Hct-27.7* MCV-72* MCH-24.2* MCHC-33.4 RDW-18.7* Plt Ct-205# [**2107-2-28**] 06:55AM BLOOD WBC-5.7 RBC-3.77* Hgb-9.1* Hct-28.1* MCV-75* MCH-24.2* MCHC-32.4 RDW-20.1* Plt Ct-333# [**2107-2-17**] 11:30PM BLOOD PT-11.7 PTT-24.9 INR(PT)-1.0 [**2107-2-26**] 01:35AM BLOOD PT-20.6* PTT-37.9* INR(PT)-2.0* [**2107-2-26**] 04:15AM BLOOD PT-20.7* PTT-37.2* INR(PT)-2.0* [**2107-2-27**] 05:20AM BLOOD PT-25.7* INR(PT)-2.6* [**2107-2-28**] 06:55AM BLOOD PT-30.7* PTT-36.5* INR(PT)-3.2* [**2107-2-17**] 11:30PM BLOOD Glucose-105 UreaN-15 Creat-0.7 Na-138 K-3.9 Cl-106 HCO3-22 AnGap-14 [**2107-2-28**] 06:55AM BLOOD Glucose-93 UreaN-9 Creat-0.8 Na-138 K-4.0 Cl-99 HCO3-30 AnGap-13 [**2107-2-26**] 04:15AM BLOOD ALT-10 AST-16 LD(LDH)-307* AlkPhos-156* Amylase-37 TotBili-0.2 Brief Hospital Course: Admitted on [**2-17**] for close monitoring given angina and SOB. Carotid US revealed no significant disease. Dental consult done, and multiple teeth extractions done [**2-20**]. Cardiac cath performed [**2-21**] showed mod. diff. LM dz, EF 45%, patent CX stents, 100% RCA, vein graft occluded, 70% left subclavian stenosis. Subclavian stent placed at time of cath. Cipro started for UTI and ampicillin started for dental infection. Rapid AFIB treated pre-op with associated hypertension and angina. Discussed with cardiology and she eventually converted to SR with beta blockade and IV NTG (which was later d/c'ed). On [**2-22**] she was brought to the operating room where she underwent a redo sternotomy, Aortic Valve Replacement, and ASD closure with Dr. [**Last Name (STitle) 1290**]. Please see operative report for surgical details. Later on op day she was weaned from sedation, awoke neurologically intact and extubated. She was started beta blockers and diuretics on post-op day one and then transferred to the floor. She was gently diuresed towards her pre-op weight during post-op course. Chest tubes removed without incident on post-op day two. Epicardial pacing wires were removed on post-op day three. Coumadin initiated with a Heparin bridge for her mechanical valve. On post-op day five she was still in severe pain and pain service was consulted. Also on this day her rhythm went into Atrial Fibrillation and Amiodarone was started. At time of discharge she was in SR with frequent PAC's with heart rate of 70. Physical therapy followed patient during entire post-op course for strength and mobility. On post-op day six she appeared to be doing well and was discharged to rehab with the appropriate follow-up appointments. Medications on Admission: crestor 30 mg daily, nambutemone 1000 mg [**Hospital1 **], isosorbide MN 120 mg daily, gemfibrozil 600 mg daily, trazadone 400-500 mg QHS, toprol XL 300 mg daily, synthroid 175 mcg daily, norvasc 15 mg daily, lisinopril 40 mg daily, Fe 325 mg TID, Vit. C daily, morphine sulfate SR 30 mg TID, vicodin prn, lasix 40 mg daily as directed, zantac 150 mg [**Hospital1 **], nitro spray prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO BID (2 times a day). 7. Nabumetone 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY () as needed for knee. 11. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg twice a day for 5 days then decrease to 400mg daily for 7 days, then decrease to 200mg daily . 13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): please give 2.5mg mon and tues then check INR wed - goal INR 2.5-3.0 for AVR mechanical valve . 14. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 15. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours): continue while on lasix. 17. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 18. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Aortic Stenosis/ASD s/p Redo-Sternotomy, Aortic Valve Replacement, ASD closure Post-operative Atrial Fibrillation Dental infection s/p Teeth extractions Urinary Tract Infection PMH: Coronary Artery Disease s/p Coronary Artery Bypass Graft [**2097**] and CX stents [**8-30**], Rheumatoid arthritis, Osteoarthritis, Fibromyalgia, Hypertension, Elev. cholesterol, Depression Cholelithiasis/cystic duct stenosis, Diabetes Mellitus, Hypothyroidism, Iron deficiency anemia, s/p Total Abd. hysterectomy, s/p Appendectomy Discharge Condition: stable Discharge Instructions: may shower over incisions and pat dry no lotions, creams , or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness or drainage Followup Instructions: see Dr. [**Last Name (STitle) **] in [**12-28**] weeks see Dr. [**Last Name (STitle) 5293**] in [**1-29**] weeks see Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**] Dental: [**Hospital Ward Name 23**] 3 Surgical services [**3-4**] at 3:00pm Dr [**First Name (STitle) **] [**Telephone/Fax (1) 274**] Completed by:[**2107-2-28**]

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icd9pcs

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54344

Discharge summary

report

Admission Date: [**2150-9-27**] Discharge Date: [**2150-10-10**] Date of Birth: [**2091-4-23**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Avandia / Combivir / Lasix / Levofloxacin Attending:[**First Name3 (LF) 2641**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Intubation Right IJ catheter Left radial arterial line Left PICC History of Present Illness: Ms. [**Known lastname **] is a 59 y/o woman w/ HTN, diastolic dysfunction, DM, CAD s/p RCA stent, restrictive pulmonary disease on 2L home O2, OSA, obesity, CKD, and on chronic narcotics for DJD, who was transferred to [**Hospital1 18**] from [**Hospital 730**] Hospital for respiratory failure. History comes from records as she is currently intubated and sedated, and no family members are present. Per records from [**Name (NI) **], pt came to ED via car, stated "I need oxygen" and became unresponsive and apneic. Per ED signout, she was already at that ED to bring her son for evaluation. She maintained her pulse and BP, and was intubated, sedated, and paralyzed. Initial gas at OSH on 100% FiO2 was 6.92/72/58/14. CXR was c/w pulm edema. Given SL NTG, SL captopril, and NTG paste. At request of her brother [**Name (NI) **]. [**Last Name (STitle) 4001**], the director of [**Hospital1 1388**] exercise stress lab), she was transferred to [**Hospital1 18**], where she generally receives her care. Systolic BP was reported to be 88 en route. . In the [**Hospital1 18**] ED, initial vs were: T P 111 BP 133/65 R 17 O2 sat 78%. Febrile to 101.8 rectal. Frothy blood was suctioned. She was initially answering questions, per report, and MAE. Pressures dropped as low as 50s systolic. She was given versed and etomidate for sedation, dobutamine then switched to levophed for blood pressure support, as well as vancomycin, Zosyn, and lasix 40 mg IV. The MICU team placed an art line and a right IJ. Past Medical History: - Restrictive lung disease [**2-10**] obesity - IDD - CAD s/p RCA stent - CHF (EF 55% [**2148**]) - [**1-18**] stable MIBI and neg stress test - Pulmonary HTN - Mitral regurgitation - Hyperlipidemia - HTN - Obstructive sleep apnea - Chronic renal insufficiency - GERD - DJD - Depression - Iron deficiency anemia - Glaucoma Social History: Patient works as a manager at Papa [**Male First Name (un) 45193**] and spends a great deal of time on her feet. She does not smoke but formerly smoked [**1-10**] ppd for 5-6 years. She has not smoked for 3-4 years now. She denies alcohol use. She denies ilicit drugs of non-prescription meds. She is a widow and has two sons, the [**Name2 (NI) 1685**] of which has autism and lives with her. Her brother is an EP doctor [**First Name (Titles) **] [**Last Name (Titles) 18**]. Family History: Significant for coronary artery disease and arrhythmia in both parents and diabetes mellitus in mother. Physical Exam: ON ADMISSION: Vitals: 101.1 95 140/72 13 94% General: Intubated, sedated, not interactive, obese body habitus HEENT: Sclera anicteric, pupils 2 mm, ETT in place Neck: supple, R IJ line in place Lungs: Ronchorous breath sounds throughout CV: Distant heart sounds, difficult to assess for murmurs. All pulses difficult to palpate. Abdomen: obese, soft, non-distended, bowel sounds present/diminished GU: foley in place Ext: warm, well perfused. R foot significantly warmer than L foot. No clubbing, cyanosis or edema. Lines: R IJ, L radial art line, R AC PIV, R hand PIV, L PIV . ON DISCHARGE: Vitals: 97.9, 135/59, 81, 18, 100% on 2L General: Alert, comfortable, NAD HEENT: Sclera anicteric, pupils reactive, clear oropharynx, MMM Neck: Supple, no JVD, no LAD Lungs: Good air entry, lungs clear bilaterally, no wheezes or crackles CV: RRR, nml S1/S2, no M/R/G Abdomen: Obese, soft, ND, NT, NABS Ext: WWP, 2+ radial/DP pulses, no edema Neuro: A&Ox3, CNs II-XII intact, strength improving, able to lift arms and legs further off the bed, able to feed herself, right foot still with decreased sensation and 1/5 strength Pertinent Results: ADMISSION LABS: [**2150-9-27**] 01:00AM BLOOD WBC-23.1* RBC-5.24 Hgb-13.9 Hct-44.3 MCV-85 MCH-26.5* MCHC-31.3 RDW-16.1* Plt Ct-432 [**2150-9-27**] 01:00AM BLOOD Neuts-79.3* Lymphs-14.2* Monos-5.6 Eos-0.3 Baso-0.7 [**2150-9-27**] 01:00AM BLOOD PT-12.4 PTT-20.3* INR(PT)-1.0 [**2150-9-27**] 07:36PM BLOOD Fibrino-718* [**2150-9-27**] 01:00AM BLOOD Glucose-393* UreaN-43* Creat-2.3* Na-133 K-8.4* Cl-98 HCO3-22 AnGap-21* [**2150-9-27**] 12:39PM BLOOD ALT-40 AST-83* LD(LDH)-568* CK(CPK)-5440* AlkPhos-146* TotBili-0.6 DirBili-0.3 IndBili-0.3 [**2150-9-27**] 07:36PM BLOOD Calcium-8.2* Phos-3.2 Mg-2.0 . PERTINENT LABS: [**2150-9-27**] 07:36PM BLOOD Fibrino-718* [**2150-10-6**] 03:40AM BLOOD Ret Aut-4.8* [**2150-10-6**] 03:40AM BLOOD calTIBC-277 Ferritn-143 TRF-213 [**2150-10-5**] 03:25AM BLOOD VitB12-794 Folate-15.4 [**2150-9-27**] 12:39PM BLOOD Hapto-112 [**2150-9-27**] 04:10PM BLOOD %HbA1c-7.6* eAG-171* [**2150-9-29**] 02:45AM BLOOD TSH-1.0 [**2150-9-29**] 02:45AM BLOOD Free T4-0.84* [**2150-9-27**] 04:35AM BLOOD Cortsol-18.0 [**2150-9-27**] 11:00PM BLOOD CK-MB-69* MB Indx-0.3 cTropnT-0.14* [**2150-9-27**] 07:36PM BLOOD CK-MB-51* MB Indx-0.4 cTropnT-0.16* [**2150-9-27**] 12:39PM BLOOD CK-MB-38* MB Indx-0.7 cTropnT-0.21* . DISCHARGE LABS: [**2150-10-10**] BLOOD WBC-14.8, Hgb-8.7, Hct-26.9, Plt-412, PT-14.2, PTT-22.7, INR-1.2, Glu-86, BUN-25, Creat-1.4, Na-140, K-4.2, Cl-101, HCO3-30 . MICRO: [**9-27**] Blood cx: no growth [**9-27**] Urine cx: negative [**9-27**] Urine legionella antigen: negative [**9-27**] Sputum cx: gram pos cocci in pairs [**9-27**] RSV viral screen and cx negative [**9-28**] BAL: no growth, no fungus, no AFB [**9-28**] Blood cx: no growth [**9-29**] Blood cx: no growth [**9-29**] Urine cx: negative [**9-29**] Catheter tip cx: no growth [**9-29**] Sputum cx: yeast, rare growth [**9-30**] Blood cx: no growth [**9-30**] Urine cx: negative [**10-1**] Sputum cx: yeast, rare growth [**10-1**] Catheter tip cx: no growth [**10-2**] Blood cx: no growth [**10-2**] CMV DNA not detected [**10-3**] Blood cx: no growth [**10-3**] Urine cx: negative [**10-3**] Sputum cx: no growth, no legionella [**10-4**] Blood cx: no growth to date [**10-4**] Urine cx: negative [**10-4**] Sputum cx: negative [**10-4**] Stool cx: no C. diff [**10-8**] Blood cx: no growth to date [**10-9**] Stool cx: no C. diff [**10-9**] Wound cx (left arm PICC): pending . IMAGING: [**10-8**] PA/LAT CXR: 1. Decreased vascular congestion and improved aeration. 2. Faint residual opacity at left lung base may represent persistant infection or atelectasis. . [**10-1**] CT Chest/Abd/Pel w/ con: 1. Persistent but improved multifocal pneumonia as compared to [**2150-9-27**]. New bilateral small pleural effusions with compressive atelectasis. 2. No acute intra-abdominal or intra-pelvic process. 3. A 2 x 1.6 cm right thyroid nodule is present. This is not encompassed on the [**2143-10-17**] chest CT. . [**9-30**] RLE U/S: no DVT . [**9-28**] TTE: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with normal free wall contractility. The number of aortic valve leaflets cannot be determined. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. . [**9-27**] CT Head w/o con: 1. No acute intracranial findings. Mild parenchymal atrophy and small vessel ischemic disease. Brief Hospital Course: 59 yo woman with diastolic CHF, CAD s/p RCA stent, DM, HTN, restrictive pulmonary disease (on 2L home O2), OSA, pulmonary HTN, CKD, who originally presented to an OSH in respiratory distress. She was intubated and transferred to [**Hospital1 18**] MICU where she was treated for septic shock in the setting of pneumonia. Hospital course was complicated by rhabdomyolysis, anemia, ICU myopathy, and right sciatic nerve compression. Brief hospital course by problem: . # Respiratory failure: The pt presented to [**Hospital 730**] Hospital on [**9-27**] c/o respiratory distress. She became unresponsive, apneic, and was intubated. CXR was c/w pulmonary edema and the patient became hypotensive. She was then transferred to [**Hospital1 18**] for further managment of presumed sepsis. In the MICU an arterial line and right IJ were placed and she was started on pressors, vancomycin, and zosyn. A CXR revealed multifocal pneumonia and an ECHO showed a dilated and hypokinetic right ventricle, normal LV systolic function (LVEF>55%), and no clinically significant valvular disease. She eventually improved hemodynamically so pressors were stopped, she was extubated, and the vanco and zosyn were switched to levofloxacin and she was transferred to the floor. She continued to improve clinically and remained afebrile with an O2 sat of 95-97% on 2L (her baseline at home). She completed a total of 14 days of antibiotics and the levofloxacin was stopped. She was restarted on all of her home medications including the advair. She was encouraged to use the CPAP at night. . # Leukocytosis: Throughout this admission the pt's WBC have waxed and waned. Her WBC rose to 15.9 two days prior to discharge with 7% eosinophilia. WBC are currently 14.8 on the day of discharge. The pt has remained afebrile with negative blood cultures. Her lungs are clear with no sputum production. UA was negative and stool was negative for C. diff. Her left arm PICC site was clean and w/o erythema, but the tip was sent for culture when the PICC was pulled on [**10-9**]. It is unlikely that there is any source of infection, and the eosinophilia suggests that there is likely a hypersensitivity reaction, perhaps to the antibiotics since all other medications the pt is currently taking are her home meds. The last day of levofloxacin was today ([**10-10**]). Recommend trending the WBC. . # Rhabdomyolysis: CK peaked to 34,000 but has been trending down and is currently 716. She denies myalgias, although reports weakness in her arms and legs with difficulty lifting extremities off the bed. Despite thorough workup, no etiology was found to explain the cause of the rhabdomyolosis. Muscle weakness is likely due to ICU myopathy since pt has been bedbound for such an extended length of time. Her strength is gradually improving and she is now able to lift her arms and legs midway off the bed and feed herself. The pt would benefit from physicial therapy to help regain her stregth. . # Right foot pain/paresthesias/foot drop: This is a new finding that developed while the pt was in the MICU. Neurology evaluated the patient and believe that it is due to sciatic nerve impingement. The patient has an outpatient appt with neurology on [**2150-11-6**]. She is written for morphine 7.5-15 mg q4 PRN, with the intention to switch to tylenol when possible. . # Chronic renal insufficiency (baseline cr ~ 1.4): On admission the pt's creatine was 2.3, and peaked to 3 while in the MICU in the setting of critical illness. The patient was catheterized and continued to have good UOP. Her creatinine has returned to baseline and is 1.3 upon discharge. . # Anemia: Patient??????s Hct has been stable in the mid 20s throughout this hospital admission. Borderline microcytic/normocytic pattern. Ferritin, TIBC, B12, folate, haptoglobin, are all WNL. Reticulocyte index is 2.1% indicating appropriate bone marrow response. Continued home dose of ferrous sulfate 325 mg daily. . # Abnormal LFTs: The pt was noted to have a rise in her AST, ALT, and Alkaline phosphatase while in the MICU. She has no known h/o liver or biliary disease and was asymptomatic. Most likely multifactorial due to shock liver and rhabdomyolosis. LFTs returned to [**Location 213**] after transfer to the floor. . # Diabetes: Blood sugars were poorly controlled in the MICU, requiring an insulin drip. After transfer to the floor we uptitrated her insulin and she is now on her home dose of novolog ISS and lantus 55 units every morning and 65 units every evening. Her sugars were well controlled in the mid-100s to low 200s. Last HgA1c was 7.6% on [**9-24**]. . # Thyroid nodule: On the CT chest on [**2150-10-1**] an incidental 2 x 1.6 cm thyroid nodule was seen which was not visualized on a previous CT chest on [**2143-10-17**]. Pt should f/u with her PCP regarding this. . # CAD s/p RCA stent: Continued plavix 75 mg daily. . # Diastolic heart failure: Patient was hypervolemic in the setting of critical illness in the MICU. After transfer to the floor she was restarted on her home dose of bumex and is now euvolemic. . # Depression: Stable, patient was restarted on her home dose of fluoxetine 20 mg daily. . # Code status: Full code (confirmed with patient after transfer from the MICU to the floor). . # Outstanding issues: - Blood cultures from [**10-4**] and [**10-8**]: pending - Left arm PICC tip culture from [**10-9**]: pending Medications on Admission: *All medications were confirmed with the patient and her pharmacy: 1. Novolog sliding scale as directed (pt seen at [**Last Name (un) **]) 2. Advair 250-50, 1 puff [**Hospital1 **] 3. Pravastatin 80 mg, 1 tab daily 4. Xalatan 0.005% eye drops, 1 drop into both eyes QHS 5. Bumetanide 1 mg, 1-2 tabs [**Hospital1 **] 6. Zetia 10 mg, 1 tab daily 7. Isosorbide MN ER 60 mg, 1 tab daily 8. Lantus, 55 units QAM, 65 units QPM 9. Potassium chloride ER 10 meq, 1 cap every other day 10. Plavix 75 mg, 1 tab daily 11. Metoprolol succinate ER 100 mg, 1 tab daily 12. Metoclopramide 10 mg, 1 tab QAM 13. Acetaminophen-Codeine #3, 1 tab TID PRN pain 14. Clonazepam 0.5 mg, 1 tab daily PRN 15. Fluoxetine 20 mg, 1 cap daily 16. Diovan 40 mg, 1 tab daily 17. Ranitidine 300 mg, 1 tab QHS 18. Vitamin D 50,000 units, one cap every week 19. Brimonidine tartrate 0.15% drops, 1 drop into both eyes [**Hospital1 **] 20. Fluticasone 50 mcg, 2 sprays into each nostril daily 21. Docusate 100 mg q8h PRN 22. Ferrous sulfate 325 mg SR daily 23. Multivitamin daily 24. Metamucil 25. Senna 8.6 mg daily 26. Aspirin 325 mg daily Discharge Medications: 1. Insulin Aspart 100 unit/mL Solution Sig: Sliding scale Subcutaneous four times a day. 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): 1 drop to both eyes at bedtime. 5. Bumetanide 1 mg Tablet Sig: 1-2 Tablets PO twice a day. 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Lantus 100 unit/mL Solution Sig: Fifty Five (55) units Subcutaneous every morning. 9. Lantus 100 unit/mL Solution Sig: Sixty Five (65) units Subcutaneous every evening. 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO every other day. 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 14. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 15. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 16. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 17. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 19. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 20. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 21. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 22. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO Q 8H (Every 8 Hours). 23. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 24. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Metamucil Oral 26. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 27. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 28. Morphine 15 mg Tablet Sig: 0.5-1 Tablet PO every four (4) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital 671**] HealthCare at [**Location (un) 3320**] Discharge Diagnosis: Primary: - Pneumonia - Rhabdomyolosis - Anemia - Myopathy - Right sciatic nerve impingement - Thyroid nodule Secondary: - Diastolic heart failure - Restrictive lung disease - Obstructive sleep apnea - CAD s/p stent - Diabetes - Chronic renal insufficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of bed with assistance to chair or wheelchair. Advance activity as tolerated. Discharge Instructions: Ms. [**Known lastname **], You were admitted to the hospital with respiratory distress and found to have pnemonia which we treated with an antibiotic called levofloxacin. During your hospitalization you developed right foot weakness and "pins and needles" which is due to compression of the sciatic nerve. The neurologist would like for you to follow up with him for this (see below for appt details). You also developed muscle weakness. We would like for you to work with the physical therapist at rehab. . On a CT scan we discovered a 2 x 1.6 cm thyroid nodule that was not seen on your [**2143-10-17**] chest CT. Please follow up with your primary care doctor regarding this finding. . Please continue to take all of your home medications. We have not started any new medications or made any changes. . Weigh yourself every morning, and call your doctor if your weight goes up more than 3 lbs. Followup Instructions: Department: NEUROLOGY When: FRIDAY [**2150-11-6**] at 1 PM With: [**Name6 (MD) 4677**] [**Name8 (MD) 4678**], MD [**Telephone/Fax (1) 3506**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: [**Hospital3 249**] When: MONDAY [**2150-12-7**] at 9:20 AM With: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2150-10-10**]

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icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "88.72", "33.24" ]

icd9pcs

[ [ [] ] ]

16752, 16836

7820, 13209

338, 405

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2297, 2775

7,095

114,849

8297

Discharge summary

report

Admission Date: [**2201-5-15**] Discharge Date: [**2201-5-17**] Date of Birth: [**2123-7-21**] Sex: M Service: MEDICINE Allergies: Cefazolin Attending:[**First Name3 (LF) 8404**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: right internal jugular central venous catheter insertion History of Present Illness: 77 year old male with a history of known 5 cm AAA and penetrating thoracic aortic ulcerations, CHF with EF 30-35%, DM, ESRD on HD(MWF) via LUE AV fistula, carotid disease, chronic dyspnea on 3LNC, previous MSSA bacteremia presents from dialysis with hypotension. Pt here from dialysis after full run with c/o bright red blood from rectum on toilet paper. Denies abd pain, CP, SOB, lightheadedness, or dizziness in dialysis. Of note, patient admitted from [**Date range (1) 29411**] for similar presenation after dialysis. He had a CT scan at that point which ruled out AAA rupture. He was initially on dopamine but once it was determined that thigh BPs were higher than arms, he was quickly weaned off. It was ultimately thought that BPs low from intravascular depletion after dialysis. He had an episode of somnolent and delirium after receiving ativan. During this admission he was also intubated on admission after reaction while getting blood and Vancomycin while hypertensive so thought to have flash pulm edema. This resolved quickly. He was guaic positive previously. . In the ED initial vitals were: 96.8 72 97/68 20 93% 3L. Triggered for BPs to 70s -> bolus. Prior to transfer, 98.6, HR 74 paced, 103/67, 16 100% 3l n/c. V-Paced, [**Doctor Last Name **] to prior. Brwn stool, guaiac positive. CBC- hct stable. Pt SBPs 90s, int then dropped to 70s, trigger x3 but asymptomatic. Cautious IVF->500cc fluids x2. Asictes thought [**1-14**] CHF in past. RIJ placed in ED for levofed on 0.01 BPs now 96/65 77. Mentating ok. Doesn't urinate a lot. . Upon arrival to the ICU, patient was asking for food but was otherwise without complaints. His SBPs in thighs showed SBPs in 200s and levofed was immediately shut off. There was noticeable difference in upper ext BPs by 100mmHG lower which had been reported previously. He reported not feeling well in the months prior but no recent changes in symptoms since recent hospital discharge. Reports having occasional episodes of spots bright red blood in toilet but no profuse bleeding. Denied CP, SOB, cough, fever, dizziness, N/V/D but did endorse abdomen more distended. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, or constipation. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: -HTN -DM -ESRD on HD MWF -PVD -Carotid stenosis -infrarenal AAA -DVT [**2195**] -Dementia -UC - quiet x 25 years -R adrenal adenoma -Gout -Prostate Ca -Kidney stones -Fe deficiency anemia -Aphasic episode - ? CVA PSH: -PM ([**Company 1543**] pacemaker, Sensia SEDR01) [**2-19**] -s/p L BK [**Doctor Last Name **]-DP w RGSVG [**6-20**] -s/p LUE AVF [**12-19**], s/p mult angioplasties -s/p prostatectomy 00 - L ureteral stent [**92**] Social History: Quit smoking at age 73. Retired as a chemical mixer from a leather tannery. No alcohol or illicit drug use. Family History: Brother had liver cancer. Father and mother had CVAs. Paternal grandfather had rectal cancer. Physical Exam: VS: Temp: 98.6 BP: 118/92 HR:78 RR: 24 O2sat 100%3L GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, jvd difficult to appreciate with line, no carotid bruits, no thyromegaly or thyroid nodules RESP: crackles at left bases, no wheezes or rhonchi CV: RR, S1 and S2 wnl, 2/6 SEM best heard at LUSB, no r/g ABD: distended with ascites, +b/s, soft, TTP in LLQ, no masses or hepatosplenomegaly appreciated, no rebound or guarding EXT: no c/c, 1+ edema to b/l knees, left 2nd toe s/p amputation, DP dopplerable b/l SKIN: no jaundice/no splinters, erythema in b/l legs c/w venous stasis changes NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps Pertinent Results: Admission labs: [**2201-5-15**] 12:30PM BLOOD WBC-12.2*# RBC-2.74* Hgb-8.8* Hct-27.5* MCV-101* MCH-32.2* MCHC-32.0 RDW-21.6* Plt Ct-140* [**2201-5-15**] 12:30PM BLOOD PT-13.9* PTT-27.1 INR(PT)-1.2* [**2201-5-15**] 12:30PM BLOOD Glucose-77 UreaN-13 Creat-3.6* Na-145 K-3.4 Cl-97 HCO3-38* AnGap-13 [**2201-5-15**] 12:30PM BLOOD cTropnT-0.72* [**2201-5-15**] 12:30PM BLOOD CK-MB-4 [**2201-5-15**] 12:43PM BLOOD Glucose-78 Na-145 K-3.4* Cl-92* calHCO3-38* . Discharge labs: [**2201-5-16**] 08:32PM BLOOD Hct-25.6* . Microbiology: Blood culture [**2201-5-15**]: no growth to date at time of discharge MRSA screen [**2201-5-16**]: pending at time of discharge . EKG: Vpaced at 77bpm, unchanged from prior [**2201-4-4**] . Imaging: . CXR (portable AP) [**2201-5-15**]: Again seen is a pacemaker with dual leads seen projecting in the right atrium and right ventricle. The degree of enlargement of the cardiac silhouette is unchanged. There is haziness of the pulmonary vasculature suggesting mild failure. There are no pleural effusions. There is trace atelectasis seen in the left lower lobe. IMPRESSION: Mild pulmonary edema. Brief Hospital Course: 77 year old male with a 5 cm AAA and penetrating thoracic aortic ulcerations, CHF with EF 30-35%, DM, ESRD on HD(MWF) via LUE AV fistula, carotid disease, chronic dyspnea on 3LNC, previous MSSA bacteremia presents from dialysis with hypotension. . #. Hypotension/hypertension: The patient was initially thought to be hypotensive, with blood pressures in his right arm as low as the 70s. He was never symptomatic. In the emergency department, he was treated with IV fluids. Additoinally, a central venous catheter was placed in the ED, norepinephrine, and the patient was transferred to the MICU. . In the MICU, prior records were reviewed, including the partially-completed discharge summary from the patient's [**Date range (1) 29412**] admission for asymptomatic hypotension after dialysis. During this prior admission, it was determined that the blood pressures in his right upper extremity were significantly different (by 100 points) from his right thigh pressures, and it was recommended that blood pressures be checked in the patient's thigh. Based on this information, the patient's right thigh pressure was checked and was found to be in the 200s. Norepinephrine was shut off, with improvement in the patient's right thigh pressure to the 160s. As before, the patient had a significant difference between his his right arm and thigh blood pressures. Antihypertensives were initially held, but the right thigh blood pressure rose to the 230s during ultrafiltration on [**2201-5-17**]. Lisinopril and metoprolol were restarted, with improvement in the patient's right blood pressure to the 160s. The patient was never symptomatic. . Consideration was given to whether the patient's arm-thigh blood pressure difference might be a sign of acute aortic pathology. The same concern was raised during the patient's [**Date range (1) 29411**] admission, during which CT angiography of the chest from showed extensive but stable aortic atherosclerotic disease, and CTA of the abdomen and pelvis showing the patient's known abdominal aortic aneurysm without evidence of leak or rupture. . The patient's arm-thigh blood pressure difference was discussed with the vascular team who cared for the patient during his prior admission. They concluded that it was very difficult to determine the patient's true aortic blood pressure, which was probably somewhere in between the blood pressures that were being measured in the patient's arm and thigh. They thought the patient's arm pressure was probably more accurate, but that it might not be completely accurate given the patient's extensive peripheral vascular disease and the fact that he was hypotensive in the right arm but asymptomatic. . At the time of discharge, the patient's right thigh blood pressure was in the 160s, and his right arm blood pressure was in the 110s with a pediatric cuff. The patient was discharged without any medication changes, with instructions to follow up with his vascular surgeon and his primary care physician for further management of his hypertension. . #. Leukocytosis: WBC count was elevated to 12.2 on admission, but the patient had no fever or focal signs of infection. CXR showed some atelectasis but no infiltrate. The patient's oxygen requirement remained at his baseline of 3L. The patient refused to be catheterized for urinalysis and culture. A blood culture showed no growth to date at the time of discharge. . #. Right red blood per rectum: The patient's hematocrit remained stable during his admission. However, the nurses noted a very small amount of blood in the commode after the patient used it. The patient's stool was brown but guaiac positive. The reported that he occasionally saw blood on his toilet paper at home. The nurses were not certain if the bleeding was coming from the patient's GI or GU tract, but the patient refused urinalysis for further evaluation of this. The patient was instructed to follow up with his primary care doctor for further evaluation of the bleeding. . #. Anemia: Chronic. Hct stable. Likely related to chronic kidney disease +/ chronic blood loss. No concern for acute bleeding. The patient was instructed to follow up with his primary care doctor regarding the bleeding. . # Thrombocytopenia: Platelet count at baseline. . # ESRD: The patient is dialyzed on a MWF schedule and also receives ultrafiltration on Saturdays. He received ultrafiltration on [**4-16**]. He continued phoslo and B complex vitamins. . # Ascites: Tapped on previous admission with SAAG 1.3 c/w portal hypertension. Likely related to CHF. . # Peripheral vascular disease: Followed by vascular surgery as outpatient for toe amputation. The wounds appeared clean dry and intact. Aspirin, plavix, and simvastatin were continued. The patient was instructed to follow up with vascular surgery. . # DM2: On glipizide at home. The patient was monitored on an insulin sliding scale while in house and was discharged on his home dose of glipizide. . TRANSITIONAL ISSUES: -PCP [**Name9 (PRE) 702**] for bright red blood on toilet paper. The patient may also require further evaluation with colonoscopy. -Vascular surgery follow-up for recent toe amputation. -Vascular surgery and PCP [**Name9 (PRE) 702**] for [**Name9 (PRE) 29413**] BP difference and further management of hypertension. The patient should undergo arterial ultrasound of his right upper extremity to evaluate for peripheral vascular disease, although he is unlikely a candidate for intervention unless he develops symptoms. -Important info for all providers: Mr. [**Known lastname **] has very significant peripheral vascular disease and BP varies very widely in each limb. -Labs pending at time of discharge: blood culture, MRSA screen Medications on Admission: Medications at home: (discharge summary [**2201-5-7**]) 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 1.5 (one and a half) Tablet Extended Release 24 hrs PO once a day. 4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day: PLEASE HOLD on days of dialysis ([**Month/Day/Year 766**], Wednesday, Friday). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. PhosLo 667 mg Capsule Sig: Two (2) Capsule PO three times a day: with meals. 7. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO twice a day. 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 9. 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* 10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Peripheral vascular disease Hypertension Hypotension . Secondary: End stage renal disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital with low blood pressure. It was determined that there is a difference between the blood pressure in your arm and the blood pressure in your thigh. Please discuss this with your vascular surgeon Dr. [**Last Name (STitle) 1391**] when you see him this week. Please also discuss this discrepancy with your primary care physician. You got some IV fluids in the emergency department and were treated with ultrafiltration on [**2201-5-16**]. You had a small amount of blood in your urine or stool, but your blood counts were stable. There are no changes to your medications. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] to arrange to be seen within the next week for further management of your blood pressure. Talk to your primary care doctor about the blood that you have had in your stool and possibly your urine. Department: HEMODIALYSIS When: [**Last Name (Titles) **] [**2201-5-18**] at 7:30 AM Department: CARDIAC SERVICES When: FRIDAY [**2201-6-12**] at 11:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]

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icd9cm

[ [ [] ] ]

[ "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

12429, 12435

5597, 10548

283, 341

12577, 12577

4452, 4452

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369, 2492

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2897, 3333

3349, 3461

69,501

199,812

41554

Discharge summary

report

Admission Date: [**2154-9-24**] Discharge Date: [**2154-10-18**] Date of Birth: [**2110-12-6**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy Exploratory laparotomy, lysis of adhesions, small bowel resection with anastomosis, Tru- Cut liver biopsy. History of Present Illness: 43 yo woman with multiple medical problems including HCV, cryoglobulinemia, cardiomyopathy, CKD, who was recently admitted to [**Hospital1 18**] for anemia workup(see recent d/c summary) now admitted for monitoring s/p ERCP. She reports intermittant nocturnal abdominal pain for which her outpatient doctor ordered an MRCP which reportedly showed intra/extrahepatic ductal dilation with choledocolithiasis. . She underwent successful ERCP with sphincterotomy with stone extraction on [**2154-9-24**]. She has felt obstipated since her procedure although she has managed to pass small amounts of gas occasionally. She had one episode of vomiting at around 7pm today of primarily food she had ingested shortly before. Denies hematemesis, melena, hematochezia, fevers, chills. KUB findings and patient's subjective complaints suggest that source of pain is likely small bowel dilatation secondary to insufflation of gas secondary to the ERCP procedure. Will follow-up on the CT abdomen/pelvis No evidence of acute bowel perforation as of right now Past Medical History: HCV - presumably contracted from birth of her second son. Untreated given chronic anemia Cryoglobulinemia CKD - Cr 2.4, thought to be [**2-13**] cryoglobulin associated MPGN s/p cholecystectomy Cardiomyopathy ef 30% Social History: Lives with son and husband in [**Name (NI) 1474**]. Homemaker. Denies tobacco, illicits or drug use. Family History: No family history of liver disease. Reports history of HTN in Mother and Maternal Aunt. [**Name (NI) **] history of CAD. Physical Exam: Vitals: T: 97.3, BP: 172/86 P: 58 R: 16 O2: 99 RA General: Alert, oriented, no acute distress, pale HEENT: + conjunctival pallor, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: +[**2-17**] holosystolic murmur, rrr Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound/guarding Ext: Warm, well perfused, 2+ pulses, no edema Skin: darkening of LE b/l - chronic Neuro: fluent speech Vital signs: upon discharge: bp=134/78, hr=62, resp. rate 20, oxygen saturation room air 95% General: Pale Neuro: alert and oriented (speaking in [**Month/Day (4) 595**] to her son) CV: [**Name (NI) **], s2, -s3, s-4, + grade 1/6 systolic murmur 2nd ICS, RSB LUNGS: Clear, decreased bs in bases ABDOMEN: soft, non-tender, staples in place, no wound exudate, mild erythema staple line EXT: lower ext. soft, no pedal edema, + dp bil., upper ext. right arm edematous, + radial pulse bil., fingers warm, pink, left arm ( normal in size) right arm: lower forearm: 11", mid (below elbow) 12", above elbow 11.5" left arm: lower forearm 8", mid (below elbow) 10.5, above elbow 10" Pertinent Results: [**2154-10-16**] 04:53AM BLOOD WBC-8.2 RBC-2.67* Hgb-7.0* Hct-22.7* MCV-85 MCH-26.4* MCHC-31.0 RDW-15.4 Plt Ct-471* [**2154-10-15**] 02:23AM BLOOD WBC-9.1 RBC-2.80* Hgb-7.5* Hct-23.9* MCV-85 MCH-26.6* MCHC-31.2 RDW-15.8* Plt Ct-501* [**2154-10-14**] 03:48AM BLOOD WBC-8.0 RBC-2.73* Hgb-7.2* Hct-23.1* MCV-85 MCH-26.5* MCHC-31.3 RDW-15.9* Plt Ct-487* [**2154-9-25**] 05:40AM BLOOD WBC-8.5 RBC-2.85* Hgb-7.6* Hct-23.7* MCV-83 MCH-26.7* MCHC-32.2 RDW-15.8* Plt Ct-291 [**2154-9-24**] 01:00PM BLOOD WBC-6.8 RBC-3.01* Hgb-8.0* Hct-24.7* MCV-82 MCH-26.7* MCHC-32.6 RDW-15.9* Plt Ct-320 [**2154-10-16**] 04:53AM BLOOD Plt Ct-471* [**2154-10-15**] 02:23AM BLOOD Plt Ct-501* [**2154-10-14**] 03:48AM BLOOD PT-12.4 PTT-25.2 INR(PT)-1.0 [**2154-10-16**] 04:53AM BLOOD Glucose-74 UreaN-62* Creat-1.6* Na-140 K-4.5 Cl-104 HCO3-29 AnGap-12 [**2154-10-15**] 02:23AM BLOOD Glucose-106* UreaN-67* Creat-1.9* Na-140 K-4.1 Cl-104 HCO3-27 AnGap-13 [**2154-10-14**] 03:18PM BLOOD Glucose-89 UreaN-70* Creat-1.9* Na-141 K-4.5 Cl-106 HCO3-26 AnGap-14 [**2154-10-5**] 01:07PM BLOOD Glucose-92 UreaN-48* Creat-2.6* Na-139 K-3.8 Cl-113* HCO3-13* AnGap-17 [**2154-10-5**] 05:45AM BLOOD Glucose-81 UreaN-47* Creat-2.5* Na-138 K-3.8 Cl-111* HCO3-13* AnGap-18 [**2154-9-24**] 01:00PM BLOOD UreaN-43* Creat-2.6* Na-139 K-5.2* Cl-109* HCO3-20* AnGap-15 [**2154-10-12**] 02:25AM BLOOD ALT-14 AST-34 AlkPhos-121* TotBili-0.6 [**2154-10-9**] 02:13AM BLOOD ALT-10 AST-22 AlkPhos-126* Amylase-246* TotBili-0.7 [**2154-9-28**] 07:10AM BLOOD ALT-35 AST-35 LD(LDH)-180 AlkPhos-316* TotBili-1.3 DirBili-1.0* IndBili-0.3 [**2154-9-26**] 05:50AM BLOOD ALT-75* AST-106* AlkPhos-435* Amylase-99 TotBili-3.6* [**2154-9-24**] 01:00PM BLOOD ALT-15 AST-21 AlkPhos-104 Amylase-76 TotBili-0.3 DirBili-0.1 IndBili-0.2 [**2154-10-5**] 05:45AM BLOOD Lipase-83* [**2154-10-4**] 04:40AM BLOOD Lipase-112* [**2154-10-1**] 04:57AM BLOOD Lipase-257* [**2154-10-8**] 04:15PM BLOOD CK-MB-3 cTropnT-0.12* [**2154-10-7**] 07:05AM BLOOD CK-MB-3 cTropnT-0.08* [**2154-10-6**] 06:45PM BLOOD CK-MB-3 cTropnT-0.08* [**2154-10-16**] 04:53AM BLOOD Albumin-2.5* Calcium-8.2* Phos-2.7 Mg-2.2 [**2154-10-15**] 02:23AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.4 [**2154-9-28**] 07:10AM BLOOD Hapto-163 [**2154-10-2**] 04:45AM BLOOD Triglyc-88 [**2154-10-9**] 11:36AM BLOOD Glucose-164* Lactate-0.7 Na-141 K-3.8 Cl-114* calHCO3-22 [**2154-10-9**] 11:36AM BLOOD freeCa-1.15 [**2154-10-8**] 04:25PM BLOOD freeCa-1.07* [**2154-9-24**]: ekg Sinus rhythm. Borderline P-R interval prolongation. Left ventricular hypertrophy with ST-T wave abnormalities. Consider early strain versus ischemia. No previous tracing available for comparison. Clinical correlation is suggested. [**2154-9-25**]: x-ray of the abdomen: IMPRESSION: Dilation of the colon likely secondary to recent ERCP, which may be contributing to the patient's symptoms. No evidence of perforation. [**2154-9-25**]: cat scan of the abdomen: Large 8.7 x 7.9 cm heterogenous area ? mass in the pelvis that may be composed of fluid and interposed bowel loops. Recommend MR to better charachterize this lesion [**2154-9-29**]: x-ray of the abdomen: IMPRESSION: Continued distention of small bowel with air-fluid levels and interval evacuation of the colon. The findings are concerning for small-bowel obstruction. A loop of bowel in the left hemipelvis is in an unusual position and the possibility of a hernia obstructing small bowel is considered. CT may be obtained for further evaluation. [**2154-9-30**]: UE US: IMPRESSION: No DVT. [**2154-9-30**]: cat scan of the abdomen and pelvis: IMPRESSION: Partial grade small-bowel obstruction with a transition point within the right lower quadrant. An underlying pelvic hernia or mass cannot be excluded; further assessment in this region is difficult due to lack of IV contrast and moderate degree of intrapelvic free fluid. Further evaluation with MRI is recommended. [**2154-10-3**]: EKG: Atrial fibrillation. Compared to the previous tracing of [**2154-9-30**] the rhythm has changed. [**2154-10-3**]: chest x-ray: IMPRESSION: Interval development of moderate bilateral pleural effusions, right greater than left. [**2154-10-4**]: cat scan of the abdomen: IMPRESSION: Worsening small bowel dilation as a result of likely obstruction described in prior studies. [**2154-10-6**]: cat scan of abdomen: IMPRESSION: 1. Persistent low-grade partial small-bowel obstruction with transition point in the left upper quadrant, likely jejunum. 2. Slight increase in pericardial effusion. 3. No other interval change. [**2154-10-7**]: x-ray of the abdomen: IMPRESSION: Dilated small bowel with decompressed colon, indicative of distal small-bowel obstruction with no marked change from prior study. Bilateral pleural effusions and possible collapse of the left lower lobe. [**2154-10-8**]: EKG: Atrial fibrillation with rapid ventricular response. QS deflections in leads V1-V2 with delayed precordial R wave transition consisent with prior anteroseptal myocardial infarction. Compared to the previous tracing of [**2154-10-8**] atrial fibrillation and rapid ventricular response have appeared. There are prominent inferolateral ST-T wave changes which may also represent a concomitant ischemic process. Rule out infarction. Followup and clinical correlation are suggested. [**2154-10-10**]: IMPRESSION: Moderately dilated left ventricle with moderate symmetric left ventricular hypertrophy and regional left ventricular wall motion abnormalities as described ablove. Mildly dilated aortic root, ascending aorta, and aortic arch. No clinically significant valvular regurgitation or stenosis. Moderate sized pericardial effusion with intermittent right ventricular diastolic collapse consistent with increased pericardial pressure, but no accentuation of tricuspid valve inflow with inspiration. [**2154-10-10**]: US of upper ext: IMPRESSION: 1. Non-occlusive thrombus around the right-sided PICC line at the right axillary vein. Right basilic and cephalic veins completely occluded. 2. No DVT in the left upper extremity. [**2154-10-12**]: chest x-ray: The NG tube tip is in the stomach. Severe cardiomegaly associated with bilateral pleural effusions, moderate to large, is unchanged. There is most likely a component of pericardial effusion as has been demonstrated on the CT abdomen from [**2154-10-2**]. The left lower lobe consolidation involves the left lower lobe and potentially the lingula. No pneumothorax is present. The right PICC line tip is at the level of superior SVC [**2154-10-2**] 12:50 pm BLOOD CULTURE **FINAL REPORT [**2154-10-8**]** Blood Culture, Routine (Final [**2154-10-8**]): NO GROWTH. [**2154-10-2**] 8:30 pm URINE Site: NOT SPECIFIED **FINAL REPORT [**2154-10-3**]** URINE CULTURE (Final [**2154-10-3**]): <10,000 organisms/ml. [**2154-10-2**] 8:29 pm STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2154-10-3**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2154-10-3**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative) [**2154-10-11**] 12:13 pm URINE Source: Catheter. **FINAL REPORT [**2154-10-12**]** URINE CULTURE (Final [**2154-10-12**]): YEAST. 10,000-100,000 ORGANISMS/ML.. [**2154-10-14**] 3:18 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2154-10-17**]** MRSA SCREEN (Final [**2154-10-17**]): No MRSA isolated The estimated right atrial pressure is 0-5 mmHg. There is a large pericardial effusion (greates posteriorly). The effusion appears circumferential. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2154-10-10**], the effusion is similar to slightly smaller. Brief Hospital Course: The patient was transferred to the ACS service on [**2154-10-5**] after developing a small bowel obstruction after an ERCP on [**2154-9-24**]. Upon admission, she was made NPO, given intravenous fluids and had a nasogastric tube placed for bowel decompression. She underwent a cat scan of the abdomen which showed a persistent low-grade partial small-bowel obstruction with a transition point in the left upper quadrant, likely jejunum. During her hospitalization, she developed rapid heart rate and an echocardiogram was done on [**10-7**] which showed an increase in the size of the patient's known pericardial effusion and signs of increase pericardial pressures without tamponade. Cardiology was consulted and recommended conservative management of the pericardial effusion and IV antihypertensive regimen to tartget SBP 0f 140-150. She was taken to the OR on [**2154-10-9**] and underwent an eploratory laparotomy. Notable findings were incarcerated bowel in internal hernia and early cirrhotic changes of the liver. She underwent lysis of adhesions, small bowel resection with anastomosis, and a Tru-Cut liver biopsy. Please refer to the operative note for details. During the procedure, she had a 50cc blood loss. Intra-op, she required esmolol and diltiazem for management of rapid atrial fibrillation and refractory hypertension. She was transferred to the intensive care unit after the procedure for management of her refractory hypertension. She had a repeat echocardiogram done 24 hours post-op which showed a moderately dilated left ventricle with an ejection fraction of 40%. Her hematocrit was closely monitored during the post-operative course because of her history of chronic anemia. She did require a blood transfusion on POD #2 for a hematocrit of 21. She was extubated on the operative day with out incident. Her TPN was resumed. Because of her history of CKD, her urine output and creatinine were closely monitored. She required lasix and resumption of her diuretics. Her oral anti-hypertensives were gradually re-introduced. As her blood pressure normalized, she was weaned off her labatelol drip on POD #5. She was transferred to the surgical floor on POD #6. Her vital signs were closely monitored. Her [**Last Name (un) **]-gastric tube was discontinued and she was started on clear liquids with advancement a regular diet. Her TPN was discontinued on POD #8 after she was tolerating a regular diet. During her hospital course Cardiology was in to evaluate her cardiac status and make recommendations for echocargiograms to assess her pericardial effusion. She is preparing for discharge home with VNA support. Her vital signs are stable and she is afebrile. She has been ambulating and has been maintained on room air with oxygen saturation of 94%. Her blood pressure has stabilzed with her current anti-hypertensive regimen. She was seen by Cardiology prior to discharge and underwent an echocardiogram which showed her pericardial effusion was slightly smaller than prior studies. Of note: she was noted to have a swollen right arm. The PICC line was discontinued. LENI done [**10-10**]: Non-occlusive thrombosis around PICC at the R axillary vein. R cephalic and basilic completely occluded. Findings addressed with Dr. [**Last Name (STitle) **] who was in to examine her right arm. No further intervention needed. Pelvic mass of unknown etiology: On CT Abd pelvis there was a "large 8.7 x 7.9 cm heterogenous area ? mass in the pelvis that may be composed of fluid and interposed bowel loops. Recommend MR to better characterize this lesion." This finding was discussed with the patient and her son with a [**Name (NI) 595**] interpreter present on [**9-27**]. The pt understands that she will need to have an MRI as an outpatient to follow this up. Repeat CT scan showed that this is where transition point was for SBO and that this area may be more consistent with bowel loops. Medications on Admission: 1.amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2.bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3.hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4.labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 5.lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7.isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): hold for systolic blood pressure <160. 4. labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): hold for systolic bp <150, hr <50. 5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 7. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stool. 9. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours: as needed for pain, may cause drowsiness. Disp:*12 Tablet(s)* Refills:*0* 10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Choledocholithiasis Small bowel obstruction refractory hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were re-admitted to the hospital with abdominal pain after you underwent an ERCP. At that time, a large gallstone was removed. You underwent a cat scan of the abdomen which showed dilated small loops of bowel and your cat scan showed a partial small bowel obstruction which was caused by a hernia. You were taken to the operating room where you had a reduction of your hernia and a small bowel resection. After your surgery, you had elevated blood pressure and rapid heart rate. You were placed on intravenous medication to control your blood pressure and you were monitored in the intensive care unit. Once your blood pressure stabilized you were transferred to the surgical floor to further regain your strength. You are now preparing for discharge home: Please call your doctor or return to the emergency room if you have 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. * 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. Activity: No heavy lifting of items [**10-26**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Please let us know if you develop: *increased shortness of breath *increased cough *ankle swelling *difficulty breathing *chest pain *dizzineess *weakness It is important that you let us know if you develop these symptoms Followup Instructions: Please follow up with the acute care service in 2 weeks. You can scheudule your appointment by calling # [**Telephone/Fax (1) 600**]. Please let them know that you will need an interpreter for the visit. Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) 46**] in 2 weeks. Dr.[**Hospital1 90387**] telephone number #[**Telephone/Fax (1) 31802**]. Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], your Cardiologist, on [**11-11**] at 8 am in the [**Hospital Ward Name 23**] building, [**Location (un) 436**]. The telephone number is [**Telephone/Fax (1) 62**]. Completed by:[**2154-10-23**]

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33117

Discharge summary

report

Admission Date: [**2141-1-1**] Discharge Date: [**2141-1-9**] Date of Birth: [**2071-11-8**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 358**] Chief Complaint: hemoptysis, hypoxic respiratory failure, s/p inferior MI and Vfib arrest, tx for palliative XRT Major Surgical or Invasive Procedure: bronchoscopy chest tube placement History of Present Illness: HPI: Mr. [**Known lastname 916**] is a 69 year old male with a history of hypertension, hyperlipidemia and recently diagnosed RLL NSCLC who initially presented to [**Hospital6 33**] on [**12-19**] with a few episodes of teaspoon sized hemoptysis that resolved quickly. He was admitted to the [**Hospital **] hospital from [**2140-12-24**] to [**2140-12-26**] with recurrent hemoptysis and profound hypokalemia and was treated briefly with potassium replacement and supportive care. He represented again from home on [**2140-12-27**] with recurrent hemoptysis at home. He was observed overnight in the CCU and had no further episodes of hemoptysis on hospital day one and was transferred to the floor in stable condition. The patient was taken to the [**Location (un) 538**] campus the morning of [**2140-12-28**] for mapping for radiation therapy. He had a planning CT scan at that time which showed a mass vs. a clot in the right bronchus intermedius. He began to experience hemoptysis again while traveling back from the [**Hospital 12162**] campus. The initial episode of hemoptysis lasted for approximately 20 minutes and he reports couging up bright blood and blood clots. The medical team and MICU team was called to assess the patient when he experienced a second episode of hemoptysis on arrival to the floor- approximately [**12-14**] cup total of hemoptysis (bright blood mixed with clots). Patient's oxygenation saturations stable on floor in high 80s to low 90s on 3 L nasal canula. He had no documented hypotension during the acute episode of hemoptysis and was transferred to the MICU for closer observation. On [**2140-12-29**] he was transported back to the JP VA and received one dose of paliative XRT. In the early morning of [**2140-12-30**] he suffered an acute STEMI with 12 lead EKG revealing ST elevations in II, III and aVF. This was associated with a polymorphic VT arrest which decompensated to Vfib. He was shocked x 1 and went into sinus tachycardia for a few beats and became asystolic. He received atropine x 1 and then went into atrial fibrillation with RVR with rates in the 190s to 200s for which he received lopressor 5 IV x 3 and diltiazem 5 IV x 2 and then a diltiazem drip. He was given ASA 325 mg po, Beta Blocker as above, Pravastatin 80 mg po for AMI. He was also started on an amiodarone drip for his arrythmia. Cardiology was consulted who recommended no further intervention. Per report, during the code bright red blood was suctioned from the patient's mouth. Following this event he was monitored closely. He did not have any further arrhythmias. His respiratory status continued to decompensate following his cardiac event. Prior to his initial presentation to the VA, he was breathing in the low 90s on room air. During his VA admission, prior to cardiac arrest he was breathing in low 90s on 3L and following the event he was satting in the high 80s to low 90s on 100% NRB. His CK MB peaked at 170 and his MB-I at 22.4. His troponins unfortunately were not trended to peak but peak value noted was 6.14. On the day PTA to [**Hospital1 18**], he was started on ceftriaxone out of concern for pulmonary infection on [**2140-12-31**] with leukocytosis but no fevers and no clear change in sputum production. On the morning of [**2141-1-1**] the patient was noted to have increasing oxygen requirment. Blood gas in the morning was 7.504/22.7/42.5 on 100% NRB. He had hemoptysis and was intubated for airway protection. Bronch was performed, and large clot was seen obstructing R main stem bronchus. Large clot was aspirated. . Per report, the patient's prognosis was discussed repeatedly with the family and intubation was decisively not recommended by the medical team. The family persistently wanted everything to be done and he was intubated. Blood pressures post intubation were in the 70s systolic which improved to mid 80s with fluid boluses. Pt was transferred to [**Hospital1 18**] for interventional pulmonology evaluation and radiation therapy. Past Medical History: STEMI c/b VT s/p defibrillation x ([**2140-12-30**]) Newly Diagnosed NSCLC c/b bl adrenal mets Hemoptsysis (adm to [**Hospital3 **] [**2140-12-19**]) Carcinoma, Basal Cell Chronic rhinitis HYPERLIPIDEMIA Hypertension Colonic Polyps Hemorrhoids Depressive Disorder Social History: Quit tobacco [**2122**], smoked 1 ppd x 40 yrs, no etoh. Mr. [**Known lastname 916**] is a retired worker from Sears. He lives at home with his wife and takes care of the cooking, laundry, and 3 year old grandaughter. Family History: unknown Physical Exam: General: afebrile, vss, sat >90% on room air Gen -- thin, NAD HEENT -- unremarkable CV: s1 s2 tachy regular no mrg LUNGS: sparse rales bilaterally ABD: +bs, benign ExT: wwp no edema NEURO: grossly intact Psych full affect Pertinent Results: [**2141-1-1**] 05:29PM PT-16.1* PTT-30.7 INR(PT)-1.4* [**2141-1-1**] 05:29PM PLT SMR-VERY HIGH PLT COUNT-740* [**2141-1-1**] 05:29PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2141-1-1**] 05:29PM NEUTS-87.2* BANDS-0 LYMPHS-8.7* MONOS-3.4 EOS-0.6 BASOS-0.1 [**2141-1-1**] 05:29PM WBC-20.7* RBC-3.08* HGB-9.1* HCT-27.6* MCV-90 MCH-29.7 MCHC-33.1 RDW-13.8 [**2141-1-1**] 05:29PM CORTISOL-15.3 [**2141-1-1**] 05:29PM CALCIUM-8.0* PHOSPHATE-4.1 MAGNESIUM-2.3 [**2141-1-1**] 05:29PM estGFR-Using this [**2141-1-1**] 05:29PM GLUCOSE-93 UREA N-31* CREAT-1.1 SODIUM-135 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-19* ANION GAP-12 [**2141-1-1**] 09:00PM LACTATE-1.2 [**2141-1-1**] 09:00PM TYPE-ART PO2-205* PCO2-32* PH-7.33* TOTAL CO2-18* BASE XS--7 INTUBATED-NOT INTUBA [**2141-1-1**] 10:00PM TYPE-ART TEMP-36.8 RATES-14/4 TIDAL VOL-600 PEEP-12 O2-50 PO2-52* PCO2-28* PH-7.37 TOTAL CO2-17* BASE XS--7 INTUBATED-INTUBATED [**2141-1-1**] 11:08PM CORTISOL-30.3* [**2141-1-1**] 11:08PM CK-MB-13* MB INDX-6.2 cTropnT-1.43* [**2141-1-1**] 11:08PM CK(CPK)-211* . . Admission CXR [**2141-1-1**](wet read):ETT is situated 6 cm above the carina. Right lower lobe density is visualized which probably represents a combination of mass and some post-obstructive atelectasis. That appears to be subsegmental. There is a right effusion as well. No pneumothorax and the remainder of the lungs is clear. MRI OF THE BRAIN: There is a 3-mm enhancing lesion within the right frontal lobe cortex versus in a leptomeningeal location within a sulcus without surrounding edema. No other areas of pathologic enhancement are identified within the brain. There are a few foci of T2/FLAIR hyperintensity within the periventricular and subcortical white matter in the cerebral hemispheres bilaterally, most suggestive of small vessel ischemic disease in a patient of this age. There is no evidence of hemorrhage, hydrocephalus, or territorial infarct. The major intracranial flow voids are intact. A retention cyst is seen in the left maxillary sinus measuring 2 cm. Scattered fluid versus mucosal thickening is noted within ethmoid air cells. The signal of the bone marrow appears normal. IMPRESSION: Three-mm enhancing lesion in the right frontal lobe cortex versus in the adjacent leptomeninges. This is highly suspicious for a metastatic focus. Findings discussed with Dr. [**First Name (STitle) **] [**Name (STitle) **]. ECHO Conclusions Subcostal views only obtained. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no pericardial effusion. CT chest: FINDINGS: There is a heterogeneous enhancing mass with significant necrotic component in the right infrahilar region measuring 4.3 x 4.8 cm representing the primary lung cancer. Significant necrotic pathological lymph nodes are seen in the mediastinal compartments, the largest is located in the subcarinal location and measures approximately 1 cm x 6.5 cm x 2.8 cm. This subcarinal lymph node has obliterated the bronchus intermedius. This has resulted in a collapse of the right middle lobe and the right lower lobe. It should be noted that the collapse of the right middle lobe and the right lower lobe is incomplete due to either fenestration in the fissures or due to the collateral air drift from the right upper lobe. The heart is not enlarged and there is no pericardial effusion. There are bilateral bibasilar small pleural effusion. On top of the left pleural effusion, there is an air-fluid level consistent with a hemopneumothorax as the attenuation coefficient of the fluid in the left pleural space approaches that of 60 units with a layering effect. Through the left pleural space, there is a chest drainage tube whose distal tip terminates in the left lung apex. The lungs are significantly emphysematous. Within the right upper lobe, there are at least three patchy areas of ground-glass opacities which could represent aspiration and/or hemorrhage. The osseous structures do not show any lesions suspicious for metastatic lesions. There is significant subcutaneous air collection in the chest wall anteriorly and along the lateral sides. There is significant gas collection which is extraperitoneal but within the fascia of the anterior abdominal muscles. There are some air pockets in the mediastinal compartments which extend into the retroperitoneal space, most likley as a continuation of pneumomediastinum. The visualized portion of the abdominal structures demonstrate bilateral mixed density adrenal masses consistent with metastases; the largest is a left adrenal metastasis measuring 2.6 x 4.1 cm and the smaller right adrenal lesion measures approximately 1.8 x 2.4 cm. In addition there are multiple necrotic retroperitoneal lymphadenopathy along the aortic margin measuring respectively 4.1 x 1.9 cm and 2.6 x 1.4 cm. The gallbladder is grossly distended secondary to starvation. There is also a small right retrocrural pathological lymph node which measures 1.4 x 1.2 cm in maximum dimension. The visualized portion of the liver do not demonstrate any metastatic lesions. IMPRESSION: 1. A large necrotic primary lung cancer in the right lower lobe with multiple pathological mediastinal lymph nodes, the largest is in the subcarinal location which has invaded/obliterated the bronchus intermedius and resulted in an incomplete collapse of the right middle lobe and right lower lobe secondary to incomplete fissure or collateral edges. 2. Multiple ground-glass opacities seen in the right upper lobe secondary to aspiration and/or hemorrhage and unlikely metastatic because of their attenuation. 3. Necrotic metastatic adrenal masses and pathological metastatic retroperitoneal lymphadenopathy. 4. Significant emphysematous lung changes. 5. Left hemopneumothorax with a chest drainage tube distal tip terminating in the left lung apex. 6. Small right pleural effusion. 7. Small pneumomediastinum with extension into the retroperitoneal area. 8. Extensive yet decreasing subcutaneous air collection in the chest wall and in the abdominal wall. Discharge Labs: [**2141-1-9**] 06:45AM BLOOD WBC-12.0* RBC-3.86* Hgb-11.5* Hct-34.1* MCV-88 MCH-29.7 MCHC-33.6 RDW-15.0 Plt Ct-279 [**2141-1-9**] 06:45AM BLOOD PT-14.6* INR(PT)-1.3* [**2141-1-9**] 06:45AM BLOOD Glucose-85 UreaN-15 Creat-0.7 Na-140 K-3.1* Cl-108 HCO3-21* AnGap-14 [**2141-1-7**] 07:30AM BLOOD ALT-67* AST-36 AlkPhos-98 TotBili-0.8 [**2141-1-2**] 08:24AM BLOOD CK-MB-12* MB Indx-6.3* cTropnT-1.05* [**2141-1-1**] 11:08PM BLOOD CK-MB-13* MB Indx-6.2 cTropnT-1.43* [**2141-1-9**] 06:45AM BLOOD Calcium-7.6* Phos-1.8* Mg-2.1 Brief Hospital Course: ASSESSMENT: 69y/o man with stage IV NSCLC complicated by worsening hemoptysis and new hypoxia transferred to the [**Hospital Ward Name 332**] ICU for IP intervention and palliative radiation and now intubated for hypoxic respiratory failure. . #. Hypoxia respiratory failure: Pt was admitted and maintained on AC and then transited to PS. On the morning of [**1-2**] pt had recurrence of hemoptysis. He was put on his right side and IP and Anesthesia services were called. Anesthesia performed bronchoscopy and large clot visualized and aspirated from right bronchus. Pt was taken emergently to the OR for Rigid bronchoscopy. He was subsequently transfered to the [**Hospital Ward Name **] for continued management of hemoptysis and airway compromise. In the OR, a rigid bronchoscopy was performed. Mechanical debridement of the right lung was performed, but the right middle and right lower lobes remained occluded. All areas that were bleeding were cauterized. He remained intubated after the procedure, and vent settings and pressors were weaned; pressors were off on the night of [**1-2**], and he was extubated on [**1-3**]. His respiratory status improved throughout hospitalization and he was discharged comfortably on room air. . #. Left pneumothorax: subsequent to rigid bronchoscopy. Chest tube was placed with resolution, removed prior to discharge. . #. Hemoptysis/NSCLC - Pt had significant hemoptysis at OSH and here. He has known endobronchial lesion with bil adrenal mets. He did receive one dose of XRT at the VA for reduction in hemoptysis. He subsequently received four XRT to the right chest during his stay, without recurrence of hemoptysis. He is scheduled to be followed at [**Hospital1 18**] radiation oncology. . # STEMI s/p VT arrest: AT the OSH, pt had clear ST elevations in inferior chest leads with reciprocal ST depressions in anterior leads. Patient required defibrillation. At the VA, Cardiology consulted during acute event who felt no indication for catheterization given metastatic disease and inability to anticoagulate given hemoptysis. He was transfered on Amiodarone gtt and in sinus bradycardia on admission. EP recommended discontinuing amiodarone as it does not have morbidity/mortality benefits when used for VT in setting of ischemia. Held metoprolol and ace-inhibitor for hypotension, but continued statin. A low-dose beta blocker was started on [**1-3**] given adequate blood pressure. . #. Hypotension- Most likely due to inferior infarct. [**Last Name (un) **] stim checked (due to bil adrenal mets) and pt stimulated appropriately. Pt transfered on neosynephrine. Which was transiently tapered down, but in the setting of hemoptysis was increased. Pressors were weaned over the course of the day on [**1-2**] and were turned off on [**1-3**]. . #. Hyperlipidemia - continued home pravastatin . #. hypokalemia -- required scheduled daily repletion, may be related to adrenal mets, discharged with VNA instructions to draw chemisty to follow potassium levels. #. brain metastases -- noted on MRI brain during hospitalization, no symptoms. Planned for evaluation by radiation oncology for palliative treatments on discharge. Medications on Admission: OUTPATIENT MEDICATIONS (AT TIME OF ADMISSION to VA): AMLODIPINE 5MG Daily ATENOLOL 12.5mg qhs FOSINOPRIL 40MG TAB Daily GEMFIBROZIL 600MG [**Hospital1 **] recently stopped ASPIRIN 81MG EC TAB 81MG due to hemoptysis . Medications on Transfer AMIODARONE TAB 400MG PO TID CAPTOPRIL TAB 6.25MG PO TID CEFTRIAXONE 1GM IVPB Q24H DOCUSATE CAP,ORAL 100MG PO BID GUAIFENESIN (100MG/5ML)/CODEINE PO Q4H prn METOPROLOL TAB 12.5MG PO TID OMEPRAZOLE CAP,EC 40MG PO DAILY PHENYLEPHRINE IV keep MAP 60-65 IV PRAVASTATIN TAB 80MG PO QDAILY SENNA TAB 8.6MG PO QDAILY Discharge Medications: 1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 4. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing or dyspnea. Disp:*QS QS 1 mo* Refills:*0* 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day. Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 6. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] S Region Discharge Diagnosis: 1. Stage IV non small cell lung cancer 2. hemoptysis, resolved 3. STEMI complicated by ventricular fibrillation arrest 4. atrial fibrillation Discharge Condition: stable Discharge Instructions: Please call your primary doctor or return to the hospital with any questions or concerns, particularly chest pain, shortness of breath, coughing or throwing up blood, blood in your stool, abdominal pain. Followup Instructions: Please arrange your oncology follow up at [**Hospital1 18**] by calling [**0-0-**]. Call your primary provider [**Last Name (LF) **],[**First Name3 (LF) **] [**Name Initial (PRE) **] [**Telephone/Fax (1) 76976**] for follow up as soon as you are discharged.

[ "162.8", "198.7", "410.72", "276.8", "786.3", "401.9", "198.3", "286.9", "518.1", "V15.82", "486", "512.8", "276.2", "197.7", "311", "455.8", "196.1" ]

icd9cm

[ [ [] ] ]

[ "92.29", "34.91", "33.24", "96.71" ]

icd9pcs

[ [ [] ] ]

17003, 17083

12339, 15532

365, 401

17269, 17278

5264, 11778

17530, 17791

4997, 5007

16139, 16980

17104, 17248

15558, 16116

17302, 17507

11794, 12316

5022, 5245

230, 327

429, 4457

4479, 4744

4760, 4981

70,184

197,421

36465

Discharge summary

report

Admission Date: [**2154-5-26**] Discharge Date: [**2154-6-22**] Date of Birth: [**2078-11-18**] Sex: M Service: SURGERY Allergies: Cephalosporins / Ceftriaxone Attending:[**First Name3 (LF) 148**] Chief Complaint: Coffee ground drainage from G-Tube Major Surgical or Invasive Procedure: 1. Exploratory laparotomy with mesenteric biopsy [**2154-6-5**]. 2. Gastroenterostomy [**2154-6-5**]. 3. Gastrostomy tube placement [**2154-6-5**]. 4. PTC placement [**2154-6-7**]. 5. PTC replacement [**2154-6-10**]. 6. Hypernatremia History of Present Illness: This is a 75yM with a complicated history including distant MVA and secondary organic brain syndrome + right sided hemiplegia who was admitted to [**Month/Day/Year 7145**] from [**Location (un) 3844**] on [**2154-5-17**] with chief complaint of coffee ground drainage from G-Tube. He had a J tube placed on [**2154-3-29**] for inability to feed while in the hospital for aspiration pneumonia. Subsequently, he had a G-tube placed on [**2154-5-2**] for "decompression" of unknown reasons. In his stay at [**Date Range 7145**], he was noted to have elevated LFTs with Alk Phos @ 1400s and elevated ALT/AST 207/100 with TBili at 0.9. Multiple studies were performed of which included an upper GI study which was significant for pyloric stenosis which may be related to an ulcer disease caused by impaction of two ingested dental fillings. An abdominal USG was significant for gallstones. A CT abdomen was significant for CBD dilitation of unknown quantification. An MRCP was positive for intrahepatic biliary ductal dilitation with no CBD stones. A HIDA was aparrently with patency of the CBD into the GI tract. An EGD was performed at [**Hospital1 18**] on [**2154-5-20**] by Dr. [**Last Name (STitle) **] which was significant for pyloric stenosis with an inability to pass the scope past the stenotic lesion. Also dental fillings were seen in the body of the stomach. He currently denies any pain and only reports complaints of occasional hiccups which have been a problem for at least a few months. He denies chest pain, shortness of breath, nausea/vomiting, or any other constitutional symptoms over his baseline. Past Medical History: PMHx: Traumatic brain injury with residual R hemiplegia DJD Eczema Hydrocele Prostate CA s/p radiation rx Hemorrhoids L shoulder traumatic arthropathy Aspiration PNA Hx of ARF [**3-11**] ceftriaxone PSHx: J Tube [**2154-3-29**]; GTube [**2154-5-2**] Social History: Lives at assisted care facility, has been taken care of by sister for > 40 [**Name2 (NI) 1686**] who is legal guardian; he is completely dependent in his ADL. Family History: Non-contributory Physical Exam: On Admission: Gen: Elderly looking gentleman, somewhat frail; alert and oriented to self and place. CV: RRR, +S1/S2 Pulm: CTAB, dull at bases Abd: G + J tube in place, GT to gravity. No obvious distension, no TTP, no r/g Skin: no obvious lesions or ulcers Pertinent Results: [**2154-5-26**] 02:50PM GLUCOSE-100 UREA N-23* CREAT-0.5 SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-23 ANION GAP-13 [**2154-5-26**] 02:50PM ALT(SGPT)-239* AST(SGOT)-97* LD(LDH)-191 ALK PHOS-1491* TOT BILI-0.7 [**2154-5-26**] 02:50PM ALBUMIN-3.2* CALCIUM-8.5 PHOSPHATE-3.2 MAGNESIUM-2.1 IRON-42* CHOLEST-195 [**2154-5-26**] 02:50PM calTIBC-213* FERRITIN-372 TRF-164* [**2154-5-26**] 02:50PM TRIGLYCER-85 HDL CHOL-51 CHOL/HDL-3.8 LDL(CALC)-127 [**2154-5-26**] 02:50PM WBC-7.5 RBC-3.52* HGB-10.6* HCT-33.0* MCV-94 MCH-30.0 MCHC-32.1 RDW-15.4 [**2154-5-26**] 02:50PM PLT COUNT-304 [**2154-5-26**] 02:50PM PT-12.7 PTT-27.3 INR(PT)-1.1 . IMAGING: [**5-27**] CTA panc: Severe intrahepatic bile duct dilatation, ?Klatskin tumor. Extension of tumor to celiac trunk and proper hepatic artery, antrum of stomach, 1st and 2nd segment of duodenum. [**6-1**] MRCP: Severe biliary ductal dilatation to level of ductal hilum, ?cholangiocarcinoma. Cholelithiasis. Simple hepatic cysts. . [**2154-6-11**] CTA CHEST W&W/O C&RECON: 1. No evidence of central or segmental PE in the upper lungs. No evidence of central PE in the lower lobes with suboptimal evaluation of the segmental and subsegmental branches in the lower lungs. 2. Extensive bilateral right more than left basal consolidations, new since [**2154-5-27**] and might represent bilateral pneumonia versus small bilateral pleural effusions. 3. Known intrahepatic bile duct dilatation partially imaged, status post percutaneous biliary drainage. Small ascites. . [**2154-6-18**] CHEST PORT. LINE PLACEM: Newly placed left PICC line with distal tip projecting over the upper SVC. Pathology: SPECIMEN SUBMITTED: FS lesion on bowel on [**2154-6-5**]. DIAGNOSIS: Soft tissue, lesion on bowel: Well-differentiated adenocarcinoma, consistent with pancreatic/biliary origin, see note. Note: Tumor cells are focally positive for keratin 7 and 20, and negative for TTF-1. Clinical: Gastric outlet obstruction, ? intrahepatic biliary dilatation. Gross: The specimen is received fresh in a container labeled with the patient's name "[**Known lastname 66673**], [**Known firstname **] M", the medical record number and additionally labeled "lesion on bowel". It consists of a fragment of pink-tan soft tissue measuring 0.3 x 0.3 x 0.2 cm. The specimen is entirely frozen. Intraoperative consultation was performed. Frozen section was performed on the tissue. The frozen section diagnosis by Dr. [**Last Name (STitle) **] is: "Adenocarcinoma". The frozen section remnant is entirely submitted in cassette A. Brief Hospital Course: Brief Pre-hospital History: *Failure to thrive x 9 mo, admitted to nursing home. *Aspiration pneumonia [**2-15**], + vomiting, pt w/early satiety, episodic vomiting, and choking, per nursing home with dysphagia and started on thick liquids but still aspirating *Admitted [**Month/Year (2) 7145**] [**3-22**] for above from [**Hospital1 1501**] *EGD [**2154-3-26**] ([**First Name9 (NamePattern2) 7145**] [**Doctor Last Name **]) obstruction at duodenal bulb Transitional gastric and intestinal/pyloric type mucosa w/chronic, active inflammation and eosinophilic infiltrate lamina propria; H pylori neg *Surgical J tube [**2154-3-29**] ([**Month/Day/Year 7145**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7871**]); symptoms thought secondary to gastroparesis *complicated by ARF leading to HD [**3-11**] [**Last Name (LF) 82595**], [**First Name3 (LF) **] ICU course, finally dc'd to [**Hospital1 1501**] [**4-19**] *Admit to [**Month/Year (2) 7145**] [**4-24**] for recurrent N/V in spite of J tube -> initially unable to pass NGT, then passed NGT, EGD *EGD [**2154-4-25**] unable to pass scope beyond pylorus ([**First Name9 (NamePattern2) 7145**] [**Doctor Last Name **]) *PEG [**2154-5-2**] ([**First Name9 (NamePattern2) 7145**] [**Doctor Last Name **]/[**Doctor Last Name 7871**]) "for gastroparesis and vomiting" *Admitted [**5-17**] for coffee-ground emesis*CT [**2154-5-17**] ([**Month/Day/Year 7145**]) IHD new since [**2154-3-26**], dental filling noted *MRCP [**2154-5-20**] ([**Month/Day/Year 7145**]) diffuse IHD with mild prominence of Common bile duct, no pancreatic lesion, prominence of gastric antral & pyloric mucosa *attempted ERCP [**2154-5-20**] ([**Hospital1 18**]) - unable to reach ampulla, unable to balloon dilate, dental fillings in ampulla Brief [**Hospital 18**] Hospital Course: [**5-26**] admitted from [**Month/Year (2) 7145**] (FYI: G-tube to gravity ventialtion for obstruction placed [**5-2**]; J-tube for feeding) [**5-27**] CTA pancreas protocol; CEA and PSA normal [**5-30**] EUS/FNA - pyloric stenosis, limited exam of pancreas parenchyma normal; pancreatic duct 3mm; celiac artery origin lesion could not be imaged. dilated intrahepatic ducts [**6-1**] MRCP [**6-5**] OR s/p ex lap bypass. Overnight drop in UOP -> decreased epidural, bolused 500cc LR once. [**6-6**] FeNA=0.1; bolused LR 500cc in AM; started Unasyn. Overnight still with decreased UOP; bolused another LR 500cc. [**6-7**] PTC only able to get into right side. Started [**Month/Day (4) 82596**]. [**6-8**] Started Vanc/levo/flagyl for wound erythema. [**6-10**] Stopped antibiotics. Bilateral biliary stents deployed 6 & 8mm to decompress (L) and (R) systems (all done via R side), (R) PTBD left in place to bag. [**6-11**] G-tube clamped, [**Month/Day (1) 82596**] restarted, advanced to clears. PTC capped. Overnight triggered for desats 80s and tachy 130s; G-tube unclamped to gravity, [**Month/Day (1) 82596**] held; transferred to SICU. CTA done showing no PE, likely secondary to aspiration pneumonia. Febrile to 104 axillary; Vanc/Zosyn started. [**6-12**] PTC uncapped to gravity. Bile cultured. [**6-13**] Question of ileus; KUB-likely no obstruction. [**6-14**] Transferred to floor, still on vanc/zosyn, G-tube and PTC to gravity, J-tube capped. [**6-15**] started [**Month/Day (4) 82596**]. Question of fluid overload; CXR showing no pneumonia or pleural effusions. [**6-16**] Advanced [**Month/Year (2) 82596**] 10 q8h. [**6-17**] Increased drainage from wound; some staples removed. Wet-to-dry dressings started [**Hospital1 **]. [**6-18**] Renal and Palliative Care consulted . Hypernatremia; given free water via J-tube. Vancomycin held for elevated trough. PICC placed. [**6-19**] Vancomycin held. Increased free water via J-tube. Ground solids and thin liquids recommended by Speech and Swallow. Overnight emesis; made NPO. [**6-20**] Vancomycin held. [**Month/Year (2) 82596**] held; Down to Interventional Radiology for part 1 of internalization of biliary drain; internal-external drain was exchanged with Amplatz drain (external only). Kept NPO. [**6-21**] NPO with [**Month/Year (2) **] on hold this am for planned Interventional Radiology procedure to re-internalize PTC. Procedure cancelled as T. bili increased from 0.6 to 0.9 and rescheduled from Thursday, [**6-27**] at 8am. Am sodium 150; restarted Free water 350mL via J-tube Q6 hours as well as D5W IV at 50mL/Hr. Sodium repeated in afternoon and was decreased to 146. Palliative care in for follow-up. Discharge planning underway. He will be discharged to rehab with free water boluses down his J-tube, but will likely not need D5W IV fluid. Medications on Admission: Medication at Outside Hospital: Jevity 1.2 @ 70/hr [**Last Name (LF) **], [**First Name3 (LF) **] 81', Ativan 0.5-1 q6h prn, compazine 25mg supp q12h PRN, prednisone 2.5mg jtube daily, dulcolax 10mg rectal daily prn, Duoneb q4h prn, Hyoscyamine 0.125mg q12h prn, magnesium oxide 400 PJT [**Hospital1 **], milk of magnesia prn PJT, Protonix 40mg IV daily, Reglan 5mg QID PJT, Atenolol 12.5mg daily PJT Discharge Medications: 1. Lorazepam 2 mg/mL Concentrate Sig: 0.25 - 0.5 mL PO Q6H (every 6 hours) as needed for anxiety, agitation. 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-8**] Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 6. ChlorproMAZINE 12.5 mg IV Q4H:PRN hiccups 7. Metoclopramide 5 mg IV Q6H 8. 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. 9. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 10. Pantoprazole 40 mg IV Q12H 11. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: 2.25 mg IV Intravenous every six (6) hours for 6 days: Completion Date: [**2154-6-26**]. 12. Insulin Regular Human 100 unit/mL Solution Sig: 2-14 units Injection ASDIR (AS DIRECTED): As directed per insulin sliding scale. 13. IV Medication: Vancomycin 1000mg IV Q24 Hours - currently on hold for elevated Vanco trough. See page 1 for restart instructions. Completion date: [**2154-6-26**]. Discharge Disposition: Extended Care Facility: Hellenic - [**Location (un) 2624**] Discharge Diagnosis: 1. Gastric outlet obstruction. 2. Biliary obstruction. 3. Gallbladder cancer metastatic with carcinomatosis. Discharge Condition: Stable Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-16**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. J-Tube and G-tube Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *If G-tube to gravity: Note color, consistency, and amount of fluid in the collection bag. Call the doctor, nurse practitioner, or nurse if the amount increases significantly or changes in character. Be sure to empty the collection bag frequently. Record the output, if instructed to do so. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Other Discharge Instructions as outlined in Page 1. Followup Instructions: You will be returning to [**Hospital1 18**] Interventional Radiology on Thursday, [**2154-6-27**] at 8am. Please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6745**], NP at ([**Telephone/Fax (1) 82597**] with any questions. Please fax requested pre-procedural laboratory results as per Page 1. Patient should be NPO after midnight [**2154-6-26**]. Please call ([**Telephone/Fax (1) 82598**] to see if you need to arrange a follow-up appointment with Dr. [**Last Name (STitle) **] (PCP). Other Appointments: Provider: [**Name10 (NameIs) 454**],THREE [**Name10 (NameIs) 454**] Date/Time:[**2154-6-27**] 8:00. Please determine if this appointment currently relevant. Provider: [**Name10 (NameIs) 6122**] WEST Phone:[**Telephone/Fax (1) 8243**] Date/Time:[**2154-6-27**] 9:30 Completed by:[**2154-6-22**]

[ "715.90", "199.0", "692.9", "584.9", "998.59", "E929.0", "156.0", "342.90", "907.0", "576.2", "537.0", "V10.46", "E878.8", "310.2", "276.0" ]

icd9cm

[ [ [] ] ]

[ "51.98", "96.6", "44.62", "54.23", "43.19", "87.51", "45.13", "44.39" ]

icd9pcs

[ [ [] ] ]

12124, 12186

5575, 7387

323, 559

12339, 12348

2986, 5552

15095, 15924

2675, 2693

10681, 12101

12207, 12318

10254, 10658

7405, 10228

12372, 13827

13843, 15072

2708, 2708

249, 285

587, 2207

2723, 2967

2229, 2482

2498, 2659

25,778

183,282

28402

Discharge summary

report

Admission Date: [**2104-10-27**] Discharge Date: [**2104-10-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Carotid Stenosis Major Surgical or Invasive Procedure: Carotid Stent Placement History of Present Illness: 83yo M without close medical care for a number of years presents with a presumed history of HTN, hyperlipidemia found to have asymptomatic 90-99% R ICA occlusion now s/p R ICA stent. Pt has not had close medical care for a number of years and recently was evaluated by a new PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**]. Found to have R carotid bruit, doppler US revealed severe stenosis. Pt does not c/o numbness, tingling, weakness, dysarthria, visual changes or scotoma. The pt does report generalized weakness/fatigue that seems worse over the last few years. Denies h/o TIA, CVA. He was not taking any medications until 1month ago. Found to have Creatinine 2.3 on pre-admission testing, but pt is unaware of prior history of CKD. . ROS: Denies recent illness, f/c/ns, intentional wt loss over last yr at urging of family- stable over last few months. Denies heat cold intolerance, + bilateral LE edema for last several months, + "flat feet" by report, denies claudication, + increased urinary frequency, no dysuria, no change in bowel habits, no BRBPR, appetite stable. Past Medical History: HTN Hyperlipidemia [**Name (NI) 30294**] pt is ? s/p TURP (pt could not recall details) . Past Surgical Hx: R total knee replacement Social History: Lives with his wife, 2 sons doing well, one recently moved back home. [**State 350**] native, served in the navy during World War II. worked for many years in [**Location 8398**]in [**Location 68914**], comedy and musician. Has traveled extensively with his act. Currently works 20 hours a week at a convenience store gas station. Never tobacco, No ETOH or Illicits. Family History: Father d.50 ?MI, Mother d.82 ?cause- "very healthy" Physical Exam: vitals- T 97, BP 134/59, HR 40 (74 on tele), R 13, 98% RA Gen- Well-appearing, talkative, very-pleasant gentleman in NAD Skin- no rashes HEENT- NCAT, MMM, partial dentures, no exudates, EOM's intact, pupils 5-->3 bilat, hearing intact to finger rub. Neck- no bruit B CV- bradycardia, auscultated and palpable at 40bpm, distant sounds, soft [**2-18**] murmur hear best at apex, nl s1 and s2 Pulm- CTA B Abd- soft, nt, nd, BS+, nonpulsatile, no HSM Extrem- 1+ pitting edema bilat to knee, 1+ DP, PT pulses, 2+ radials B Groin- no mass, no bruit Bilaterally, R fem w angioseal. NEURO- Alert and oriented to person, place, time. CN's II-XII, names, repeats, FST [**5-16**] globally. Two point discrimination intact R vs. L fingertips. Pertinent Results: pre-procedure WBC 7.7 HCT 33 PLT 195 INR 1.0 Na 139 K 4.2 Cl108 CO2 20 BUN 13 Cr 2.6 . EKG: [**2104-10-27**] NSR 69, nl axis, 1st Degree AV block. [**2104-10-27**] Sinus rhythm with bigeminy, electrical rate 77. Low voltages in III, aVF, No ST segment changes . Carotid Cath- RECA: WNL [**Country **]: Tubular, ulcerated 99% lesion with normal folowy fills MCA but not ACA LECA: WNL [**Doctor First Name 3098**]: fills L MCA, L ACA, Contralat R ACA without lesions. . [**2104-10-28**] 05:28AM BLOOD WBC-8.5 RBC-3.27* Hgb-10.3* Hct-28.7* MCV-88 MCH-31.5 MCHC-35.8* RDW-13.6 Plt Ct-191 [**2104-10-28**] 05:28AM BLOOD Glucose-102 UreaN-33* Creat-2.3* Na-140 K-4.0 Cl-106 HCO3-25 AnGap-13 [**2104-10-28**] 05:28AM BLOOD ALT-11 AST-11 CK(CPK)-83 AlkPhos-52 [**2104-10-28**] 05:28AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.1 [**2104-10-28**] 05:28AM BLOOD TSH-2.2 Brief Hospital Course: 83yo gentleman with hypertension, hyperlipidemia, asymptomatic 99% R ICA stenosis s/p carotid stent placement. . 1) Carotid Stenosis: Patient underwent R ICA stent for asymptomatic 99% R ICA stenosis. The patient was admitted to the CCU for 24hrs for monitoring post procedure. Serial neurological exams did not reveal any deficits. The patient was quickly weaned from Nitroglycerin gtt. He was continued on Aspirin 325mg daily, Clopidogrel 75mg daily, simvastatin. The patient should follow up with Dr. [**First Name (STitle) **] in four weeks including carotid ultrasound and neurology follow up per study protocol. . 2) Cardiac: Rhythm- The patient's pre-procedure EKG revealed 1st degree heart block. Upon transfer to the CCU the patient was in atrial bigeminy/atrial premature beats. This is not related to his carotid procedure and the patient has periods without bigeminy while on telemetry monitoring. The patient's blood pressures were stable and he did not complain of any symptoms of palpitations, chest pain, or shortness of breath. . LV function- It is recommended the patient have an exercise tolerance test as an outpatient for further work-up of patient's complaint of chronic fatigue. . 3) Renal- Patient was admitted with baseline creatinine of 2.3. This is likely chronic renal insufficiency. Possibly hypertensive nephrosclerosis vs. possible obstructive nephropathy. History of renal insufficiency with increased frequency raises possibility of obstructive process. Prior to discharge the patient did mention history of prior urological procedures ? TURP for "bladder troubles." A post-void residual was checked via bladder scan revealing 120cc retained urine. He should have further evaluation for etiology of his CKD on an outpatient basis. Given his renal insufficiency the patient was given n-acetylcysteine and bicarbonate hydration protocal for renoprotection from contrast. Creatinine . 4) Heme- Patient was found to be anemic prior to admission. Hematocrit the morning following the procedure had decreased to 28.7. This was likely secondary to small procedural blood loss in combination with hydration given for renoprotection. Further work-up for pt's chronic anemia should continue on an outpatient basis. . 5) Health Maintenance- The patient has several chronic health issues and need for screening. He has only recently entered back into the health care system by visiting his new PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**] four weeks ago. Prior to this he has not had any medical care, nor taken any medications for several years. He will require close follow-up for further screening exams- especially coloscopy given evidence for chronic anemia. He was given influenza vaccination and pneumococcal vaccination prior to discharge. Medications on Admission: Clopidogrel 75mg PO daily Aspirin 81mg PO daily Simvastatin 40mg PO daily Doxazosin 2mg qhs Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary: Carotid Stenosis Secondary: Hypertension Hyperlipidemia atrial arrhythmia Discharge Condition: Good. Discharge Instructions: You had a carotid stent placed for carotid stenosis. It is essential that you take all of your medications as prescribed- especially aspirin and plavix (clopidogrel). Failure to do so could result in a clot forming in the stent, stroke, or even death. Call Dr. [**First Name (STitle) 14190**] or 911 if you should experience new weakness, numbness or tingling, slurred speech or confusion. Chest pain, shortness of breath, bleeding or swelling at your groin catheterization site. Followup Instructions: You should follow up with Dr. [**First Name (STitle) **] in 4 weeks. You should see Dr. [**Last Name (STitle) 3314**] (your PCP) for follow up within 3 weeks for continued preventive health screening. Furthermore we recommend, you discuss the need for an exercise tolerance test and further evaluation of your kidney function.

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icd9cm

[ [ [] ] ]

[ "00.63", "00.61", "00.40", "88.41", "00.45" ]

icd9pcs

[ [ [] ] ]

6955, 6961

3687, 6482

281, 307

7089, 7097

2812, 3664

7628, 7959

1992, 2045

6625, 6932

6982, 7068

6508, 6602

7121, 7605

2060, 2793

225, 243

335, 1435

1457, 1592

1608, 1976

15,503

104,643

20139

Discharge summary

report

Admission Date: [**2202-1-27**] Discharge Date: [**2202-2-15**] Date of Birth: [**2131-4-24**] Sex: M Service: MEDICINE Allergies: Iodine / Penicillins / Iodine; Iodine Containing Attending:[**First Name3 (LF) 759**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: R internal jugular central line GJ tube placement History of Present Illness: The pt. is a 70 year-old male with irrestectable pan CA who presented complaints of fever and increased drainage from G/J tube found to be hypotensive. He had been having fevers at home. His PCP ordered [**Name Initial (PRE) **] CT torso which per neice report showed b/l PNA and no intraadbominal process. He was started on levo/clinda last Thursday. He has had increased difficulty with breathing, fever, chills and increased drainage from G/J tube. In the ED BP initially 68/45, HR 95, T 98.8. CXR, KUB done and labs drawn. Lactate was 1.9. A RIJ was placed and he recieved vanc/lev/flagl. He was given 4 L of NS with CVP's from [**7-18**]. He remained hypotensive with MAP of 55-58 and levophed was started. Has Hx of peritonitis and tumor encasing SMA. Was seen by surgery who felt no surgical intervention was warrented. . ROS (-)headache, N/V, dysuria, guiac negative per ED report (+)SOB, diarrhea, productive cough Allergies: Iodine / Penicillins Past Medical History: Past Onc Hx :Orginally presented with elevated liver function tests in [**7-12**]. ERPC done in [**9-12**] showed biliary stricture with cytology negative. He had multiple CBD stents and 7 negative biopsies. A bipsy in [**9-13**] was positive for adenocarcinoma. . He presented in [**8-14**] with pneumoperitoneum and peritonitis. At that time he had an exploratory laparotomy and drainage of intra-abdominal fluid, loop gastrojejunostomy, combined gastrostomy-jejunostomy tube. He was hospitalized for ~9 days treated with levo/flagyl and discharged to rehab. He was re-admitted 5 days later with N/V and treated with IVF and discharged again to rehab. He does not have an Oncologist and has been followed by [**First Name8 (NamePattern2) **] [**Doctor Last Name 468**] in Surgery. . PMHx -COPD on home O2 -Type 2 DM -PUD -Ventricular ectopy -Osteoarthritis -Emphysmea -Anxiety Social History: : Italian-speaking, retired shoe-factory worker. Hx of heavy smoking; currently a few cigarettes per day. Drinks [**1-11**] glasses of wine per day; no hx of heavy EtOH use. Lives with his sister and her husband in [**Name (NI) 1475**]. Is single without children. Very close with family and especially [**Name (NI) 802**]. Contact/healthcare proxy: [**Name (NI) **], [**Name (NI) **] [**Name (NI) **], ([**Telephone/Fax (1) 53776**] Family History: Negative for pancreatic, colorectal, or any other CA. CAD in mother, father, and sister. Cerebral aneurysms in sister Physical Exam: General: Awake, alert, NAD. thin cahectic man. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD Pulmonary: Decreased at bases with b/l exp wheezes Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, G/J tube with erythema and yellow drainage. Extremities: ppp, trace edema Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. CN II-XII intact . Motor/sensory grossly intact. To floor: Vs: T: 98.2, P: 90, R: 24, BP: 107/68, R22 SaO2: 98% on 70% FM General: Thin cachectic man, NAD. HEENT: MMM,OP clear,no scleral icterus Neck: supple, no JVD Pulmonary: Decreased BS at bases Cardiac: RRR, nl. S1S2, gmr Abdomen: Very distended, no-tender, tympanic, soft, normoactive bowel sounds. Extremities: no cce. Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Pertinent Results: [**2202-1-27**] 08:20PM BLOOD WBC-20.1*# RBC-3.29* Hgb-8.5* Hct-24.0* MCV-73*# MCH-26.0* MCHC-35.6* RDW-15.5 Plt Ct-347 [**2202-2-9**] 06:55AM BLOOD WBC-15.6* RBC-4.62 Hgb-11.6* Hct-35.1* MCV-76* MCH-25.1* MCHC-33.0 RDW-17.9* Plt Ct-320 [**2202-1-27**] 08:20PM BLOOD PT-14.5* PTT-26.7 INR(PT)-1.4 [**2202-2-2**] 05:25AM BLOOD PT-16.1* PTT-32.8 INR(PT)-1.8 [**2202-1-27**] 08:20PM BLOOD Glucose-124* UreaN-20 Creat-0.7 Na-131* K-4.1 Cl-98 HCO3-22 AnGap-15 [**2202-2-9**] 06:55AM BLOOD Glucose-84 UreaN-11 Creat-0.6 Na-128* K-4.6 Cl-93* HCO3-24 AnGap-16 [**2202-1-27**] 08:20PM BLOOD ALT-41* AST-50* CK(CPK)-14* AlkPhos-422* TotBili-1.1 [**2202-1-30**] 04:33AM BLOOD ALT-20 AST-21 LD(LDH)-181 AlkPhos-292* TotBili-1.1 [**2202-1-27**] 08:20PM BLOOD Lipase-7 [**2202-1-28**] 02:04AM BLOOD Calcium-6.9* Phos-3.4 Mg-1.6 [**2202-2-9**] 06:55AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.8 [**2202-2-5**] 06:25AM BLOOD calTIBC-101* Ferritn-349 TRF-78* [**2202-1-28**] 11:11AM BLOOD Cortsol-34.6* Brief Hospital Course: Assessment: 70 YOM with known pancreatic CA s/p multiple CBD stents who presented with sepsis. ================== Prior to presentation the patient had fevers and was hypotensive. His PCP ordered [**Name Initial (PRE) **] CT of the torso which showed bilateral pneumonia and no intra-abdominal process. On presentation the patient was in septic (spiking fevers and hypotensive). The patient was started on Levo/Clinda. Despite this intervention he continued to have increased respiratory distress. ================== Course in the ED In the ED the patient was hypotensive with SBPs in the 60. The rest of his vitals were stable. Lactate was 1.9. Central access was obtained and the patient received vanc/lev/flagyl. The patient received 4L of NS with CVP of [**7-18**] and MAP of 55-58. Levophed was started. Of note the patient also had increased drainage of his G/J tube. ================== In the [**Hospital Unit Name 153**] the patient's hypotension resolved and he was weaned off of pressors. Surgery replaced his G/J tube with a G tube. TF were resumed. Throughout his course in the [**Hospital Unit Name 153**] the patient remained tachypneic and tacchycardic. . Prelim blood cultures were identified as growing gram positives. As a result the patient was maintained on vancomycin. This was later identified as B. fragilis. The vancomycin was d/c and the patient was started on metronidazole. The cefepime was d/c 1.26 and levofloxacin started. If the patient became hypotensive or spike fevers (started to look septic) the plan was to resend cultures and try a stress dose of steroids. . On this regimen of Abx the patient clinically improved. He remained afebrile and was called out to the floor. On the floor multiple issues were addressed. ================== #Nausea - The patient had his G/J tube removed and a G tube placed on admission. He tolerated this for a short time. There were no signs of obstruction. He was restarted tube feeds with out complication but at a slower rate. Ativan for nausea. . #Tachpnea - The patient developed hypoxia and dyspnea [**2-11**] COPD and PNA. He changed his code to DNR/DNI on admission and was treated w/ abx and supplemetal O2. After an episode of desaturation to the 80s requiring NRB O2 therapy, his code status was again addressed and the patient and his family decided to focus on comfort rather than cure. He completed a course of abx and was maintained on his nebulizer treatments and supplemental oxygen for comfort. He was given morphine as well for respiratory discomfort. . #Hyponatremia - The patient has a chronic hyponatremia per OMR records. He was originally fluid restricted after osms showed SIADH pathology but this restriction was lifted as his code status changed. . #Anemia - Chronic problem that was stable after transfusion. . #Pancreatic cancer - Pt has no oncologist and did not undergoing treatment. The PCP and family treated his symtpoms as an outpatient with goal of comfort not cure. The palliative care team followed the patient throughout his course and was invaluable in end of life discussions and d/c planning. He was provided morphine, ativan, and compazine prn for symptomatic control. . # Code Status: The patient was made DNR/DNI on admission and, after discussion with the patient and family, he was changed to comfort measures only on the floor and was sent to a skilled nursing facility with hospice care closer to his family in [**Location (un) **]. . # Contact: [**Name (NI) **] [**Name (NI) **], ([**Telephone/Fax (1) 53776**] Medications on Admission: RISS, albuterol, ipratropium, heparin SC, colace, pancrease, tylenol, morphine PO, mirtazapine, fluticasone-salmeterol, Vit D3, MVI, megestrol, CaCO3, MOM, [**Name (NI) 13426**]. Discharge Medications: 1. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical PRN (as needed). Disp:*1 bottle* Refills:*1* 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 month supply* Refills:*0* 3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal QID (4 times a day) as needed. Disp:*1 bottle* Refills:*1* 4. Lorazepam 0.5-1 mg IV Q4H:PRN nausea/anxiety 5. Morphine Concentrate 20 mg/mL Solution Sig: 1-40 mg PO q2-4h as needed for pain, anxiety, SOB. Disp:*100 mL* Refills:*1* 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb neb Inhalation Q6H (every 6 hours). Disp:*2 week supply* Refills:*1* 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. Disp:*250 ML(s)* Refills:*1* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*1* 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed. Disp:*30 Suppository(s)* Refills:*0* 10. Compazine 5 mg Suppository Sig: One (1) supp Rectal every 4-6 hours as needed for nausea. Disp:*20 suppository* Refills:*1* Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: Primary: Pancreatic cancer, bilateral lower lobe community acquired pneumonia Secondary: Chronic Obstructive Pulmonary Disease, O2 dependent, Type 2 Diabetes Mellitus, Malnutrition, severe, delirium Discharge Condition: Stable Discharge Instructions: Please take your meds as directed by the hospice facility. The patient has terminal pancreatic cancer and has entered hospice care. The goal of admission to NH is for comfort care. Followup Instructions: None Completed by:[**2202-2-15**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "44.32", "99.04" ]

icd9pcs

[ [ [] ] ]

9772, 9843

4819, 8364

320, 372

10086, 10095

3816, 4796

10327, 10363

2728, 2847

8593, 9749

9864, 10065

8390, 8570

10119, 10304

2862, 3797

269, 282

400, 1358

1380, 2261

2278, 2712

75,509

122,870

50735

Discharge summary

report

Admission Date: [**2194-4-12**] Discharge Date: [**2194-4-23**] Date of Birth: [**2122-7-16**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1234**] Chief Complaint: venous stasis ulcers Major Surgical or Invasive Procedure: [**2194-4-11**]: Right anterior tibial artery stenting [**2194-4-13**]: Right 4th toe open ray amputation [**2194-4-17**]: Ligation of left upper arm atrioventricular fistula. History of Present Illness: The patient is a 71-year-old male who has been followed by Dr. [**Last Name (STitle) **] for venous stasis ulcers and bilateral lower extremity ischemia. He recently had a trip to the emergency room. He was followed up Dr.[**Name (NI) 1720**] clinic. The patient had noninvasive arterial study which showed SFA and tibia disease. At that time, it was thought that the patient would be best served by an angiogram. He is admitted for this on [**2194-4-11**]. Past Medical History: PAD CHF Ef 50%([**2193**]) ESRD, dialysis dependent T/Th/Sat schedule COPD atrial fibrillation s/p pacemaker for bradycardia s/p AV fistula left wrist (clotted off) s/p AV fistula ([**2194-1-26**]) in LUE Social History: From [**Location (un) 686**], lives in [**Location (un) **] with wife, 2 daughters. Retired social worker (21 years). 60-80 pack year history quit 25 years ago. No alcohol or recreational drugs. Family History: Non-contributory Physical Exam: vss gen: alert and oriented, in nad card: irreg (afib), no m/r/g lungs: cta bilat abd: soft no m/t/o wound: right foot with wet to dry dressing pulses: dp pt right d d left d d Pertinent Results: [**2194-4-12**] 07:40AM BLOOD WBC-8.4 RBC-2.74* Hgb-9.6* Hct-29.8* MCV-109* MCH-35.0* MCHC-32.2 RDW-15.7* Plt Ct-174 [**2194-4-13**] 11:55AM BLOOD WBC-6.8 RBC-2.68* Hgb-9.5* Hct-30.1* MCV-112* MCH-35.4* MCHC-31.6 RDW-15.7* Plt Ct-133* [**2194-4-13**] 04:55PM BLOOD WBC-9.5 RBC-2.77* Hgb-9.7* Hct-30.6* MCV-110* MCH-35.1* MCHC-31.8 RDW-15.8* Plt Ct-177 [**2194-4-14**] 01:49AM BLOOD WBC-8.9 RBC-2.55* Hgb-8.9* Hct-28.4* MCV-111* MCH-35.1* MCHC-31.5 RDW-15.9* Plt Ct-128* [**2194-4-15**] 01:13AM BLOOD WBC-9.0 RBC-2.50* Hgb-8.6* Hct-27.4* MCV-110* MCH-34.5* MCHC-31.5 RDW-15.5 Plt Ct-148* [**2194-4-16**] 02:05AM BLOOD WBC-7.8 RBC-2.51* Hgb-8.7* Hct-27.5* MCV-110* MCH-34.6* MCHC-31.6 RDW-15.5 Plt Ct-125* [**2194-4-17**] 04:56AM BLOOD WBC-9.2 RBC-2.61* Hgb-8.8* Hct-29.0* MCV-111* MCH-33.7* MCHC-30.3* RDW-15.4 Plt Ct-168 [**2194-4-18**] 05:02AM BLOOD WBC-8.9 RBC-2.57* Hgb-8.9* Hct-28.2* MCV-110* MCH-34.6* MCHC-31.5 RDW-15.7* Plt Ct-147* [**2194-4-19**] 12:30PM BLOOD WBC-9.2 RBC-2.62* Hgb-8.8* Hct-29.2* MCV-112* MCH-33.6* MCHC-30.1* RDW-15.7* Plt Ct-195 [**2194-4-21**] 04:07AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.9* Hct-29.6* MCV-112* MCH-33.7* MCHC-30.1* RDW-15.9* Plt Ct-170 [**2194-4-22**] 07:01AM BLOOD WBC-10.5 RBC-2.65* Hgb-9.1* Hct-29.8* MCV-112* MCH-34.3* MCHC-30.5* RDW-16.2* Plt Ct-177 [**2194-4-11**] 06:16PM BLOOD PT-24.2* INR(PT)-2.3* [**2194-4-11**] 08:30PM BLOOD PT-19.1* INR(PT)-1.7* [**2194-4-12**] 07:40AM BLOOD PT-18.7* PTT-32.4 INR(PT)-1.7* [**2194-4-12**] 07:40AM BLOOD Plt Ct-174 [**2194-4-13**] 11:55AM BLOOD PT-18.6* PTT-32.7 INR(PT)-1.7* [**2194-4-13**] 11:55AM BLOOD Plt Ct-133* [**2194-4-13**] 04:55PM BLOOD PT-18.9* PTT-32.5 INR(PT)-1.7* [**2194-4-13**] 04:55PM BLOOD Plt Ct-177 [**2194-4-14**] 01:49AM BLOOD PT-19.1* PTT-33.1 INR(PT)-1.7* [**2194-4-14**] 01:49AM BLOOD Plt Ct-128* [**2194-4-16**] 02:05AM BLOOD PT-23.5* PTT-37.5* INR(PT)-2.2* [**2194-4-17**] 04:56AM BLOOD PT-47.0* PTT-42.8* INR(PT)-4.9* [**2194-4-17**] 04:22PM BLOOD PT-60.9* INR(PT)-6.7* [**2194-4-17**] 08:41PM BLOOD PT-34.0* PTT-42.7* INR(PT)-3.4* [**2194-4-18**] 05:02AM BLOOD PT-24.4* INR(PT)-2.3* [**2194-4-18**] 04:39PM BLOOD PT-20.6* PTT-35.6* INR(PT)-1.9* [**2194-4-19**] 12:30PM BLOOD PT-20.0* PTT-33.9 INR(PT)-1.8* [**2194-4-20**] 04:56AM BLOOD PT-21.8* PTT-34.3 INR(PT)-2.0* [**2194-4-21**] 04:07AM BLOOD PT-24.8* PTT-36.5* INR(PT)-2.3* [**2194-4-22**] 07:01AM BLOOD PT-26.4* PTT-37.0* INR(PT)-2.5* [**2194-4-23**] 04:14AM BLOOD PT-24.1* PTT-37.3* INR(PT)-2.3* [**2194-4-12**] 07:40AM BLOOD Glucose-91 UreaN-80* Creat-5.5*# Na-138 K-5.2* Cl-99 HCO3-24 AnGap-20 [**2194-4-13**] 11:55AM BLOOD Glucose-92 UreaN-41* Creat-3.8*# Na-138 K-4.4 Cl-102 HCO3-25 AnGap-15 [**2194-4-13**] 04:55PM BLOOD Glucose-137* UreaN-43* Creat-4.0* Na-137 K-4.1 Cl-100 HCO3-26 AnGap-15 [**2194-4-14**] 01:49AM BLOOD Glucose-97 UreaN-47* Creat-4.2* Na-137 K-4.2 Cl-102 HCO3-23 AnGap-16 [**2194-4-15**] 01:13AM BLOOD Glucose-126* UreaN-58* Creat-5.1* Na-135 K-4.8 Cl-98 HCO3-24 AnGap-18 [**2194-4-16**] 02:05AM BLOOD Glucose-124* UreaN-33* Creat-3.4*# Na-138 K-4.0 Cl-100 HCO3-32 AnGap-10 [**2194-4-17**] 04:56AM BLOOD Glucose-99 UreaN-46* Creat-4.5*# Na-137 K-4.5 Cl-98 HCO3-28 AnGap-16 [**2194-4-18**] 05:02AM BLOOD Glucose-67* UreaN-28* Creat-3.1*# Na-142 K-4.0 Cl-99 HCO3-34* AnGap-13 [**2194-4-19**] 12:30PM BLOOD Glucose-139* UreaN-44* Creat-4.4*# Na-139 K-4.2 Cl-100 HCO3-27 AnGap-16 [**2194-4-20**] 04:56AM BLOOD Glucose-98 UreaN-26* Creat-2.9*# Na-139 K-3.7 Cl-98 HCO3-35* AnGap-10 [**2194-4-21**] 04:07AM BLOOD Glucose-78 UreaN-37* Creat-3.9* Na-137 K-3.9 Cl-98 HCO3-32 AnGap-11 [**2194-4-22**] 12:00PM BLOOD Glucose-123* UreaN-53* Creat-5.2*# Na-137 K-4.5 Cl-96 HCO3-33* AnGap-13 [**2194-4-13**] 8:00 am TISSUE FOURTH TOE. **FINAL REPORT [**2194-4-17**]** GRAM STAIN (Final [**2194-4-13**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. TISSUE (Final [**2194-4-17**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. ANAEROBIC CULTURE (Final [**2194-4-17**]): NO ANAEROBES ISOLATED. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 542**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 105542**]Portable TTE (Complete) Done [**2194-4-15**] at 11:04:05 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - [**Hospital Ward Name 517**] [**Hospital Unit Name 22682**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2122-7-16**] Age (years): 71 M Hgt (in): 66 BP (mm Hg): 84/37 Wgt (lb): 190 HR (bpm): 71 BSA (m2): 1.96 m2 Indication: Left ventricular function. Right ventricular function. ICD-9 Codes: 427.31, 424.0, 424.2 Test Information Date/Time: [**2194-4-15**] at 11:04 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 16812**] [**Last Name (un) 16813**], RDCS Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2011W000-0:00 Machine: Vivid q-1 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.3 cm <= 4.0 cm Left Atrium - Four Chamber Length: *7.4 cm <= 5.2 cm Right Atrium - Four Chamber Length: *6.8 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 30% to 35% >= 55% Left Ventricle - Stroke Volume: 55 ml/beat Left Ventricle - Cardiac Output: 3.93 L/min Left Ventricle - Cardiac Index: 2.01 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.13 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.13 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 7 < 15 Aorta - Sinus Level: 3.0 cm <= 3.6 cm Aorta - Ascending: 3.0 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 16 Aortic Valve - LVOT diam: 2.1 cm Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - E Wave deceleration time: 166 ms 140-250 ms TR Gradient (+ RA = PASP): *30 to 34 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Dilated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline dilated LV cavity size. Depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size. RV function depressed. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Moderately thickened aortic valve leaflets. Minimal AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of mitral valve chordae. Mild to moderate ([**12-29**]+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate [[**12-29**]+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Ascites. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. LV systolic function appears depressed with inferior, basal inferoseptal and mid inferolateral akinesis with mild to moderate hypokinesis elsewhere. Right ventricular chamber size is normal. with depressed free wall contractility. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-29**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. ART EXT (REST ONLY) Clip # [**Clip Number (Radiology) 105543**] Reason: Please do bilat ABIs and forefoot PVRs. [**Hospital 93**] MEDICAL CONDITION: 71 year old man with R toe ulcer REASON FOR THIS EXAMINATION: Please do bilat ABIs and forefoot PVRs. Final Report ARTERIAL STUDY HISTORY: Right toe ulcer. FINDINGS: Current study is compared to that done on [**2194-2-3**]. Indications appear to be the same. ABI measurements are inaccurate due to vessel non-compressibility. Doppler tracings again demonstrate triphasic waveforms at the femoral levels, all other waveforms are monophasic. The volume recordings are in [**Location (un) **] with the Doppler tracings. IMPRESSION: No change compared to the prior exam of [**2194-2-3**]. This includes significant bilateral SFA disease. [**Known lastname 542**],[**Known firstname **] [**Medical Record Number 105544**] M 71 [**2122-7-16**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2194-4-20**] 2:33 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] VICU [**2194-4-20**] 2:33 PM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 105545**] Reason: ? aspiration, possibly aspirating earlier, ? lung consolidat [**Hospital 93**] MEDICAL CONDITION: 71 year old man with new SOB after eating soup REASON FOR THIS EXAMINATION: ? aspiration, possibly aspirating earlier, ? lung consolidation Final Report CHEST HISTORY: Short of breath after eating soup, question aspiration. One view. Comparison with the previous study done [**2194-4-14**]. There may be slight interval improvement in mild vascular congestion. There is no focal consolidation. The heart and mediastinal structures are unchanged. Bilateral internal jugular catheters remain in place. IMPRESSION: Probable interval improvement in vascular congestion. No acute focal consolidation is identified. Brief Hospital Course: Admitted on [**4-10**] for Right lower extremity angio. Underwent R at stent without compolications. Was transfered to the pacu for recovery where he remained stable. He was transfered to the VICU for further monitoring. He is an HD patient, and was followed by renal throughout his stay. On POD 1 he was doing well.It was decided that he would need a right 4th ray amp, and he was preop'd and consented for this. On [**4-13**] he underwent the R 4th ray amputation without complications. He went to the PACU for recovery, and shortly thereafter became hypotensive with bp's in the 60s/40s. An aline was placed and phenylephrine started. He was transfered to the ICU, and a R ij central line was placed. His gtt was changed to levo and cardiology was consulted. There was concern that he may be septic and vancomycin/zosyn were started. On [**4-30**] the pressors were weaned and the pt was improving. He continued to be monitored in the ICU until [**4-16**] when he was transfered to the VICU where he was stable. On [**4-17**] the transplant surgery team took the pt to the OR for Ligation of left upper arm AV fistula for STEAL syndrome. He returned to the VICU where he was again moniotred closely . He remained hemodynamically stable. The right foot wound was slow to improve and on [**4-18**] it was decided to place a VAC on the right foot wound. He began working with PT and was found to need substantial rehab services. On [**4-20**] the pt aspirated while eating soup. On [**4-21**] he had a swallow evaluation, and was found to be safe for ground solids with thin liquids. He tolerated this diet well. At this time he was medically and surgically stable and rehab screening was initiated. On [**4-23**] he was discharged to a rehab facility. He will need to come back next week for a repeat RLE angiogram and likely a right TMA. Coumadin should be stopped 3 days prior to admission . He will be d/c'd on augmentin which should continue through his next admission. Also, his sutures (LUE) should be removed on [**4-27**]. Medications on Admission: +Simvastatin 40, Gabapentin 100''', Folic acid 1, Lisinopril 20, Nephrocaps 1 tab, Ipratropium-albuerol 1-2 puffs INH Q6H prn wheeze, warfarin 2, ferrous sulfate 325, sevelamer HCl 800''', Fish Oil 1000, Tricor 48, ASA 81, Vitamin C 250, Calcium 500 + Vitamin D 400, Glargine 8 units QHS . Discharge Medications: 1. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-29**] Puffs Inhalation Q6H (every 6 hours). 2. sevelamer HCl 400 mg Tablet Sig: Eight (8) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. ascorbic acid 250 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 14. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for constipation. 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for constipation. 17. white petrolatum-mineral oil Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for dry skin. 18. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): give after HD on HD days. cont through TMA operation. 19. warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once): check pt/inr frequently. 20. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous once a day: at breakfast. 21. insulin regular human 100 unit/mL Solution Sig: sliding scale Injection four times a day: please see below . 22. sliding scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose 0-70mg/dL ----Proceed with hypoglycemia protocol---- 71-150mg/dL 0Units 0Units 0Units 0Units 151-200mg/dL 2Units 2Units 2Units 2Units 201-250mg/dL 4Units 4Units 4Units 4Units 251-300mg/dL 6Units 6Units 6Units 6Units 301-350mg/dL 8Units 8Units 8Units 8Units 351-400mg/dL 10Units 10Units 10Units 10Units Instructons for NPO Patients: Evening Prior to Surgery/Procedure: If on glargine or detemir: give 80% of usual dose; If on NPH: give 100% usual dose. Morning of Surgery/Procedure: If on glargine or detemir: give 80% of usual dose; If on NPH: give 50% of usual dose; If on premix insulin (e.g. 70/30, 75/25): take total number of AM units ordered, divide by 3, and give that many units as NPH; If on sliding scale of short acting insulin: administer according to HS schedule. Hold all oral antidiabetic medications, and consider sliding scale coverage; If appropriate, give IVF with dextrose to prevent hypoglycemia. 23. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 24. Outpatient Lab Work please check PT/INR at least two - three times per week Goal INR: 2.0-3.0 Dx: Afib Discharge Disposition: Extended Care Facility: [**Location (un) 2251**] Nursing and Rehabilitation - [**Location (un) 2251**] Discharge Diagnosis: Bilateral lower extremity ischemia with venous stasis ulcers. Gangrene infection right 4th toe. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Weigh yourself every morning, call your cardiologist if weight goes up more than 3 lbs. This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. .ACTIVITY: .There are restrictions on activity. On the side of your transmetatarsal amputation you are non weight bearing for [**4-2**] weeks. You should keep this amputation site elevated when ever possible. .You may use the heel of your amputation site for transfer and pivots. But try not to exert to much pressure on the site when transferring and or pivoting. If possible avoid using the heel of your amputation site when transferring and pivoting. .No driving until cleared by your Surgeon. .PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: .Redness in or drainage from your leg wound(s). .New pain, numbness or discoloration of your foot or toes. .Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. .Exercise: .Limit strenuous activity for 6 weeks. .Do not drive a car unless cleared by your Surgeon. .No heavy lifting greater than 20 pounds for the next 14 days. .Try to keep leg elevated when able. BATHING/SHOWERING: .You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. .WOUND CARE: You will have a wound VAC placed at the rehab facility. This will be changed three times per week. .Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. .When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. . Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. .MEDICATIONS: .Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. .Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: .NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. .Avoid pressure to your amputation site. .No strenuous activity for 6 weeks after surgery. .DIET: .There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. .For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. .If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. .If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: .Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! .Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. .PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: You are scheduled for an angiogram on [**4-29**], the preop nurse will call you with time and details Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2194-5-30**] 10:00 Completed by:[**2194-4-23**]

[ "996.73", "428.32", "038.8", "438.20", "250.40", "403.91", "V58.61", "428.0", "458.29", "518.5", "707.03", "V15.82", "V43.64", "272.0", "V12.51", "707.10", "707.21", "440.24", "V58.67", "995.92", "585.6", "V45.01", "496", "V45.11", "427.31", "459.81", "285.9" ]

icd9cm

[ [ [] ] ]

[ "88.48", "39.95", "00.46", "39.90", "84.11", "38.93", "88.42", "39.50", "93.90", "39.53", "00.40", "88.47", "38.91" ]

icd9pcs

[ [ [] ] ]

17981, 18086

12132, 14170

325, 503

18226, 18226

1708, 9222

24016, 24303

1452, 1470

14512, 17958

11485, 11532

18107, 18205

14196, 14489

18402, 20293

9267, 10288

1485, 1689

264, 287

11564, 12109

20306, 23315

23339, 23993

531, 994

18241, 18378

1016, 1223

1239, 1436

66,275

127,955

39886

Discharge summary

report

Admission Date: [**2121-10-9**] Discharge Date: [**2121-10-14**] Date of Birth: [**2046-7-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Respiratory Distress, PEA arrest Major Surgical or Invasive Procedure: Intubation Cardiac Catherization History of Present Illness: 75 year old male with past medical history of HTN, HLD, CAD, DMII and COPD who became progressively dyspneic and fatigued starting last night. This morning the patient was gasping for air and his wife called 911. [**Name2 (NI) **] was transported to [**Hospital 6451**] Medical Center. On arrival to ED at OSH patient was in respiratory distress and intubated. Patient was found to have PEA, received epinephrine and converted to SVT, and received lidocaine. He was then noted to be in AF with RVR in the 150s and was cardioverted with 200 J x 1 biphasic sync shock. The patient's EKG revealed q waves and ST elevation in III and aVF with widespread ST depression. Patient was taken for an emergent catherization. Catherization showed LAD 80% mid lesion, occluded posterior lateral, 70-80% occulsion of the PDA, and 50% OM1. No intervention was performed in outside cath lab and patient was transferred to [**Hospital1 **] for definitive treatment of CABG vs. PCI. . On review of systems unable to obtain due to patient non-communicative and family not present . Cardiac review of systems unable to obtain due to patient non-communicative and family not present. Past Medical History: CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension OTHER PAST MEDICAL HISTORY: COPD Asthma Prostate CA s/p radiation 10 years ago Tylenol poisoning Social History: married; otherwise history unknown -Tobacco history: Unknown amount, quit in [**2096**] -ETOH: wife states no -Illicit drugs: wife states no Family History: Unknown per wife Physical Exam: T=100.6 BP=116/69 HR=99 RR=15 O2 sat= 97%; Intubated on CMV with tidal volumes of 600, RR 15, PEEP of 10 GENERAL: Intubated and sedated. Twitching of tongue. HEENT: NCAT. Sclera anicteric. Pinpoint pupils. CARDIAC: RRR, normal S1, S2. No m/r/g appreciated. LUNGS: Coarse breath sounds with wheezing throughout. ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e. Right femoral site still has two lines in place with plastic covering. PULSES: Radial 2+ and PT 2+ Bilaterally NEURO: Patient not responsive. Spontaneously moves lower extremities and spontaneously opens eyes. Does not follow commands. Tongue twitching present. Pertinent Results: Admission Labs: [**2121-10-9**] 12:14PM BLOOD WBC-11.8* RBC-3.79* Hgb-10.4* Hct-31.2* MCV-82 MCH-27.5 MCHC-33.4 RDW-15.9* Plt Ct-256 [**2121-10-9**] 12:14PM BLOOD Neuts-89.1* Lymphs-7.6* Monos-2.6 Eos-0.2 Baso-0.4 [**2121-10-9**] 12:14PM BLOOD PT-14.9* PTT-52.8* INR(PT)-1.3* [**2121-10-9**] 12:14PM BLOOD Glucose-399* UreaN-42* Creat-2.0* Na-145 K-4.1 Cl-106 HCO3-30 AnGap-13 [**2121-10-9**] 12:14PM BLOOD CK(CPK)-220 [**2121-10-9**] 12:14PM BLOOD CK-MB-15* MB Indx-6.8* [**2121-10-9**] 12:14PM BLOOD Calcium-9.1 Phos-5.1* Mg-1.9 [**2121-10-9**] 01:29PM BLOOD Lactate-1.9 Microbiology: - GRAM STAIN (Final [**2121-10-12**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. YEAST. MODERATE GROWTH. GRAM NEGATIVE ROD(S). MODERATE GROWTH. BC NGTD UC NGTD Imaging: Echo [**10-9**] (Please see chart for further details) The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) secondary to severe hypokinesis of the inferior and posterior walls with inferobasal and posterobasal ANEURYSM. MRI: [**2121-10-11**] Findings indicative of diffuse hypoxic injury to the brain along with several foci of acute infarcts involving both cerebellum and right periatrial region. No hemorrhage is seen. Studies: [**2121-10-13**] This is an abnormal continuous EEG continuous low voltage suppressed background. This record is worse compared to the previous tracing due to the disappearance of GPED activity and severe diffuse background attenuation. While there is no definite evidence of cerebral activity, this study was not performed according to ACNS guidelines for electrocerebral inactivity and, therefore, cannot be used as a confirmatory test for the determination of brain death. Brief Hospital Course: 75 year old man with respiratory distress requiring intubation at OSH s/p PEA arrest, SVT, and AF with RVR now in Sinus rhythm who underwent cooling protocol. . In brief, the patient initially presented to an OSH with respiratory distress resulting in respiratory distress requiring intubation. At the time he developed PEA arrest necessitating medications and DC cardioversion. His ECG demonstrated ST depressions and elevations necessitating emergent catheterization. Cauterization showed LAD 80% mid lesion, occluded posterior lateral, 70-80% occlusion of the PDA, and 50% OM1. No intervention was performed in outside cath lab and patient was transferred to [**Hospital1 **] for definitive treatment of CABG vs. PCI. He was then cooled per the artic sun protocol. . His hospital course was complicated by hypotension, seizure activity, and acute on chronic renal failure secondary to ATN. An MRI demonstrated diffuse anoxic brain injury and his neuro exam suggestive minimal function above brainstem activity. His goals of care was discussed with his wife, and [**Name2 (NI) **] measures were initiated after the endotracheal tube was pulled. The patient expired several hours after extubation on a morphine drip. Medications on Admission: Advair Diskus 250-50 Albuterol 90 MCG Amlodipine 5 mg Furosemide 20 mg Lisinopril 40mg two tablets daily Lopid 600 mg [**Hospital1 **] Oxybutynin 5 mg [**Hospital1 **] Promethazine-Codeine 6.25-10mg Singular 10 mg po qhs Spiriva 18 mcg Metformin glyburide Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: PEA arrest Discharge Condition: Expired Discharge Instructions: None. Followup Instructions: None Completed by:[**2121-10-15**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6245, 6254

4683, 5909

348, 382

6308, 6317

2611, 2611

6371, 6407

1938, 1956

6216, 6222

6275, 6287

5935, 6193

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1971, 2592

3503, 4660

276, 310

410, 1578

2627, 3462

1694, 1764

1780, 1922

61,492

162,292

15536

Discharge summary

report

Admission Date: [**2143-12-9**] Discharge Date: [**2143-12-13**] Date of Birth: [**2089-10-11**] Sex: M Service: NEUROLOGY Allergies: Dairycare / Egg Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: left sided weakness Major Surgical or Invasive Procedure: IA tPA and Merci clot retrieval History of Present Illness: 54 yo left-handed man with sudden onset of bilateral vision loss, dizziness and left sided weakness who presents from [**Hospital **] hospital as a code stroke. He has a past medical history that is significant for severe cardiomyopathy (EF 10-15% - etiology unknown, thought possible secondary to cocaine/EtOH), HTN currently controlled, and diabetes (on insulin). Patient had been in the hospital and discharged on [**2143-12-6**] after presentation for chest pain, and then found to have a severely depressed EF. He was diuresed during that admission and started on Lasix, coumadin and digoxin. After the hospitalization he stated that he had been up and around at home with little difficulty. He noted a few episodes of dizziness while standing that had resolved after he was able to sit down. This morning, he was in the kitchen having some melon when he states that he felt suddenly short of breath and then started to lose vision in both eyes. He was feeling dizzy, so he went over to his couch and sat down. He thought the episode may be related to his blood sugars, so he tried to take his insulin, but then realized he could not see it and dropped it on the floor. He fell to the ground while trying to retrieve it, and then according to his mother he was unable to get up. She reports that he was still moving his hands bilaterally as well as his feet, but was unable to get up. She called 911 and he was brought to [**Location (un) **] where he received IV tPA. Patient was transferred to [**Hospital1 18**] where stroke scale was 17 mostly for neglect, L arm and leg weakness and sensory loss. He was admitted to the neuro-ICU. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension . 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: Cath 10 years ago showing clean coronaries reports stress test several years ago that was negative . 3. OTHER PAST MEDICAL HISTORY: DMII Gout GERD HTN HL L Charcot foot peripheral neuropathy Social History: Patient states that he is currently unemployed and living with his mother. [**Name (NI) **] worked in the past installing swimming pools. He has had variable accounts of EtOH intake and stated that he typically drank between 5-6 beers/day but stopped last week. He was noted to have cocaine + urine but denied use in the past. Denies smoking. Family History: Father diverticulitis Mother - healthy Physical Exam: T 98 P 91 BP 110/82 R 18 SpO2 100% ra GEN: NAD, atraumatic HEENT: no carotid bruits, non-icteric sclera CV: RRR, soft heart sounds nS1S2 Pulm: b/l crackles at bases Abd: soft, NT, ND Ext: minimal b/l edema at ankles Neuro: MS: alert, oriented to hospital, date, was very slow to respond to questions and slight dysarthria, had subtle anomia for low-frequency words (no cactus or hammock), able to follow complex commands involving L/R hemibody, repetition intact to "no ifs ands or buts", would perseverate on tasks after performing commands, [**Location (un) 1131**] intact, writing intact, hemineglect of left arm and hand, 7 quarters in $1.75, no apraxia CN: pupils [**1-29**] b/l to light, visual fields - difficult to assess given hemineglect, but likely intact, EOMI - no nystagmus, facial sensation intact, smile with diminished excursion on L side, hearing intact b/l, palate symmetric Motor: R side full in upper and lower extremities; no tremor or increased tone - difficulty with formal testing of left side due to neglect, but able to hold up left arm after being elevated by examiner; deltoids [**3-3**]; biceps [**3-3**]; triceps 4-/5; WE 4-/5; FE [**2-1**]; FF [**3-3**]; left leg can be sustained in elevated position for several seconds; IP [**3-3**]; H [**3-3**]; Q 4-/5; TA [**3-3**]; [**Last Name (un) 938**] 4-/5; Gastroc 4+/5 Reflexes: symmetric and present; toes upgoing on the left Sensation: diminished to DSS on the left side, present to light touch and painful on the left and right Coordination: limited testing on left side; right side - no dysmetria on FNF or HTS Gait: not tested Pertinent Results: [**2143-12-11**] 06:25AM BLOOD WBC-8.6 RBC-5.56 Hgb-17.5 Hct-50.9 MCV-92 MCH-31.4 MCHC-34.3 RDW-13.5 Plt Ct-232 [**2143-12-9**] 10:30AM BLOOD PT-18.8* PTT-23.8 INR(PT)-1.7* [**2143-12-11**] 06:25AM BLOOD Glucose-134* UreaN-15 Creat-0.9 Na-135 K-4.3 Cl-103 HCO3-20* AnGap-16 [**2143-12-10**] 11:23AM BLOOD CK(CPK)-53 [**2143-12-11**] 06:25AM BLOOD cTropnT-0.10* [**2143-12-9**] 02:20PM BLOOD CK-MB-3 cTropnT-0.16* [**2143-12-11**] 06:25AM BLOOD Calcium-9.6 Phos-3.0 Mg-2.1 Cholest-PND [**2143-12-11**] 06:25AM BLOOD Digoxin-0.5* EKG [**2143-12-9**]: Sinus rhythm. Consider left ventricular hypertrophy by voltage with ST-T wave abnormalities of strain and/or myocardial ischemia. Since the previous tracing opf [**2143-12-4**] the rate is slower. Limb lead voltage is more prominent. T wave abnormalities can now be seen. Previously, P wave was superimposed on T wave. Intervals Axes Rate PR QRS QT/QTc P QRS T 83 164 98 372/412 -4 -16 130 CT head/CTA head and neck/CT Perfusion head [**2143-12-9**]: NON-CONTRAST HEAD CT: There is subtle loss of [**Doctor Last Name 352**]-white matter differentiation in the right insula and hypodensity within the right posterior putamen suggesting right MCA territory acute infarction. No acute intracranial hemorrhage is seen. There is no hydrocephalus, nor shift of normally midline structures. The basal cisterns are patent. The soft tissues and orbits are unremarkable. Mucus retention cyst is noted in the right maxillary sinus. Vascular calcifications are noted in bilateral cavernous carotid arteries. CT PERFUSION: There are areas of matched increased mean transit time (MTT) and decreased blood volume (BV) in the right frontal and parietal lobes, in the MCA territory, consistent with acute infarction. In the periphery of the right MCA territory, in the inferior right temporal lobe and superior right frontal lobe, there are small regions of mismatched increased MTT without definite decreased BV, possibly representing small areas of ischemic penumbra. CTA NECK: Imaging is slightly limited due to suboptimal timing of the contrast bolus. Atherosclerotic calcifications are noted at the origin of the left common carotid artery as well as the separate origin of the left vertebral artery from the aortic arch. Mild calcified plaque is noted at the right carotid bulb and proximal right internal carotid artery. The right internal carotid artery measures 6.5 mm proximally and 4.5 mm distally. On the left, there is partially calcified and noncalcified plaque at the carotid bulb and proximal ICA, causing some luminal narrowing. The left ICA measures 4.5 mm proximally and 4.5 mm distally. The cervical vertebral arteries are patent. Allowing for imaging during expiration, no lesion is seen within the visualized lung apices. No adenopathy is noted by size criteria within the visualized upper mediastinum and neck. Degenerative changes are noted in the visualized cervical spine. CTA HEAD: There is atherosclerotic calcification and irregular narrowing of the right cavernous carotid artery. The M1 and all three M2 branches of the right MCA arteries are patent; however, note is made of relative decreased opacification of distal branches of the superior right MCA division compared to the left (5:260). The left MCA and bilateral ACAs are patent. Incidental note is made of bifurcation of the right A1 with arteries supplying both the right and left ACA. Bilateral posterior communicating arteries are patent. The intracranial posterior circulation is patent. IMPRESSIONS: 1. Loss of [**Doctor Last Name 352**]-white matter differentiation in the right insula and also posterior right putamen suggest acute right MCA territory infarction. No acute intracranial hemorrhage seen. 2. CT perfusion suggests acute infarction in right frontal and parietal lobes, in MCA territory. Relatively small areas of ischemic penumbra suggested in peripheral right MCA territory, in superior frontal and inferior temporal lobes. 3. CTA head shows patent M1 and M2 branches of the right MCA, with decreased opacification of distal branches of the superior right MCA division compared to the left. MRI Brain [**2143-12-9**]: IMPRESSION: 1. Multiple areas of restricted diffusion, in the right MCA territory as described above, presenting acute infarcts. Nonvisualization of the distal M1 segment and proximal M2 segments of the right middle cerebral artery needs further evaluation with MR angiogram, as it is unclear if this relates to the course/stenosis/occlusion in the interval since the prior CTA study. D/w Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) **] by Dr.[**Last Name (STitle) **] on [**2143-12-10**] at 9.30AM. 2. Areas of negative susceptibility in the right putamen, representing hemorrhage, post-TPA. Consider followup with non-contrast CT head. Mass effect on the right lateral ventricle. 3. Small foci of icnreased DWI signal in the left frontal and posterior temporal/occipital lobes- attention on follow up. Clinical workup toe xclude central embolic etiology. Surface Echo [**2143-12-10**]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There is no pericardial effusion. IMPRESSION: No left ventricular thrombus. Severe global left ventricular systolic dysfunction. Brief Hospital Course: After IV tPA and IA tPA/Merci clot retrieval, there was improvement of the left sided weakness, but there was still some element of left neglect, slowness to motor movements/apraxia on the left, and psychomotor delay. A NCHCT the day after the procedure showed hemorrhagic transformation, so he was started on ASA 81 mg Qday to strike a balance between clot prophylaxis and bleed risk. The following day, coumadin was started at a low dose (1 mg Qday). Coumadin was felt to be indicated in the setting of his new stroke and very poor EF (10-20%) (Also, he had been started on coumadin by the cardiologists due to the severity of his heart failure just days prior to this admission). His goal was to reach INR [**1-2**] in about 7 days. However, after just two doses of 1 mg coumadin, INR was 3.4. Coumadin is now being held, and INR should be monitored daily. He should be started on just one half mg coumadin when INR is below 2. He was continued on home dose lovastatin, with good fasting lipid panel. Diabetes was controlled with insulin and sliding scale. He was monitored on CIWA scale but showed no clinical evidence of withdrawal. He will follow up with cardiology and neurology stroke. Medications on Admission: 1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA). Disp:*60 Tablet(s)* Refills:*2* 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 10. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: One (1) 52 Subcutaneous twice a day. Discharge Medications: 1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4 hours) as needed for per CIWA protocol. 13. insulin regular human 100 unit/mL Solution Sig: per sliding scale Injection four times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Stroke Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with a stroke that was responsible for your left sided weakness. You underwent an intervention and received [**Location (un) **] to remove the offending clot. You had been on coumadin previously and will need to continue on this. You will need your blood monitored regularly, with a goal INR of [**1-2**]. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2143-12-23**] 11:00 Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2144-1-22**] 2:00

[ "530.81", "428.0", "434.11", "401.9", "431", "342.91", "713.5", "V45.88", "250.60", "274.9", "425.4", "428.22" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13406, 13503

10056, 11253

307, 341

13554, 13554

4437, 5455

14177, 14505

2748, 2788

12340, 13383

13524, 13533

11279, 12317

13739, 14154

2803, 4418

2141, 2280

248, 269

369, 2013

5464, 10033

13569, 13715

2311, 2371

2057, 2121

2387, 2732

23

152,223

4310

Discharge summary

report

Admission Date: [**2153-9-3**] Discharge Date: [**2153-9-8**] Date of Birth: [**2082-7-17**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain, SOB, positive ETT Major Surgical or Invasive Procedure: [**2153-9-3**] Four vessel coronary artery bypass grafting(LIMA to LAD, SVG to Diagonal, SVG to OM, SVG to PDA) History of Present Illness: This is a 71 year old male with known CAD. He underwent PTCA to LAD and diagonal in [**2145**]. Prior to hernia repair operation, an ETT in [**2153-7-27**] was notable for EKG changes. An ECHO in [**Month (only) 205**] [**2153**] was notable for mild MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] AS. The [**Location (un) 109**] was estimated at 1.1 cm2 with peak/mean gradients of 34 and 22 mmHg. The was mild concentric LVH with an LVEF of 60%. He was subsequently referred for cardiac catheterization. This was performed at the [**Hospital1 18**] on [**2153-8-16**]. Angiography showed a right dominant system with 80% ostial LAD lesion; first diagonal had a 60% stenosis; the circumflex had a 60% lesion while the RCA had a 40% stenosis. There was only mild AS with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 1.8 cm2 and mean gradient of 18mmHg. Left ventriculogram showed preserved LV function. Based on the above results, he was referred for CABG. Past Medical History: CAD - s/p PTCA, HTN, Hypercholesterolemia, BPH, Hernia, Decreased hearing, s/p L knee arthroscopy, s/p appy Social History: 50 year history of pipe smoking. Admits to [**5-2**] ETOH drinks per week. Family History: No premature CAD Physical Exam: Temp 98.0, BP 126/74, HR 61, Resp 18(sat 98% on RA) General: elderly male in NAD Neck: supple, no JVD HEENT: benign Lungs: clear bilaterally Heart: regular rate and rhythm, 4/6 SEM radiating to carotids Abdomen: benign Ext: warm, no edema, no varicosities Neuro: nonfocal Pulses: 2+ distally, no femoral bruits Pertinent Results: [**2153-9-8**] 10:00AM BLOOD Hct-26.1* [**2153-9-5**] 05:55AM BLOOD WBC-8.6 RBC-2.89* Hgb-9.3* Hct-25.7* MCV-89 MCH-32.0 MCHC-36.0* RDW-13.8 Plt Ct-113* [**2153-9-6**] 05:45AM BLOOD UreaN-20 Creat-0.8 K-3.8 [**2153-9-5**] 05:55AM BLOOD Glucose-115* UreaN-20 Creat-0.7 Na-140 K-4.1 Cl-107 HCO3-27 AnGap-10 [**2153-9-6**] 05:45AM BLOOD Mg-1.9 Brief Hospital Course: Patient was admitted and underwent four vessel CABG on [**2153-9-3**] by Dr. [**Last Name (STitle) **]. Surgery was uneventful - see op note for further details. Following the operation, he was brought to the CSRU in stable condition. There he was weaned from inotropic support and was extubated without difficulty. He was noted to have some ventricular ectopy which improved after intravenous Lidocaine and PO beta blockade. K and Mg levels were monitored closely and repleted per protocol. He otherwise maintained stable hemodynamics. Units of PRBCs were intermittently transfused to maintain hematocrit close to 30%. On POD 1, he transferred to the SDU. He remained in a normal sinus - no further ventricular ectopy was noted. Beta blockade was slowly advanced as tolerated. Over several days, he made clinical improvements. By discharge, he was near his preoperative weight with oxygen saturations over 96% on room air. He also worked daily with physical therapy and made steady progress. His hospital course was otherwise uneventful and he was cleared for discharge to home on POD 5. He is scheduled to follow up with Dr. [**Last Name (STitle) **] and his local cardiologist in approximately 4 weeks. Medications on Admission: Isordil 20 [**Hospital1 **], Lescol 40 qd, Accupril 40 qd, Hytrin 5 qd, HCTZ 12.5 [**Last Name (LF) **], [**First Name3 (LF) **] 325 qd, Cartia 80 qd, KCL 20 [**Hospital1 **], TNG prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours for 10 days. Disp:*50 Tablet(s)* Refills:*0* 9. Lescol 40 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: s/p CABGx4 (Lima->LAD, SVG->Diag, SVG->OM, SVG->PDA) PMH: CAD s/p PCI, HTN, ^chol, BPH, Hernia repair Discharge Condition: Good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds Followup Instructions: [**Hospital 409**] clinic in 1 week Dr [**Last Name (STitle) **] in [**3-30**] weeks Dr [**Last Name (STitle) **] in 4 weeks Completed by:[**2153-9-20**]

[ "411.1", "414.01", "424.1", "V45.82", "389.9", "600.00", "401.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.13", "36.15", "88.72", "99.07", "99.04", "99.05" ]

icd9pcs

[ [ [] ] ]

5021, 5076

2445, 3653

349, 462

5222, 5229

2080, 2422

5430, 5586

1716, 1734

3887, 4998

5097, 5201

3679, 3864

5253, 5407

1749, 2061

280, 311

490, 1477

1499, 1608

1624, 1700

27,102

115,757

19150

Discharge summary

report

Admission Date: [**2203-2-18**] Discharge Date: [**2203-2-24**] Date of Birth: [**2123-12-6**] Sex: M Service: MEDICINE Allergies: Lisinopril / Macrobid / metformin Attending:[**First Name3 (LF) 603**] Chief Complaint: Flank pain Major Surgical or Invasive Procedure: [**2203-2-18**] - Left nephrostomy tube replacement [**2203-2-18**] - Mechanical ventilation during nephrostomy replacement [**2203-2-18**] - Central venous line placement in right internal jugular vein History of Present Illness: 79yo male w/ dCHF, COPD, OSA on CPAP and metastatic, castrate resistant prostate cancer who comes in with left-flank pain and fevers. Two days ago he was feeling well. Yesterday he developed fevers and left flank pain. Overnight he had nausea with a small amount of non-bloody emesis. No diarrhea, he has actually been constipated. He came into the ED. Of note, he had a nephrostomy tube placed [**2-9**] by interventional radiology because of hydronephrosis on CT scan. . In the ED, initial VS were: 102.0 109 145/71 24 96%. Triggered for tachycardia. Given 3L IV fluids. A CT scan his nephrostomy tube was out of place, with resultant hydronephrosis and surrounding fat-stranding concerning for pyelonephritis. He was given vanc/zosyn. A right IJ was placed. Is making urine, with negative UA. No foley in place. 110, 132/64, 30, 97% on RA. . On arrival to the MICU, patient alert, oriented, but tachypneic. He confirmed that he had been feeling unwell since yesterday, with left flank pain that is much worse with movement, but no pain elsewhere. He was unable to lie flat. He was intubated for nephrostomy replacement. He was unable to provide further ROS. Past Medical History: Adenocarcinoma of the prostate - metastatic, androgen resistant Benign Prostatic Hypertrophy s/p TURP with GreenLight [**10-9**] COPD - FEV1 67% predicted in [**2198**] Low back pain Type II Diabetes Diastolic Congestive Heart Failure Coronary Artery Disease: Mild, reversible inferior wall defect on stress MIBI [**6-6**]; [**9-11**] cath showed microvascular disease Hypertension GERD Obstructive Sleep Apnea on CPAP (intermittently) Migraine Headaches Hypercholesterolemia s/p CCY [**12-11**] Social History: The patient has never smoked. He previously used alcohol but quit many years ago. He is married and lives with his wife. From the [**Country 13622**] Republic with 9 children. He previously worked in agriculture 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: Admission exam: Vitals: T: 101 BP: 130/60 P: 83 R: 22 O2: 94%RA General: Alert, oriented, moderate respiratory distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: supple, JVP difficult to appreciate, no LAD CV: Regular rate, tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, basilar crackles posteriorly. Abdomen: soft, left flank very tender. Obese with mild abdominal distention. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. Trace L>R edema. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation. Discharge exam - unchanged from above, except as below: General: Alert, comfortable, no resp distress CV: RRR, no m/r/g Back: left sided nephrostomy tube in place Pertinent Results: Admission labs: [**2203-2-18**] 10:40AM BLOOD WBC-11.8* RBC-3.83* Hgb-10.6* Hct-31.0* MCV-81* MCH-27.7 MCHC-34.1 RDW-14.1 Plt Ct-276 [**2203-2-19**] 04:39AM BLOOD PT-12.6* PTT-33.5 INR(PT)-1.2* [**2203-2-18**] 10:40AM BLOOD Glucose-153* UreaN-35* Creat-1.8* Na-131* K-5.3* Cl-94* HCO3-23 AnGap-19 [**2203-2-18**] 10:40AM BLOOD ALT-38 AST-74* AlkPhos-113 TotBili-0.9 [**2203-2-19**] 04:39AM BLOOD Calcium-8.0* Phos-6.5* Mg-2.2 [**2203-2-18**] 10:20AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 [**2203-2-18**] 10:20AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG Discharge labs: [**2203-2-24**] 07:38AM BLOOD WBC-7.3 RBC-3.18* Hgb-8.6* Hct-25.9* MCV-82 MCH-27.1 MCHC-33.2 RDW-14.3 Plt Ct-334 [**2203-2-24**] 07:38AM BLOOD Glucose-93 UreaN-31* Creat-1.5* Na-140 K-3.4 Cl-103 HCO3-26 AnGap-14 [**2203-2-24**] 07:38AM BLOOD Calcium-7.2* Phos-3.4 Mg-2.1 Micro: -UCx ([**2203-2-18**]): URINE CULTURE (Final [**2203-2-22**]): MORGANELLA MORGANII. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ MORGANELLA MORGANII | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- <=1 S 2 S CEFTAZIDIME----------- <=1 S 4 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 1 S <=0.25 S GENTAMICIN------------ =>16 R 2 S MEROPENEM-------------<=0.25 S 0.5 S NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R -UCx ([**2203-2-18**]), from nephrostomy tube: (L) PARCUTANEOUS NEPHROSTOMY TUBE. **FINAL REPORT [**2203-2-21**]** URINE CULTURE (Final [**2203-2-21**]): PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S -BCx ([**2203-2-18**]): No growth final Imaging: -CT Abd/Pelvis ([**2203-2-18**]): IMPRESSION: Misplaced left percutaneous nephrostomy catheter with the pigtail coiled in the lateral perinephric fat. 2. Moderate-to-severe left hydroureteronephrosis with extensive perinephric fat stranding and pararenal fascial thickening. This could represent pyelonephritis in a closed urinary collecting system, or post-surgical changes from the recent procedure and displacement of the catheter. 3. Stable thickening of the soft tissues adjacent to the prostate, likely representing prostate cancer, with unchanged paraaortic mass causing left reteric malignant obstruction. 4. Sclerotic appearance of right posterior 10th rib and adjacent pedicle of the T10 vertebra, with increased uptake seen on bone scan in [**2201**], which may represent an old traumatic injury, however, is also concerning for metastatic disease given the patient's history of metastatic prostate cancer. Routine followup with bone scan is recommended. -AP CXR ([**2203-2-18**]): enlarged heart. Bibasilar opacities, likely atelectasis. Worsening congestion. -KUB ([**2203-2-19**]): There is some overlying artifact and motion on the study. A percutaneous nephrostomy tube appears to be projecting over the left mid abdomen. No nasogastric tube or Foley catheter is visualized. Calcification in the right hemipelvis is felt to most likely represent a phlebolith. Degenerative changes are seen in the spine. No acute bony abnormality. There is scattered air in nondistended loops of colon. -KUB ([**2203-2-22**]): Unchanged left nephrostomy tube position. Brief Hospital Course: 79yo male with dCHF, COPD, OSA on home CPAP and metastatic prostate cancer causing left-sided hydronephrosis who presents with displacement of his nephrostomy tube and pyelonephritis with sepsis. # Pyelonephritis with sepsis: At admission, the patient was started on broad spectrum antibiotics with vanc/zosyn and his nephrostomy tube was replaced by IR. A foley was placed which required a guidewire and assistance by [**Month/Day/Year **] given his prostate cancer and large prostate. His urine culture (from the replaced nephrostomy tube) showed pansensitive Pseudomonas. Antibiotics were narrowed to cipro which he will receive for a total of 14 days, course to be finished after discharge. Given his sepsis and chronic steroid use at home he was given stress dose steroids which were eventually tapered back to his home dose of hydrocortisone. At discharge, he still has a 3-way Foley in place and will follow-up with his urologist as an outpatient for a voiding trial. # Leaking nephrostomy tube: IR was [**Month/Day/Year 653**] prior to discharge regarding leaking of urine from around the nephrostomy tube. This was not improved after flushing the tube with 15cc of NS. We considered a nephrostogram to ensure proper placement of the tube, however IR felt the tube was correctly placed based on a KUB that was obtained. They did not want to perform the nephrostogram given that he would have to lie prone and required intubation for this last time. The nephrostomy tube continued to drain urine into the collection bag at the time of discharge. # Tachypnea/respiratory failure: The patient was intubated upon arrival to the MICU for his nephrostomy tube change, which required him to lie prone. His tachypnea was thought to be due to primarily CHF. Also may have a component of baseline COPD. He was started back on his home lasix once his sepsis improved and continued on his home combivent, advair, montelukast. He was extubated soon after the nephrostomy tube was replaced and remained on room air at the time of discharge. # Acute on chronic diastolic CHF: The patient was found to be congested on CXR and exam, he was also significantly orthopneic. He was intubated for his procedure as above. He was restarted on his home dose of Lasix after his sepsis improved and continued on his home metoprolol. # Metastatic prostate cancer: Currently on ketoconazole and hydrocortisone at the time of admission. Despite this therapy, his PSA was found to have doubled over the past month. His outpatient oncologist, Dr. [**Last Name (STitle) 1365**], was [**Last Name (STitle) 653**] during this admission. He continued to receive palliative radiation during his admission. After his renal function improved, he was restarted on his home dose of gabapentin. # Diabetes: His metformin was held and he was covered with an insulin sliding scale. Ta discharge, he was restarted on metformin. # Coronary artery disease: Continued home aspirin, rosuvastatin, beta blocker. # Depression: Continued home dose of fluoxetine # Transitional issues: -Will follow-up with his urologist regarding removal of his Foley catheter -Will follow-up with his oncologist regarding his metastatic prostate cancer and alternative treatment options given that his PSA continued to rise on the current regimen -Amlodipine was held at discharge given SBP of 110-120, BP control should be re-evaluated as an outpatient -He will continue Cipro PO after discharge for a total 14 day course Medications on Admission: - albuterol 90mcg 2puffs QID - albuterol nebs - amlodipine 5mg daily - finasteride 5mg daily - fluoxetine 20mg daily - fluticasone 100 mcg nasal daily - Advair 500/50mcg 1 puff [**Hospital1 **] - furosemide 80mg daily - gabapentin 300mg QHS - hydrocortisone 20mg QAM, 10mgQPM - ketoconazole 400mg [**Hospital1 **] - loratadine 10mg daily - lorazepam 0.5mg 1-2 tabs QHS - metformin 500mg [**Hospital1 **] - metoprolol succinate 50mg Q24hr - montelukast 10mg daily - omeprazole 40mg daily - rosuvastatin 20mg daily - tiotropium 18mcg daily - tramadolol 50mg 1-2 tabs QID - Aspirin 81mg daily - ferrous sulfate 325mg [**Hospital1 **] - senna 8.6mg 2 tabs daily Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) sprays Nasal once a day: Each nostril. 5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day. 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime. 8. hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 9. hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO Each afternoon. 10. ketoconazole 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime. 13. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 14. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 15. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 17. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 19. tramadol 50 mg Tablet Sig: 1-2 Tablets PO four times a day. 20. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 21. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 22. senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day. 23. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation four times a day as needed for shortness of breath or wheezing. 24. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 25. ammonium lactate 12 % Cream Sig: One (1) application Topical twice a day. 26. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 27. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 8 days: Last dose on [**2203-3-4**]. Disp:*16 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnoses: Sepsis Pyelonephritis Urinary tract infection Secondary diagnoses: Metastatic prostate cancer Chronic obstructive pulmonary disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or [**Hospital **]). Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you during your admission to [**Hospital1 18**] for left flank pain and displaced nephrostomy tube. You were found to have sepsis from an infection in your kidney. Your left nephrostomy tube was replaced and you were treated with IV antibiotics. You were initially admitted to the ICU and were then transferred to the floor after your condition improved. A Foley catheter was placed at admission. This will remain in place until you see your urologist on Monday [**2203-2-28**], at which time they will attempt to remove it. You also continued to receive radiation treatments during your admission. We stopped your amlodipine because your blood pressure was normal without it. Please discuss this your PCP at [**Name9 (PRE) 702**]. The following changes were made to your medications: START Cipro 500mg twice daily for 9 more days (last dose on [**2203-3-4**]) STOP amlodipine until you are seen by your PCP in [**Name9 (PRE) 702**] Followup Instructions: Department: [**Hospital3 249**] When: FRIDAY [**2203-2-25**] at 3:25 PM With:DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (works on Dr. [**Last Name (STitle) 52249**] team) Phone:[**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: SURGICAL SPECIALTIES When: MONDAY [**2203-2-28**] at 4:30 PM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/[**Hospital Ward Name **] When: TUESDAY [**2203-3-8**] at 1:30 PM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 10784**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage **We are working on a sooner follow up appointment with Dr. [**Last Name (STitle) **] than the scheduled appointment of [**3-8**] as seen above. You will be called at home with that appointment. If you have not heard within 2 business days or have questions, please call [**Telephone/Fax (1) 10784**].

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icd9cm

[ [ [] ] ]

[ "96.71", "38.97", "55.93", "96.04" ]

icd9pcs

[ [ [] ] ]

14520, 14578

7960, 10997

304, 509

14774, 14774

3465, 3465

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2489, 2620

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11020, 11443

1723, 2220

2236, 2473

82,104

169,095

47805

Discharge summary

report

Admission Date: [**2177-3-14**] Discharge Date: [**2177-3-18**] Date of Birth: [**2104-11-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2751**] Chief Complaint: respiratory distress and fever Major Surgical or Invasive Procedure: none History of Present Illness: 72F AFib, HTN, breast and thyroid CA, s/p tracheostomy several years ago after breast cancer surgery and hysterectomy presenting from [**Hospital3 **] with respiratory distress and fever. EMS crew arrived on scene to find her in respiratory distress, with a heart rate of 180, febrile although temperature not documented. Patient was in atrial flutter versus atrial fibrillation per EMS report. She was saturating at 75-80% on her trach collar without any supplemental oxygen when EMS arrived, was put on a nonrebreather blow by into the trach collar and quickly raised her saturations to the mid 90s. Of note patient recently was evaluated for cough and fever with CXR done at [**Hospital3 **] that showed possible early PNA, started on avelox on [**3-4**], but either did not receive this at all or not a full course per [**Hospital3 **] staff. UTI recently dx, on cipro starting [**3-2**], completed 3 day course. Per family has lived in [**Hospital3 **] for about 6 months. Looked well on Monday when they saw her. . In the ED, she was quickly put on the ventilator with 5 of PEEP 50% FiO2 and raised her oxygen yet further to 97. Copious blood tinged purulent secretions were noted from trach on arrival. CXR with multiple opacities noted, RUL most prominent, concerning for multifocal PNA. UA concerning for UTI so pt was started on vancomycin, zosyn, and ciprofloxacin. Temp noted to be 101.2 in ED, given 650 mg of tylenol x 2. Exam notable for rhonchi throughout lung fields. Also received IV NS. HR on arrival was HR on arrival was 138 Aflutter or afib per report, w BP 130s-140s systolic. Around 10:20 AM pt converted to sinus rhythm with subsequent decrease in BP to 90's systolic, bolus of IV NS given with improvement. VS on transfer BP 107/48 MAP 62 HR 56 on CPAP 10/5 with 50% FiO2. . On arrival to the ICU, pt is nonverbal but shakes head no when asked if she has any pain, looks comfortable. Pt is still on CPAP 10/5, weaned down to 5/0. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Depression Bilateral breast CA Thyroid CA (had short term trach after this, was removed at age 29) Movement disorder (blepharospasm) psychosis bilateral blindness (recent trauma to R eye) HTN atrial fibrillation hypercholesterolemia hypoparathyroidism s/p tracheostomy (complication of intubation from lumpectomy about 4 years ago) Social History: lives at [**Hospital3 2558**], sister and brother-in-law live nearby but spend the summers in [**Country 6607**] Retired in [**2165**], social worker quit tobacco in [**2134**] rare EtOH Family History: maternal aunt with [**Name (NI) **] [**Name (NI) **] heart failure in his 60s Physical Exam: ADMISSION EXAM General: alert, appears comfortable, nonverbal HEENT: MMM, oropharynx clear, pupils 5 mm and irregular bilaterally, nonreactive Neck: supple, JVP not elevated, no LAD Lungs: rhonchi throughout auscultated anteriorly CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic murmur best heard at RUSB, no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place with clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. nonverbal but responds to commands to open eyes, hold fingers, wiggle toes. Pertinent Results: ADMISSION LABS [**2177-3-14**] 08:30AM BLOOD WBC-11.3*# RBC-4.13* Hgb-12.2 Hct-36.1 MCV-88 MCH-29.5 MCHC-33.8 RDW-12.8 Plt Ct-267# [**2177-3-14**] 08:30AM BLOOD Glucose-110* UreaN-31* Creat-0.6 Na-143 K-4.4 Cl-105 HCO3-25 AnGap-17 [**2177-3-14**] 08:30AM BLOOD Calcium-9.8 Phos-5.0* Mg-1.7 CXR [**2177-3-14**] New multifocal opacities worrisome for multifocal pneumonia, although an unusual pattern of asymmetric edema could also be considered in the appropriate clinical setting. Persistent colonic dilatation, for which clinical correlation is suggested. Brief Hospital Course: 72F AFib, HTN, breast and thyroid CA, s/p tracheostomy several years ago presenting from [**Hospital3 **] with respiratory distress and fever, UTI, multifocal PNA . # Respiratory distress: Most likely in setting of multifocal PNA. Pt with h/o tracheostomy placement after thyroid surgery and lumpectomy, normally on trach collar but initially required CPAP ventilation when admitted. Covered for HCAP with vancomycin, zosyn for 10 day course, requiring PICC line insertion. . # UTI: UA suggestive of UTI, culture showing pansensitive Klebsiella. Covered by vanc/zosyn. . # Afib: RVR initially on admission and prior to transfer to medical [**Hospital1 **]. Now resolved, most likely in setting of illness and having had her AV nodal blockers held on admission. Not on warfarin. Continued outpatient doseing of metoprolol, diltiazem, and aspirin. Telemetry monitor misread her as having rapid heart rate, and was disconcordant with same time EKG showing good rate control in 50-60s. . # breast cancer: cont home anastrozole . # depression and psychosis: cont perphenazine . # blindness: cont eye drops from home . # hypothyroidism: cont levothyroxine . # Code = DNR, ok to intubate. Medications on Admission: heparin 5000 units TID fluticasone 110 mg inhaled [**Hospital1 **] ipratropium bromide Q4H PRN dorzolamide-timolol 2-0.5 % Drops [**Hospital1 **] diltiazem HCl 45 mg PO Q6H anastrozole 1 mg daily pantoprazole 40 mg daily levothyroxine 137 mcg daily metoprolol tartrate 100 mg [**Hospital1 **] calcitriol 0.25 mcg daily perphenazine 16 mg [**Hospital1 **] Colace 100 mg [**Hospital1 **] potassium chloride 20 mEq Two (2) packets TID ciprofloxacin 400 mg daily (dc'ed [**2177-3-4**]) multivitamin albuterol nebs [**Hospital1 **] prednisolone acetate eyedrops 1 drop right eye TID tylenol 325 mg Q4H PRN pain/fever aspirin 81 mg daily Discharge Medications: 1. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation [**Hospital1 **] (2 times a day). 4. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic TID (3 times a day). 5. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. perphenazine 8 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for affected area. 14. levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 15. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. diltiazem HCl 90 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). 17. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days: through [**2177-3-21**]. 18. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Respiratory Distress Multifocal Pneumonia URI - Klebsiella Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with difficulty breathing due to pneumonia. You also were found with a urinary tract infection. You were treated with IV then oral antibiotics and non-invasive ventilation through your trach mask. You had a few episodes of fast heart rate which were controlled with resumption of your normal medications. You did well and made a good recovery. You are discharged on your home medications, as well as an antibiotic that you will need to complete. Followup Instructions: f/u with your PCP at [**Hospital3 2558**] -- Dr. [**First Name4 (NamePattern1) 1258**] [**Last Name (NamePattern1) 4610**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

8190, 8260

4720, 5908

335, 341

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265, 297

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2827, 3161

3177, 3366

53,676

148,647

37746

Discharge summary

report

Admission Date: [**2171-12-25**] Discharge Date: [**2172-1-9**] Date of Birth: [**2110-6-4**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4282**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Thoracentesis Pleurex Catheter Placement History of Present Illness: This is a 61 year old female with a history of type II diabetes, hypertension and recently diagnosed stage IIIb to IV non-small cell lung cancer who presents with three days of progressive dyspnea. She was in her usual state of health until three days prior to this presentation when she noticed worsenign shortness of breath and non-productive cough. She initially attributed this to her cancer but the shortness of breath progressively worsened to dyspnea at rest. It was not associated with fevers, chills, nasal congestion, rhinorrhea, orthopnea, paroxysmal nocturnal dyspnea. It was not associated with leg pain or swelling. It was associated with non-productive cough, lethargy and decreased PO intake. She has never had dyspnea like this in the past. She presented to the emergency room. She initial presented to [**Hospital6 84551**] where her initial HR was 100 and her BP was 102/64. Labs were notable for a WBC count of 12.4, Hct 45.4, Plts 277, INR 1.16, Creatinine 0.7, CK 26, Trop < 0.03, BNP 13. She had a CTA which showed a large right sided PE, large right sided pleural effusion and right sided collapse. She received lovenox 60 mg SC. She was transferred here for further management. In the ED, initial vs were: T: 97.2 P: 101 BP: 104/76 R: 22 O2 sat 95% on non-rebreather. She had an EKG which showed normal sinus rhythm, normal axis, normal intervals, TWF III, avF, otherwise no acute ST segment changes. She had a CXR which showed complete opacification of the right lung. She is admitted to the MICU for further management. On arrival to the ICU she reports that her dyspnea has improved since arrival to the hospital. She denies fevers, chills, lightheadedness, dizziness, nausea, vomiting, abdominal pain, diarrhea, constipation, hematochezia, melena, hematemasis, hemoptysis, dysuria, hematuria, leg pain, leg swelling. She endorses worsening non-productive cough and dyspnea on exertion as above. All other review of systems negative in detail. Past Medical History: Hypertension Diabetes (diet controlled) Hyperlipidemia Moderatly differentiated adenocarcinoma of the right lung either IIIB versus stage IV scheduled to begin chemotherapy this week Lyme Disease Social History: The patient is married and lives with her husband in [**Name (NI) 30940**], [**State 350**]. Lifetime non-smoker. No alcohol or illicit drug use. Family History: No family history of blood clots. Father died of emphysema at age 84, mother of CVA at age 67, brother of lung cancer at age 50. Physical Exam: Vitals: T: 97.5 BP: 132/94 P: 100 R: 36 O2: 95% on NRB General: Alert, oriented, speaking in short sentences, mild respiratory distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP at 12 cm, no LAD Lungs: Decreased breath sounds on the right with bronchial breath sounds in the right upper lung field, left side clear CV: Mild tachycardia, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Exam at discharge: T: 97.9 BP 130/74 HR 77 RR 20 99% 1 liter n/c General: Alert, oriented, slightly anxious HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP at 12 cm, no LAD Lungs: Decreased breath sounds on the right, otherwise CTA CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Images: CXR: Complete opacification of the right lung field. CTA (wet read): left sided subsegmental pulmonary embolism, large right pleural effusion, right sided collapse. EKG: normal sinus rhythm, normal axis, normal intervals, TWF III, avF, otherwise no acute ST segment changes. Echocardiogram [**2171-12-24**]: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is mildly dilated with normal free wall contractility. The diameters of aorta at the sinus and ascending levels 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. There is mild-moderate pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion without echocardiographic signs of tamponade. CXR [**2171-12-25**]: Again seen is complete whiteout of the right hemithorax and worsening opacification of a previously seen small area of spared lung parenchyma in the right upper chest. Central air bronchograms are noted. The left lung is clear. The aorta demonstrates normal contour. Incidentally noted is contrast in the pelvis of the kidneys consistent with recent IV contrast injection. Bilateral Lower Extremity Ultrasounds [**2171-12-25**]: : Grayscale and color Doppler ultrasound were performed. There is normal compressibility, color flow, and Doppler signal within the common femoral, superficial femoral and popliteal veins. Hematology: [**2171-12-25**] 12:01AM BLOOD WBC-13.1* RBC-5.11 Hgb-14.5 Hct-41.8 MCV-82 MCH-28.4 MCHC-34.7 RDW-14.0 Plt Ct-277 [**2171-12-25**] 12:01AM BLOOD Neuts-79.1* Lymphs-14.1* Monos-4.8 Eos-1.0 Baso-1.0 [**2171-12-25**] 02:12PM BLOOD PT-14.4* PTT-35.8* INR(PT)-1.2* Chemistries: [**2171-12-25**] 12:01AM BLOOD Glucose-191* UreaN-16 Creat-0.7 Na-136 K-4.5 Cl-102 HCO3-22 AnGap-17 [**2171-12-25**] 04:22AM BLOOD CK(CPK)-23* [**2171-12-25**] 04:22AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2171-12-25**] 04:22AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.2 Labs at discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 8.2 3.91 10.9 31.4 80 27.8 34.5 13.0 298 Glucose UreaN Creat Na K Cl HCO3 AnGap 181 14 0.5 133 4.8 96 28 14 Calcium Phos Mg 8.9 3.3 2.2 Pleural fluid: GRAM STAIN (Final [**2171-12-27**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 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 [**2171-12-30**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2172-1-2**]): NO GROWTH Pleural fluid: POSITIVE FOR MALIGNANT CELLS. Consistent with metastatic non-small cell lung carcinoma. See note. TTE: Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) 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. There is borderline pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2171-12-25**], estimated pulmonary artery pressures are lower. The other findings are similar. The pericardial effusion has not changed appreciably in size. AP portable chest film, [**2172-1-8**]: Small to moderate right pleural effusion has minimally decreased. Right supraclavicular catheter remains in place. Right chest tube is in place. There is no pneumothorax. Diffuse increase in the interstitial markings in the right lung thought to represent reexpansion edema or lymphangitic spread. This is stable from prior study. The left lung is clear. Cardiomediastinal contours are unchanged. Brief Hospital Course: Assessment and Plan: 61 year old female with a history of type II diabetes, hypertension and recently diagnosed stage IIIb non-small cell lung cancer who presents with three days of progressive dyspnea found to have large right sided pulmonary embolism, pleural effusion and right sided collapse. Dyspnea: Likely multifactorial secondary to large left sided pulmonary embolism, large right sided pleural effusion, right lung collapse. All findings not present on previous CT scan from late [**Month (only) 462**] when she was diagnosed with non-small cell lung cancer. No signs and symptoms of infection presently. Lymphangitic spread of tumor may also be contributing to her symptoms. No indications for lysis given that she was hemodynamically stable and BNP and troponins were within normal limits. LENIs were without evidence of DVT. Echocardiogram without significant right heart strain. She was initially started on lovenox and this was transitioned to heparin to allow for thoracentesis. Thoracentesis removed 2.3L of fluid. Fluid sent for cytology, which showed malignant cells consistent with non-small cell lung cancer. The patient then had a pleurx catheter placed in her right thorax for symptomatic relief, with good effect. Lovenox was restarted for long-term management of her thromboembolic disease, which was continued at discharge. The patient was discharged with home oxygen. She will also receive VNA services to assist with pleurx catheter drainage three times weekly. Metastatic (stage IV) non-small cell lung cancer: Patient was scheduled to initiate chemotherapy shortly. Now presents with dyspnea, large effusion and pulmonary embolism. Oncology is following and will determine whether to initiate chemotherapy. It was decided to start gemcitabine, day 1 on [**2172-1-4**]. The day 8 dose was actually administered on [**2172-1-8**], day 5, to allow for discharge over the holiday. The patient tolerated chemotherapy well. She was discharged with short term anti-emetics. Patient has anxiety regarding diagnosis and treatment plan, information was given to Hope Lodge for future needs. Anemia: HCT improved during admission; there was concern for bleed into pleural space. No signs or symptoms of bleeding were evident, stool guaiac was negative. labs showed iron deficient, no hemolysis. Patient received one unit of packed red blood cells one day prior to discharge with excellent response. Hypertension: Initially held all antihypertensive agents, and restarted at time of discharge. Diabetes: Insulin sliding scale, managed well. This was discontinued at discharge. Hyperlipidemia: Continued simvastatin. Code: Full Communication: Patient, Husband [**Name (NI) **] [**Telephone/Fax (1) 84552**] Medications on Admission: 1. Lisinopril 10 mg p.o. daily. 2. Simvastatin 20 mg p.o. daily. 3. Xanax 0.5 mg p.o. b.i.d. 4. Trazodone 50 mg p.o. at bedtime. 5. Zolpidem 10 mg p.o. daily. 6. Cough medicine. Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain: please do not exceep 3000mg/day . 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*2* 3. Cortisone 1 % Cream Sig: One (1) Appl Topical TID (3 times a day). Disp:*1 tube * Refills:*2* 4. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). Disp:*60 syringes* Refills:*2* 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety/nausea : Causes sedation. please do not drink alcohol or perform activities that require a fast reaction time while taking this medication. . Disp:*90 Tablet(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain : causes sedation. Please do not perform activities that require a fast reaction time, or drink alcohol when taking this medication. . Disp:*90 Tablet(s)* Refills:*0* 7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*30 Capsule(s)* Refills:*2* 10. supplemental oxygen Sig: Two (2) L of continous oxygen via pulse dose : for portability. Disp:*1 tank * Refills:*0* 11. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days. Disp:*4 Tablet(s)* Refills:*0* 12. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 2 days. Disp:*6 Tablet(s)* Refills:*0* 13. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 11485**] VNA Discharge Diagnosis: Primary Non Small Cell Lung Cancer, metastatic Pulmonary embolus Secondary Anxiety Hypertension Diabetes Discharge Condition: stable, ambulatory, on home oxygen Discharge Instructions: You were admitted to the hospital because you were found to have a pulmonary embolus and fluid in your lungs. This was thought to be because of your lung cancer. You had fluid drained from your lungs and a pleurex catheter drained. You were given chemotherapy for your cancer, which you will continue to receive as an outpatient. You continued to need oxygen, so you went home with oxygen. When you follow up with your outpatient doctor they can assess whether you still need the oxygen. . We have made the following changes to your medications. . 1. We ADDED lorazepam 0.5mg every 8 hours as needed for anxiety. 2. We ADDED dilaudid 2mg by mouth every 8 hours as needed for pain. 3. We ADDED docusate 100mg [**Hospital1 **] as needed for constipation 4. We ADDED senna 100mg [**Hospital1 **] as needed for constipation. 5. We ADDED lovenox 60mg injection one every 12 hours. 6. We ADDED hydrocortisone 1% cream as needed PRN itch 7. We ADDED decadron 5mg twice a day until Friday ([**1-10**]) 8. We ADDED Zofran 8mg every 8 hrs for nausea as needed until Frday ([**1-10**]) . We STOPPED xanax. We STOPPED ambien. . Please return to the hospital or call your doctor if you experience any shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, headache, fever, chills, night sweats, muscle aches, joint aches, light headedness, fainting, blood in your stool, blood in your urine, or any other problems that are concerning to you. Followup Instructions: Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2172-1-20**] 8:00 Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4322**], MD, Oncology Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2172-1-16**] 11:30 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD, Oncology Phone:[**0-0-**] Date/Time:[**2172-1-23**] 9:00 Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **], [**Name Initial (NameIs) **].D Interventional Pulmonology, [**Hospital1 18**] [**Hospital Ward Name 12837**] [**Hospital1 **] One: Phone:([**Telephone/Fax (1) 18313**] Date/Time:[**2172-1-20**] 8:00am

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4376

Discharge summary

report

Admission Date: [**2130-4-19**] Discharge Date: [**2130-4-27**] Date of Birth: [**2071-4-17**] Sex: F Service: MEDICINE Allergies: Sulfamethoxazole/Trimethoprim / Wool Alcohols / Latex / Trimethoprim Attending:[**First Name3 (LF) 1377**] Chief Complaint: Left foot infection. Major Surgical or Invasive Procedure: Left foot wound debridement with forgein body removal, [**4-20**]. Bedside left foot wound debridement, [**4-21**]. PICC line placement, [**4-26**]. History of Present Illness: This is a 59 year old woman with a h/o CAD s/p stenting and DM2 who was admitted from podiatry clinic [**4-19**] with purulent discharge from left foot ulcer, also with erythema of surrounding tissue. She subsequently became hypotensive and confused, prompting micu transfer. There she became hemodynamically stable with minimal ivf. She was taken to the OR for debridement of her wound and removal of hardware [**2130-4-20**]. Post-op she has had fevers but remained hemodynamically stable. She also developed hypoxia, requiring up to 6L NC, which has improved with diuresis. She has been confused, espcially when her fever is high, but not aggitated. She has been treated with cipro/vanco/flagyl and has strep virdans from her hardware but other cultures negative to date. She had a repeat debridement at the bedside [**4-21**] for an area of loculation with purulent discharge. Currently she is complaining of pain from neuropathy which is long standing for her. Past Medical History: -Hyperlipidemia -Hypertension -CAD s/p stent (EF >55%) DES to the LAD in [**2125**] -Tobacco abuse -Hypothyroidism -Depression -Lumbar laminectomy -IDDM for over 40 yrs -Diabetic neuropathy and retinopathy -obesity Social History: Disabled. Lives w/ husband at home. Best friend [**Doctor First Name **] visits her regularly. EtOH: Denies Tobacco: 1ppd x20 years Illicits: Denies Family History: Postive for DM in Mother, father, both grandmothers & both grandfathers. Physical Exam: VS:T> 98.7 BP 100/58, HR 87, RR 18, sat 95% on RA Gen: NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, no exudates or ulceration. Neck: Supple, JVP not elevated.obese CV: RRR, normal S1, S2. No m/r/g. Chest: Resp were unlabored, no accessory muscle use. CTAB, no rales, wheezes or rhonchi. Abd: Obese, Soft, NTND. No HSM or tenderness. Ext: No c/c/edema. 2+pulses. L.foot in gauze wrap. Pertinent Results: Admission labs: 131 95 49 -----------<204 5.1 26 2.0 estGFR: 26/31 (click for details) Ca: 8.2 Mg: 2.2 P: 5.3 10.6 17.4>-<260 32.1 %HbA1c: 8.0 Iron 23* ug/dL Iron Binding Capacity, Total 247* ug/dL Vitamin B12 415 pg/mL Folate 9.8 ng/mL Ferritin 222* ng/mL Transferrin 190* mg/dL Alanine Aminotransferase (ALT) 22 IU/L Asparate Aminotransferase (AST) 27 IU/L Lactate Dehydrogenase (LD) 255* IU/L Creatine Kinase (CK) 266* IU/L Alkaline Phosphatase 108 IU/L Bilirubin, Total 0.4 mg/dL C-Reactive Protein 168.0* ESR: 125 Wound swab [**2130-4-19**]: GRAM STAIN (Final [**2130-4-19**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [**2130-4-23**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. ANAEROBIC CULTURE (Final [**2130-4-23**]): NO ANAEROBES ISOLATED. Foot culture [**2130-4-20**]: WOUND CULTURE (Final [**2130-4-24**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. VIRIDANS STREPTOCOCCI. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. ANAEROBIC CULTURE (Final [**2130-4-24**]): NO ANAEROBES ISOLATED. Forgein body [**2130-4-20**]: VIRIDANS STREPTOCOCCI. Wound swab [**2130-4-21**]: GRAM STAIN (Final [**2130-4-21**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2130-4-25**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. ANAEROBIC CULTURE (Final [**2130-4-25**]): NO ANAEROBES ISOLATED. Urine cx [**2130-4-20**]: NO GROWTH. Urine cx [**2130-4-21**]: NO GROWTH. Urine cx [**2130-4-24**]: NO GROWTH. Urine cx [**2130-4-25**]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Blood cultures [**2130-4-20**] x6: No growth. Blood cultures [**2130-4-21**]: pending Blood cultures [**2130-4-24**]: pending CXR (PA/Lat) [**4-19**]: IMPRESSION: No acute cardiopulmonary process. Left foot xray [**4-19**]: FINDINGS: Comparison is made to prior study from [**2130-1-4**]. Since the previous study, there has been migration of several screws consistent with loosening. There is significant backing out of the distal most screw within the talonavicular joint. The screw is no longer flush with the side plate and has migrated more medially by 1.7 cm. There is prominent soft tissue swelling within the medial aspect of the foot. There has also been some backing out of the more proximal screws within the navicular. No acute fractures are identified. There is some gas within the adjacent soft tissues. There is prominent dorsal soft tissue swelling as well. There are extensive neuropathic changes of the mid foot with inferior tilting of the talus. Pathology [**4-20**]: Medial cuneiform, left: Bone with necrosis and focal acute inflammation. TTE [**2130-4-21**]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the mid- and distal lateral walls (LCx territory). The remaining segments contract normally (LVEF = 45-50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. No significant valvular disease. Mild pulmonary hypertension. CXR (port) [**2130-4-21**]: CHF with an element of pulmonary edema. Patchy opacity at left base likely relates to this, but an early infiltrate would be difficult to exclude. CXR (port) [**2130-4-24**]: Pulmonary edema has cleared. Residual opacification at the left lung base is mild and may represent persistent edema. Followup is needed to exclude developing pneumonia. Heart size normal. No appreciable pleural effusion. Brief Hospital Course: ASSESSMENT/Plan: 59 y.o. woman with HTN, HL, CAD, DM, hypothyroidism with left foot infection. 1) Left foot infection: This was noted on arrival at her podiatrist, Dr.[**Name (NI) 18870**] office on [**4-19**]. He noted purulence from an ulcer so admitted her for debridement. She was transferred to the ICU oovernight after she became hypotensive and confused. The following day she went to the OR for wound debridement, bone and screw removal. She was treated initially with vancomycin, ciprofloxacin, and flagyl, but the cipro was changed to zosyn on transfer to the micu. She was febrile during this time as well with an elevated white blood cell count. The following day, [**4-21**], she was noted by podiatry to have continued purulent discharge requiring bedside debridement. She stabilized hemodynamically and transferred out to the floor on [**4-22**]. Her antibiotics were changed to vancomycin, ciprofloxacin, and flagyl. She had multiple wound cultures which showed GNR's on gram stain, but growth only of strep virdans and coag negative staph. There was osteonecrosis of the bone noted, ESR and CRP were both markedly elevated consistent with osteomyelitis. She also had a plate that was left in the foot for the charcot deformity repair. She was followed daily by podiatry for wound care and they recommended a wound vac that was placed [**4-26**]. She was discharged to complete a 6 week course of vancomycin and likely a 4 week course of ciprofloxacin. Since there was no growth of anaerobic bacteria the flagyl was discontinued after 7 days of treatment. She had no growth in her blood cultures and had a transthoracic echocardiogram that did not show any vegetations so was not thought to have an endovascular infection. She will follow up with Dr. [**Last Name (STitle) **] after discharge and is to maintain non-weight bearing status on the left lower extremity. She worked with physical therapy to be sure she would be safe with transfers at home and have all assistive devices necessary. 2) Hypoxia: She developed hypoxia after volume resusciation in the setting of hypotension in the icu. She required diuresis with iv lasix initially but her hypoxia improved. She was restarted on lasix 20mg po for discharge. This will need to be titrated at home depending on her volume status. 3) Anemia: Normocytic, related to anemia of chronic disease based on her iron studies, b12 and folate were replete. No bleeding was noted and hct remained stable. 4) Kideny disease: She was noted to develop acute kidney injury in the context of hypotension but this improved over her hospital course and she was able to restart lisinopril which was titrated up to her home dose. 5) Diabetes Mellitus: She was initially continued on her home glargine: 45u q am and 70 q pm but had several mornings of hypoglycemia so her pm dose was slowly titrated down. She related these to not eating her normal home foods/snack so she was discharged to resume home dosing. She was otherwise well controlled so required very little sliding scale insulin. 6) Systolic heart failure: She did require diuresis as noted above, and her lisinopril and atenolol were held in the context of hypotension but both were restarted in turn and titrated up to her home dose. This was well tolerated. She was also restarted on a home regimen of lasix orally, 20mg [**Hospital1 **]. 7) Coronary Artery Disease: She was continued on aspirin and statin, then resumed slowly lisinopril and atenolol. 8) Hypothyroid: She was continued on her home levothyroxine. 9) Mood: She was continued on home venlafaxine. Medications on Admission: Lipitor 20mg qd Celebrex 100mg [**Hospital1 **], ASA 325 mg qd Ativan 2mg qhs Atenolol 50mg qd Lisinopril 20mg qd Tramadol 100 Q4h Synthroid 200mcg qd Neurontin 800mg Q4h insulin lantus 45units q am and 70units q pm with glulisine insulin sliding scale venlafaxine 150mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 3. Atorvastatin 20 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). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 7. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 8. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 10. Outpatient Physical Therapy Gait training. 11. Wheelchair 12. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours). 13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H (every 12 hours). 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45) units Subcutaneous once a day. 17. Insulin Glargine 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous q evening. 18. Insulin Glulisine 100 unit/mL Solution Sig: as directed units Subcutaneous five times a day: per home sliding scale. 19. Outpatient Lab Work Please draw CBC, BUN, creatinine, ast, alt, alkaline phosphotase, total bilirubin, vancomycin trough, ESR and c-reactive protein one per week on Thursdays and fax the result to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**], [**Hospital1 18**] Infectious Disease, fax: ([**Telephone/Fax (1) 18871**]; phone: ([**Telephone/Fax (1) 4170**]. 20. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 weeks: Day 1=[**4-20**]. Disp:*70 Tablet(s)* Refills:*0* 21. Vancomycin 500 mg Recon Soln Sig: 2.5 Recon Solns Intravenous Q 12H (Every 12 Hours) for 5 weeks: last day of antibiotics is [**2130-6-2**]. Disp:*QS Recon Soln(s)* Refills:*0* 22. wound care Please perform wet to dry dressing changes to left food daily until wound vac applied. Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Therapies Discharge Diagnosis: Primary: Infected diabetic foot ulcer. Secondary: Diabetes melitus, hypertension, systolic heart failure, coronary artery disease, hyperlipidemia, neuropathy, depression, tobacco use, hypothyroidism. Discharge Condition: Stable vital signs, alert, on room air. Discharge Instructions: You were admitted with a left foot infection. You were treated by surgical debridement, removal of hardware, and antibiotics. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] within 1 week of discharge. Please call [**Telephone/Fax (1) 682**] for this appointment. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of podiatry on Wednesday, [**2130-5-3**] at 11:40 am. Please call ([**Telephone/Fax (1) 4335**] for this questions about this appointment. Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] of infectious disease on [**Last Name (LF) 766**], [**2130-5-29**] at 10:00 am. Please call ([**Telephone/Fax (1) 4170**] with questions about this appointment. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

[ "362.01", "041.09", "428.22", "250.60", "285.29", "041.19", "414.01", "428.0", "584.9", "996.49", "305.1", "E878.1", "276.51", "250.50", "278.00", "276.52", "244.9", "730.27", "272.4", "401.9", "311", "V45.82", "682.7", "707.15" ]

icd9cm

[ [ [] ] ]

[ "78.68", "77.68", "86.04", "38.93", "83.09" ]

icd9pcs

[ [ [] ] ]

13596, 13665

7415, 11005

350, 500

13909, 13951

2438, 2438

14245, 15049

1917, 1991

11332, 13573

13686, 13888

11031, 11309

13975, 14222

2006, 2419

290, 312

528, 1495

2454, 7392

1517, 1734

1750, 1901

44,139

161,887

40650

Discharge summary

report

Admission Date: [**2186-6-14**] Discharge Date: [**2186-6-23**] Date of Birth: [**2120-7-29**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: aortic stenosis/coronary artery disease Major Surgical or Invasive Procedure: [**6-14**] Aortic valve replacement (23mm ON-X mechanical), coronary artery bypass grafting times two (LIMA to LAD, SVG to Ramus), aortic endarterectomy History of Present Illness: Mr. [**Name14 (STitle) 88927**] is a 65 year old male with long standing ischemic heart disease and progressive aortic stenosis who presented to an outside hospital with chest pain. An EKG showed no specific ST changes, but his enzymes were elevated. He underwent a heart catheterization which revealed multi-vessel coronary artery disease as well as moderate aortic stenosis. He underwent workup previously and was admitted now for elective surgery. Past Medical History: coronary artery disease aortic stenosis noninsulin dependent diabetes mellitus hypertension benign prostatic hypertrophy h/ prostate cancer s/p colon resection s/p coronary interventions/stents Social History: former smoker 2-4 packs per day for 10 years, but quit 40 years ago. stopped drinking alcohol in [**Month (only) 404**] of this year but used to drink whiskey. He lives at home with his wife and has three kids. Family History: His mother is deceased of a cerabral vascular accident in her 80's and his father is deceased of an acute myocardial infarction at age 62. Physical Exam: Pulse:66 Resp:12 O2 sat:98/RA B/P Right:93/56 Left:95/58 Height:6' Weight:215 lbs General: awake alert oriented 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 3/6 systolic ejection murmur with radiation to both carotid areas L>R Abdomen: Soft [x] non-distended [x] non-tender [x] + bowel sounds Extremities: Warm [x], well-perfused [x] no Edema no Varicosities; chronic venous insufficiency changes on the lower legs; Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 2 Left: 2 Carotids: bilateral soft murmur L>R Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Pre Bypass: The left atrium is mildly dilated and elongated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. Significant aortic stenosis is present but consistent and adequate gradients could not be obtained, nor could plainemetry be adequately performed due to degree of stenosis. The mitral valve leaflets are moderately thickened. Mild to moderate ([**1-1**]+) mitral regurgitation is seen. Post Bypass: Preserved Biventricular Function, LVEF 50-55%. There is a mechnaical Aortic Valve (#23 Onyx per surgeons) insitu with no perivalvular leak or AI. There is a peak gradient of 17 mm Hg, mean 7 mm Hg across the valve. Mitral regurgitation is now moderate. Aortic contours appear without luminal irregularties. [**2186-6-23**] 06:05AM BLOOD WBC-6.9 RBC-3.67* Hgb-10.4* Hct-31.7* MCV-87 MCH-28.5 MCHC-32.9 RDW-14.4 Plt Ct-469* [**2186-6-14**] 03:07PM BLOOD WBC-12.6*# RBC-3.30* Hgb-9.8* Hct-28.5* MCV-87 MCH-29.6 MCHC-34.2 RDW-15.1 Plt Ct-118* [**2186-6-23**] 06:05AM BLOOD PT-22.2* INR(PT)-2.1* [**2186-6-22**] 05:45AM BLOOD PT-28.1* INR(PT)-2.7* [**2186-6-21**] 06:05AM BLOOD PT-29.2* INR(PT)-2.8* [**2186-6-20**] 06:10AM BLOOD PT-31.7* INR(PT)-3.1* [**2186-6-19**] 05:05PM BLOOD PT-49.1* INR(PT)-5.2* [**2186-6-19**] 06:33AM BLOOD PT-38.1* PTT-47.4* INR(PT)-3.9* [**2186-6-18**] 06:09AM BLOOD PT-21.3* PTT-36.7* INR(PT)-2.0* [**2186-6-23**] 06:05AM BLOOD Glucose-118* UreaN-20 Creat-1.1 Na-137 K-4.8 Cl-99 HCO3-29 AnGap-14 Brief Hospital Course: On [**6-14**] Mr. [**Known lastname **] [**Last Name (Titles) 88928**] aortic valve replacement (23mm ON-X mechanical), coronary artery bypass grafting times two (LIMA to LAD, SVG to Ramus), and aortic endarterectomy. Please see the operative note for details. He tolerated this procedure well and was transferred in critical but stable condition to the surgical intensive care unit. He was extubated and weaned from pressors. He was confused on waking but moved all extremities. All narcotics were stopped and he was started on Ultram for pain with resolution on his confusion. Ultram was subsequently stopped and Tylenol was used for pain control. His chest tubes and epicardial wires were removed and he was started on Coumadin for his mechanical valve. He was seen by dermatology for resolving Herpes Zoster. Scars and post-inflammatory hyperpigmentation were consistent with prior Zoster inflammation. On POD 4 INR was 2.0 and Heparin was discontinued. He was given Coumadin 3 mg, 5 mg, 5mg, 7.5 mg with INR increased from 2.0 ->3.9. Coumadin was held and he was given 2 units fresh frozen plasma with INR decreased to 3.1 the following day. He was therapeutic on Coumadin with INR goal 2.5-3.5 at the time of discharge. He did go into atrial fibrillation POD 5 and was put on Amiodarone with conversion to sinus rhythm on postoperative day 6. He was continued on Vancomycin for a right internal jugular triple lumen site that was erythematous and draining. Blood and tip cultures were obtained and he was continued on the Vancomycin until cultures came back negative. He was afebrile and white blood count was within normal limits at the time of discharge. He was noted to have a large left pleural effusion on CXR and on POD 9 he underwent a thoracentesis after allowing INR to drift down which drained 2800 cc of fluid. Repeat CXR showed left basilar atelectasis but better aeration of the side. He felt well. and he was He was discharged to home on [**6-23**] with Dr. [**Last Name (STitle) 8421**] to follow Coumadin dosing. Arrangements were made for same with the first INR draw on [**6-24**]. Medications on Admission: - Atenolol 75mg PO daily - Imdur 30 mg PO daily - Lisinopril 2.5 mg PO daily - Metformin 1000 mg PO daily (? [**Hospital1 **]) - Plavix 75 mg PO daily - Simvastatin 20 mg PO daily - Tamsulosin 0.4mg PO daily - ASA 81 mg daily - Vitamin B 100mg Daily - MVI Daily - Nitro SL PRN Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for toes. Disp:*15 1* Refills:*0* 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. amiodarone 200 mg Tablet Sig: as ordered Tablet PO BID (2 times a day): two tablets twice daily for two weeks, then one tablet twice daily for two weeks then one tablet daily . Disp:*100 Tablet(s)* Refills:*2* 9. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 10. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 11. warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a day: Take 2 tablets [**6-23**],then as directed by Dr. [**Last Name (STitle) 8421**]. Disp:*100 Tablet(s)* Refills:*2* 12. Outpatient Lab Work INR/PT on [**6-24**],then as necessary. Phone results to Dr. [**Last Name (STitle) 8421**] ([**Telephone/Fax (1) 45578**]Fax [**Telephone/Fax (1) 85551**]. He will manage Coumadin dosing. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Aortic stenosis coronary artery disease s/p coronary arteery bypass grafts s/p aortic valve replacement/aortic endarterectomy hypertension noninsulin dependent diabetes mellitus benign prostatic hypertrophy h/o prostate cnacer s/p partial colectomy 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 - 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: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] ([**Telephone/Fax (1) 11763**] on [**7-18**] at 3:00pm Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8421**] on [**7-24**] at 3:30pm Please call to schedule appointments with: Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (un) 88910**] ([**Telephone/Fax (1) 9146**]) in [**4-4**] 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 Mech AVR Goal INR 2.5-3.5 First draw [**2186-6-24**] Dr. [**Last Name (STitle) 8421**] will manage Coumadin Phone- [**Telephone/Fax (1) 45578**] FAX [**Telephone/Fax (1) 85551**] Completed by:[**2186-6-23**]

[ "293.9", "600.01", "276.4", "E878.8", "110.4", "440.0", "790.92", "293.0", "518.0", "427.31", "053.9", "250.00", "185", "E849.7", "511.9", "396.2", "414.01", "788.29" ]

icd9cm

[ [ [] ] ]

[ "39.61", "38.14", "36.11", "36.15", "35.22", "34.91", "00.40" ]

icd9pcs

[ [ [] ] ]

8188, 8237

4271, 6394

349, 504

8532, 8761

2371, 4248

9602, 10493

1450, 1590

6722, 8165

8258, 8509

6420, 6699

8785, 9579

1605, 2352

270, 311

532, 987

1009, 1204

1220, 1434

44,486

118,499

13893

Discharge summary

report

Admission Date: [**2139-7-16**] Discharge Date: [**2139-7-25**] Date of Birth: [**2061-10-28**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Codeine / Diazepam / Benzodiazepines / Iodine Attending:[**First Name3 (LF) 1253**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: IR coiling of superior rectal artery PICC placement History of Present Illness: 77 y/o woman with Afib not on coumadin, dCHF, HTN, hyperlipidemia, COPD, IBS, CKD, and myeloproliferative disorder transferred from OSH for management of recurrent GI bleeding s/p hemorrhoidectomy requiring multiple hospitalizations and transfusions. The patient has had about 1.5 years of intermittent GI bleeding, with painless BRBPR, maroon stools, and clots, which worsened over past 4-5 months. Per report, she has also had intermittent hematochezia. Colonoscopy on [**6-10**] at OSH showed diverticulosis and hemorrhoids, which were believed to be the source of the bleeding. She had large amounts of rectal bleeding s/p hemorrhoidectomy on [**7-9**] and was transferred to ICU of OSH from [**Date range (1) 9463**], where she received 7 units PRBC and 3 units FFP and Vit K. Last Hct was 30.7. Post-op, she was started on flagyl x 5 days and levoquin for Klebsiella UTI. She is s/p upper and lower endoscopy suggestive of duodenitis and mild gastritis, colonoscopy, and a tagged RBC scan without clear source (stomach or transverse colon). A second colonoscopy was attempted but patient was unable to tolerate prep. A hemodialysis trauma line was placed in the right IJ. Hct was 30.7. Her Cr was 1.5, INR 1.68, and WBC 21 (chronically elevated WBC in 18) at OSH. She was transferred to MICU for angiography to help localize source of persistent GI bleed with the plan of returning to outside hospital for non-emergent surgery if source cannot be embolized. Upon arrival to the floor, initial vs were T 96.3 F, HR 106 BP 127/57, RR 16, 95% on 3L NC. Patient reports she has been incontinent of stool since procedure. She was guaiac positive without frank blood per rectum and was given additional fluid given elevated Cr 1.5 in preparation for angiography. She denied feeling lightheaded since this morning. She has SOB, orthopnea, chronic hot flashes, night sweats, and 130 lb weight loss over past year. She denies fever or chills. She has history of constipation and diarrhea. ROS otherwise negative. Review of systems: (+) Per HPI (-) Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: CAD s/p RCA stent [**2-/2136**] HTN Hyperlipidemia Afib off coumadin x 2 years due to bleeding Chronic kidney disease CHF with diastolic dysfunction but normal EF GERD pericardial effusion pulmonary hypertension - right heart cath in [**2136**] s/p TIA depression angina pneumonia/bronchitis gout Anemia Arthritis Irritable Bowel Syndrome Chronic Kidney Disease OSA Myeloproliferative disorder with leukocytosis s/p TAH//BSO - reports R ovary explosion s/p CCY and appendectomry bilateral cataract surgery Social History: Widowed and lives alone in [**Hospital3 4634**] in [**Location (un) 5110**], MA. Unable to walk up stairs without SOB. 6 children and 17 grandchildren. Tobacco: [**1-8**] cig/day x 30 years EtOH: social Illicits: none Family History: Father had colitis. Granddaughter with ulcerative colitis Physical Exam: ADMISSION PHYSICAL EXAM: General: Lying comfortably on 4 pillows, no acute distress HEENT: Sclear anicteric. HD trauma line in right IJ, no Skin: Pale, bruising on arms, no petechiae Heart: nl S1 and S2, irregular rhythm, flow murmur Lungs: Bibasilar crackles, R>L Abdomen: Soft, nontender, nondistended, hypertympanic around umbilicus, transverse surgical scar, no rebound, no guarding Rectum: Incision visible with sutures, dilated anal sphincter, no draining fistulas, ~ 4 cm hematoma lateral to sphincter, confluent patch of perirectal erythema, yellow stool Ext: warm and well perfused, no edema Neuro: AOx3, no focal deficits . DISCHARGE PHYSICAL EXAM: VS Tm 99.7 119/56 87 22 97% 3L Gen: pt resting quietly, tearful when talking about rehab. HEENT: moist mucous membranes Neck: supple, no thyromegaly CV: irregularly irregular, systolic flow murmur LUNGS: crackles bilaterally at bases. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: 2+ peripheral pulses. SKIN: large hematoma in right groin with surrounding ecchymosis, tender to palpation, diffuse erythema of inner thighs and sacrum Pertinent Results: Admission Labs: [**2139-7-16**] 05:02PM GLUCOSE-78 UREA N-34* CREAT-1.5* SODIUM-141 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-32 ANION GAP-14 [**2139-7-16**] 05:02PM CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-2.0 [**2139-7-16**] 05:02PM WBC-19.7* RBC-3.50* HGB-10.8* HCT-32.6* MCV-93 MCH-30.8 MCHC-33.0 RDW-22.2* [**2139-7-16**] 05:02PM PT-16.5* PTT-29.3 INR(PT)-1.5* [**2139-7-16**] 05:02PM CK-MB-1 cTropnT-<0.01 [**2139-7-16**] 11:29PM CK-MB-1 cTropnT-<0.01 . DISCHARGE LABS [**2139-7-25**] 05:44AM BLOOD WBC-14.9* RBC-3.26* Hgb-10.3* Hct-28.7* MCV-88 MCH-31.5 MCHC-35.9* RDW-19.6* Plt Ct-188 [**2139-7-25**] 05:44AM BLOOD Glucose-89 UreaN-48* Creat-1.0 Na-138 K-4.2 Cl-100 HCO3-34* AnGap-8 [**2139-7-25**] 05:44AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.8 . Imaging: [**7-16**] CXR: Moderate cardiomegaly is less pronounced, and although there is mild vascular engorgement in the upper lungs, mediastinal veins are not dilated. Therefore, the mild-to-moderate generalized pulmonary edema could be due to transfusion reaction rather than the hemodynamic effect of blood product administration. Dual-channel right supraclavicular line ends in the upper right atrium. No pneumothorax. Pleural effusions are minimal if any. . [**7-16**] CTA: IMPRESSION: 1. Non-contrast CT scan performed due to contrast allergy. Significant residual barium within the bowel is noted which limits evaluation for GI bleeding. 2. Splenomegaly measuring 15.5 cm. 3. Diverticulosis of descending colon and sigmoid colon without evidence of acute diverticulitis. 4. Multiple compression fractures noted of T9, L1, L3 and L5 which are age indeterminate. 5. Small bilateral pleural effusions greater on the right than the left. 6. Severe four-chamber cardiac enlargement. . [**7-21**] Tagged RBC scan: IMPRESSION: Moderate hemorrhage into the sigmoid colon beginning 15 minutes into the study. . [**7-21**] Angio: FINDINGS: 1. [**Female First Name (un) 899**] gram demonstrated normal anatomy with opacification of left colic, sigmoidal, and superior rectal arterial branches. 2. Sigmoidal and superior rectal arteriograms demonstrated contrast extravasation in the region of distal rectum, associated with some early filling veins. 3. Following embolization of a superior rectal artery, there was no contrast extravasation. . [**7-22**] KUB: FINDINGS: There continues to be borderline dilatation of the transverse colon. This might be consistent with mild ileus. A small amount of residual barium is still observed in the cecum or ascending colon. No evidence of calcifications or free air. Brief Hospital Course: 77 y/o woman with Afib not on coumadin due to various bleeding disorders, dCHF, HTN, hyperlipidemia, COPD, and myeloproliferative disorder transferred from OSH for management of several months of recurrent GI bleeding s/p hemorrhoidectomy, massive transfusion protocol, and IR coiling of superior rectal artery. . ACTIVE ISSUES: # GI Bleed: The patient was transferred from an outside hospital with GI bleed requiring 7 units PRBCs. Work-up at OSH included upper and lower endoscopy, colonoscopy, and tagged RBC scan unable to localize bleeding (either stomach or transverse colon). On admission, the patient had intermittent episodes of bright red blood per rectum. However, her hematocrit remained stable. She underwent a non-contrast CT that was limited by residual barium in her intestines from a past study prior to hospital transfer. Given the length of time barium remained in her colon, gastroenterolgy felt that her bleeding was not from either an upper GI or an intestinal source. She was then seen by colorectal who felt that her bleeding was related to her recent hemorrhoidectomy. The patient was transferred to the medical floor. On the medical floor, the patient began to experience massive GIB with BRBPR and clots. She was transferred back to the MICU, where she was transfused 12 units pRBC, 4 units FFP, 3 units platelets. She underwent iodine desensitization and tagged RBC scan that showed bleeding localized to the sigmoid colon. She then went to angio, and underwent coiling of her right superior rectal artery with resolution of her bleeding. The patient did have a small right hematoma as a result of the angiogram. However, she had no bruits and pulses remained intact. Her diet was advanced and she tolerated it well. Pt continued to have loose stools throughout her hospitalization. She was ruled out for C. diff and it was thought that her loose stools were secondary to absent rectal tone from her hemorrhoidectomy. . #Hemorrhoids s/p hemorrhoidectomy: The patient was admitted with a healing wounds s/p hemorrhoidectomy surrounded by diffuse erythema from stool incontinence. She was seen by wound care and given [**Last Name (un) **] baths as tolerated. She was also followed by colorectal surgery who did not feel any additional intervention was necessary. Pt is at high infection risk given that she does have an open wound with stool incontinence and she will need close monitoring by wound care with frequent repositioning in bed. We kept her foley in place given her open rectal wound. Wound care recommendations are included in this summary. . # acute on chronic diastolic CHF: Last Echo in [**2136**] showed EF>55%, moderate RV dilation signs of RV overload, and moderate pericardial effusion. The patient was admitted with crackles on exam, and CXR with cardiomegaly and evidence of pulmonary edema. Lasix was initially held on admission due to concern for potential hypotension from GI bleed. She was intermittently diuresed as needed for fluid overload throughout admission. Following angio coil and cessation of bleeding, the patient was started on standing lasix dose. She remained euvolemic and was discharged to rehab on lasix with metolazone PRN. . #Acute on Chronic Kidney Disease: Patient had elevated creatinine on admission with urine lytes consistent with intrinsic renal or post-renal etiology. Home lasix and metolazone were held on admission. Renal function slowly improved on admission. With cessation of bleeding, renal function improved to baseline. . #Afib not on coumadin: Patient has CHADS score of 5 but not candidate for coumadin in context of history of bleeding disorder and current GI bleeding. INR 1.5 on admission. The patient's lopressor was held on admission out of concern for hemodynamic instability. However, once she stablized, she was restarted on lopressor with dose increased to 37.5mg daily for improved rate control. . #C.diff: Stools were concerning for C. diff on admission. The patient was empirically covered with Flagyl while at OSH. A C. diff toxin assay was sent on admission to MICU. Empiric flagyl therapy was stopped following return of negative C. diff assay. Loose stools are attributed to absent rectal tone and fecal incontinence . #UTI: Patient has history of Klebsiella UTI. Patient completed 3 of planned 7 day course of at OSH. 7 day course of Levaquin was completed while in the MICU. Pt continued to complain of dysuria, though UA was not concerning. Dysuria was likely secondary to foley. . INACTIVE ISSUES: . #Myeloproliferative disorder: Chronic leukocytosis for approximately 11 years. The patient remained on home hydroxyurea and folic acid with baseline WBC around 18. . #COPD - Patient was continued on home 2L O2. She did not have increasing oxygen requirements throughout admission. . #Pulmonary Hypertension: Right heart cath in [**2136**] consistent with both cardiogenic and pulmonary contributions with elevated wedge pressure and even greater elevated PA diastolic pressure per report. Monitored during admission. . # Gout: Chronic. Allopurinol and cholchicine held on admission. . TRANSITIONAL ISSUES: . # Code: Full (discussed with patient) . # Pt will need follow up with colorectal surgeon at [**Hospital1 **] who performed her surgery. Per the patient, the appointment is already scheduled and her daughter has the information regarding time and place. . # Pt is at high risk for infection given her open rectal wound. She will need multiple dressing changes daily to keep the area clean and dry. She will likely need to keep the foley in place for a period of time to aid in healing. . # Pt has had long hospital course and is severely deconditioned. She will need frequent PT to return to baseline. . # Pt lasix dose was increased while hospitalized. She will need monitoring of her Cr and may require adjustment of her lasix dose . # Pt sent with PICC line, please remove if persistently stable and no further need for IV access (assess in 3 days time). Medications on Admission: Lasix 40 mg x 2 qAM Lasix 40 mg x 1 at 4 pm Toprol xL 75 mg Prozac 40 mg Colchicine 0.6mg Allopurinol 100 mg x 2 Protonix 40 mg Mag Oxide 400 mg TID Folic acid 1 mg Aspirin 325 mg Hydrea 500 mg MWF Vitamin D 400 mg Metolazone 2.5 mg Mon Lipitor 80 mg QHS Metamucil 4 capsules QHS Lidoderm Patch q 12 hrs on/q12 hrs off prn pain Lidocaine Viscous 2% 4x per day prn pain Anusol [**Hospital1 **] prn Xanax 0.25 mg [**Hospital1 **] prn anxiety Trazodone 50 mg QHS prn anxiety Vicodin 5mg/500 1-2 tabs q8hrs prn pain Nitrostat 0.4 mg 1 tab q 5 min prn angina nystatin ointment 100,000 U 15 gm [**Hospital1 **] prn Home O2 2-3L Discharge Medications: 1. Wound Care Pressure relief per pressure ulcer guidelines Support surface: Atmos Air Turn and reposition every 1-2 hours and prn off back If OOB, limit sit time to one hour at a time and sit on a pressure relief cushion. Gentle cleansing of perianal tissue with warm water and disposable washcloths. (Pt is allergic to Aloe so do not use the Foam cleanser). Pat the tissue dry. Apply a thin layer of Antifungal Critic Aid Clear Moisture Barrier Ointment daily and prn or every 3rd cleansing. Lay a Xeroform gauze on either side of the anus to protect the open tissue when she is stooling Lay a large Sofsorb sponge under her anal area and change daily or prn. 2. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. nystatin-triamcinolone 100,000-0.1 unit/gram-% Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for infection. 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 3X/WEEK (MO,WE,FR). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. 14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 18. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. 19. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain. 20. MagOx 400 mg Tablet Sig: One (1) Tablet PO three times a day. 21. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a day. 22. Metamucil 0.52 g Capsule Sig: Four (4) Capsule PO at bedtime. 23. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a week as needed for weight gain > 2 lbs or signs of fluid overload. 24. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tab Sublingual q5 min as needed for chest pain. 25. Outpatient Lab Work Check Chem 7 every 3 days to assess renal function. If renal injury, consider reducing total daily dose of lasix. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Arterial Hemorrhage from hemorrhoidal artery Malnutrition Rectal incontinence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Ms. [**Known lastname **], You were transferred to the [**Hospital1 18**] for ongoing evaluation of your bleeding. After carefully monitoring you for sometime and co-ordinating with a multidisciplinary team, you ultimately received a radiological procedure that fixed the bleeding artery. Your major problems thereafter were the malnutrition from your prolonged illness and the wound care required to keep your skin intact around the rectum We did make some changes to your medicines. We continued but reduced the dose of your aspirin to 81mg We increased the dose of your lasix to 80 mg twice daily Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please have the rehab schedule an appointment with your PCP on discharge Completed by:[**2139-7-26**]

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icd9cm

[ [ [] ] ]

[ "38.93", "39.79", "88.47", "99.15" ]

icd9pcs

[ [ [] ] ]

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7343, 7657

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17137, 17137

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25803

Discharge summary

report

Admission Date: [**2157-1-1**] Discharge Date: [**2157-1-10**] Date of Birth: [**2094-3-28**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Exploratory laparotomy, drainage intra-abdominal abscess, resection necrotic distal common bile duct and hepaticocholedochojejunostomy. History of Present Illness: 62 yo M s/p Liver transplant [**2156-12-8**], s/p C. Cath [**12-27**], prox LAD calcification, occlusion D2 & mid RCA, dissection D2 during cath w/guidewire, presents with 8/10 chest pain that began day of admission. The pain was [**8-27**] started in the center of the chest and radiated to both shoulders. The pain was associated with dyspnea and felt like pressure. He took 1 sl NTG that brought the pain from an 8 to [**4-27**]. The pain persisted during the day but lessened. His wife found that his heart rate was 120s and called the cardiologist (Dr. [**Last Name (STitle) **] who recommended evaluation at [**Hospital3 **]. There he was found to be in atrial fibrillation and was treated with lopressor x 3 and dig x1. His heart rate was difficult to control and had decreased BP that limited further beta blocker administration. He was given sl NTG. Found to have elevated trop at 0.39. At [**Hospital1 18**] ED initial vitals were 98.6, 120 93/55 96% RA. He was given metoprolol 25 mg once and oxycodone 5 mg. . Patient reports that he has been essentially pain free since leaving [**Hospital3 **] at rest. However, when he moves or gets up he again has chest pain. Patient reports that the pain is similar in severity and quality to the pain he had during the cardiac catherization this week. . Of note, pt feels like he hasn't felt great since leaving [**Hospital1 18**] last week. He has been anxious about the chest pain and feels nervous that no intervention was done. Past Medical History: 1. Alcohol-related cirrhosis status post TIPS placement [**2154-10-8**] requiring dilatation [**2154-10-15**] now s/p orthotopic liver transplant [**2156-12-8**] 2. Upper GI bleeding in [**2152**]. Patient was treated at an outside hospital and it is unclear whether his upper GI bleed was secondary to esophageal varices or peptic ulcer disease. 3. Coronary artery disease status post angioplasty in the [**2129**]. 4. Diabetes mellitus type 2 diagnosed in [**2152**]. Hemoglobin A1c [**2154-10-4**] was 6.3 5. Umbilical hernia status post repair [**2154-11-3**] 6. Right knee surgery 7. Depression 8. HCC, growth [**Last Name (un) 64259**] 2.5x2.5cm confirmed on [**2156-9-8**] at the dome of the liver 9. Recurrent recent paracentesis due to refractory ascites Social History: Married with two adult sons. Formerly worked as a vice president of a trucking company. Drank from the age of 20 until [**2154-9-19**]. He never smoked. Denies IV drug use. Family History: Father and brother died of MI at the age of 52. His mother and sister have diabetes. Physical Exam: T 99.1 BP 130/59 HR 67 RR 18 O2 sat 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 approx 8-10 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, diffusely tender, but mildly so. Large scar that is mildly erythematous with bandages but no drainage or sigificant tenderness. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Multiple ecchymoses on arms Guaiac negative Pertinent Results: [**2157-1-1**] 07:45PM BLOOD WBC-6.9 RBC-3.26* Hgb-10.1* Hct-29.0* MCV-89 MCH-30.8 MCHC-34.6 RDW-17.0* Plt Ct-185 [**2157-1-10**] 05:40AM BLOOD WBC-6.8 RBC-3.16* Hgb-10.0* Hct-28.1* MCV-89 MCH-31.7 MCHC-35.6* RDW-16.0* Plt Ct-164 [**2157-1-1**] 07:45PM BLOOD Neuts-93.8* Lymphs-4.5* Monos-1.2* Eos-0.6 Baso-0 [**2157-1-2**] 01:43AM BLOOD PT-15.6* PTT-31.1 INR(PT)-1.4* [**2157-1-10**] 05:40AM BLOOD PT-21.1* PTT-76.2* INR(PT)-2.0* [**2157-1-3**] 11:49AM BLOOD Fibrino-654*# [**2157-1-3**] 12:53AM BLOOD Gran Ct-1040* [**2157-1-1**] 07:45PM BLOOD Glucose-148* UreaN-27* Creat-1.7* Na-136 K-4.7 Cl-105 HCO3-21* AnGap-15 [**2157-1-10**] 05:40AM BLOOD Glucose-128* UreaN-34* Creat-2.1* Na-135 K-3.9 Cl-105 HCO3-21* AnGap-13 [**2157-1-10**] 05:40AM BLOOD ALT-21 AST-19 AlkPhos-260* TotBili-0.9 [**2157-1-9**] 05:50AM BLOOD ALT-20 AST-18 LD(LDH)-193 AlkPhos-245* Amylase-59 TotBili-1.1 [**2157-1-8**] 06:40AM BLOOD ALT-13 AST-16 AlkPhos-184* TotBili-1.3 [**2157-1-7**] 05:10AM BLOOD ALT-10 AST-13 CK(CPK)-12* AlkPhos-115 Amylase-34 TotBili-2.3* DirBili-1.6* IndBili-0.7 [**2157-1-6**] 07:19AM BLOOD ALT-12 AST-13 CK(CPK)-23* AlkPhos-91 Amylase-17 TotBili-3.9* [**2157-1-6**] 02:22AM BLOOD ALT-9 AST-12 AlkPhos-87 Amylase-16 TotBili-3.6* [**2157-1-5**] 08:20PM BLOOD CK(CPK)-33* [**2157-1-5**] 02:19PM BLOOD ALT-12 AST-12 CK(CPK)-25* AlkPhos-82 Amylase-11 TotBili-3.3* [**2157-1-4**] 10:20PM BLOOD CK(CPK)-50 [**2157-1-4**] 05:40AM BLOOD CK(CPK)-38 [**2157-1-4**] 03:00AM BLOOD ALT-13 AST-12 LD(LDH)-156 AlkPhos-78 Amylase-6 TotBili-3.7* [**2157-1-3**] 10:34PM BLOOD CK(CPK)-28* [**2157-1-3**] 03:19PM BLOOD CK(CPK)-27* [**2157-1-3**] 12:53AM BLOOD ALT-14 AST-10 LD(LDH)-150 AlkPhos-141* Amylase-19 TotBili-1.3 [**2157-1-2**] 06:00AM BLOOD ALT-15 AST-12 CK(CPK)-20* AlkPhos-165* TotBili-1.0 [**2157-1-2**] 01:42AM BLOOD CK(CPK)-25* [**2157-1-1**] 07:45PM BLOOD ALT-18 AST-15 LD(LDH)-174 CK(CPK)-21* AlkPhos-186* TotBili-0.8 [**2157-1-9**] 05:50AM BLOOD Lipase-57 [**2157-1-3**] 12:53AM BLOOD Lipase-16 [**2157-1-7**] 05:10AM BLOOD CK-MB-NotDone cTropnT-0.04* [**2157-1-6**] 07:19AM BLOOD CK-MB-NotDone cTropnT-0.06* [**2157-1-5**] 08:20PM BLOOD CK-MB-NotDone cTropnT-0.06* [**2157-1-5**] 02:19PM BLOOD CK-MB-NotDone cTropnT-0.08* [**2157-1-4**] 10:20PM BLOOD cTropnT-0.10* [**2157-1-4**] 05:40AM BLOOD CK-MB-NotDone cTropnT-0.11* [**2157-1-3**] 10:34PM BLOOD CK-MB-NotDone cTropnT-0.10* [**2157-1-3**] 03:19PM BLOOD CK-MB-NotDone cTropnT-0.09* [**2157-1-2**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.17* [**2157-1-1**] 07:45PM BLOOD cTropnT-0.15* [**2157-1-1**] 07:45PM BLOOD Albumin-2.8* Calcium-7.7* Phos-3.3 Mg-1.3* [**2157-1-10**] 05:40AM BLOOD Albumin-2.3* Calcium-7.5* Phos-3.0 Mg-1.6 [**2157-1-2**] 06:00AM BLOOD FK506-6.9 [**2157-1-3**] 06:25AM BLOOD FK506-6.1 [**2157-1-4**] 05:40AM BLOOD FK506-11.7 [**2157-1-5**] 05:35AM BLOOD FK506-25.4* [**2157-1-7**] 05:10AM BLOOD FK506-21.2* [**2157-1-8**] 06:40AM BLOOD FK506-11.4 [**2157-1-9**] 05:50AM BLOOD FK506-12.1 [**2157-1-4**] 10:55AM BLOOD Lactate-1.3 [**2157-1-3**] 11:49AM BLOOD Glucose-135* Lactate-1.6 Na-130* K-4.3 Cl-105 liver biopsy [**1-3**]: Features consistent with resolving zone 3 preservation/reperfusion injury; no active necrosis is identified, minimal portal and scant lobular mononuclear cell inflammation, likely non-specific, no features of acute cellular rejection are seen, rare cholestasis and focal, minimal bile duct proliferation seen; no significant bile duct damage or associated neutrophilic inflammation identified, no steatosis or intracellular hyalin present, trichrome stain shows mild portal and pericentrivenular fibrosis; a rare focus of sinusoidal fibrosis is seen, iron stain shows rare, minimal iron deposition in Kupffer cells. echo [**1-3**]: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. There are complex (mobile) atheroma in the descending aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. [**1-7**] biliary cath check: Gravity cholangiogram through a previously placed biliary catheter demonstrates mild stenosis at the hepaticojejunostomy anastamosis with mild left greater than right intrahepatic biliary ductal dilatation and mild delay of contrast passage into jejunal loops. This is likely secondary to postoperative edema at the anastamosis. No evidence of biliary leak. Brief Hospital Course: Mr. [**Known lastname 64260**] was admitted to the cardiology service for management of unstable angina along with his new onset atrial fibrillation and rapid ventricular response. He was seen by cardiac surgery who agreed with medical management at that point. He was started on a heparin drip and continued on his PO metoprolol/Imdur and aspirin. However, on [**2157-1-3**] he developed sharp pain in his epigastric region. A CT scan revealed new intraperitoneal free air in the setting of recent liver transplant and bile leak with increasing gas and fluid collection with the appearance of a developing abscess in the retrohepatic space. Because of this he was started on IV vancomycin and zosyn and was taken the operating room for exploratory laparotomy, drainage of the intra-abdominal abscess, resection of the necrotic distal common bile duct and hepaticocholedochojejunostomy. He was transfered to the ICU following the procedure. Initially he was difficult to extubate and went into rapid atrial fibrillation on [**2157-1-4**]. He was placed on a diltiazem drip and converted to sinus rhythm on [**2157-1-5**]. After this point, he did well and was transferred to the floor. On [**2157-1-7**] he underwent a cholangiogram which demonstrated mild stenosis at the hepaticojejunostomy anastamosis with mild left greater than right intrahepatic biliary ductal dilatation and mild delay of contrast passage into jejunal loops with no evidence of biliary leak. The vancomycin and zosyn were discontinued and his diet was advanced without difficulty. On [**2157-1-8**] he was started on coumadin for anticoagulation for his atrial fibrillation. His JP drain was discontinued on [**2157-1-9**] and he was tolerating a regular diet. He was discharged in good/stable condition. Medications on Admission: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily). 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 2 doses. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Tablet(s) 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 17. Lantus 18 U SC qhs Discharge Medications: 1. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 9. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. 10. Insulin Lispro 100 unit/mL Solution Sig: Zero (0) units (sliding scale as below) Subcutaneous three times a day: Glargine 12 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL 1 amp D50 1 amp D50 1 amp D50 1 amp D50 71-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 3 Units 3 Units 3 Units 3 Units 201-250 mg/dL 6 Units 6 Units 6 Units 6 Units 251-300 mg/dL 9 Units 9 Units 9 Units 9 Units 301-350 mg/dL 12 Units 12 Units 12 Units 12 Units 351-400 mg/dL 15 Units 15 Units 15 Units 15 Units . 11. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 14. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Tacrolimus 1 mg Capsule Sig: One Capsule PO Q12H (every 12 hours). 16. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day: Please get labs on Thursday and adjust your dosing as instructed at that time (start by taking 3 mg of coumadin daily). Disp:*40 Tablet(s)* Refills:*2* 17. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Disp:*21 Tablet(s)* Refills:*0* 18. Outpatient Lab Work Please check CBC, chem 10, AST, ALT, amylase, lipase, tbili, alk phos, albumin, PT, PTT, INR, and FK level on Thursday [**2157-1-13**]. Please fax these results to [**Telephone/Fax (1) 697**]. Discharge Disposition: Home With Service Facility: [**Location (un) 6138**] VNA Discharge Diagnosis: CAD, biliary leak Discharge Condition: improved/good/stable Discharge Instructions: You were admitted to the hospital with chest pain. You have known coronary artery disease. Please continue on all of your cardiac medications. Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Please schedule a follow-up appointment with your PCP if you have continued symptoms. * Continue to amubulate several times per day. * Please return to have your labs checked on Wednesday Followup Instructions: Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2157-1-13**] 8:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2157-1-19**] 2:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2157-1-26**] 1:40 Completed by:[**2157-1-10**]

[ "E878.0", "996.82", "411.1", "V58.67", "250.00", "427.31", "410.72", "567.81", "V58.61", "276.2", "414.01" ]

icd9cm

[ [ [] ] ]

[ "87.54", "50.11", "51.63", "51.37" ]

icd9pcs

[ [ [] ] ]

14902, 14961

9051, 10842

323, 461

15023, 15046

3920, 9028

16422, 16948

2974, 3062

12372, 14879

14982, 15002

10868, 12349

15070, 16399

3077, 3901

273, 285

489, 1975

1997, 2763

2779, 2958

6,692

141,308

28526

Discharge summary

report

Admission Date: [**2100-11-10**] Discharge Date: [**2100-11-14**] Date of Birth: [**2046-1-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11495**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: Mr. [**Known lastname 68242**] is a 54 year old morbidly obese M with h/o CAD s/p inferior MI with occlusion of RCA treated with medical management ('[**89**]), hyperlipidemia, HTN who presented to [**Hospital 487**] Hospital on [**11-9**] complaining of chest pain. The patient reports right sided chest pain which had been present since [**1-29**]. He notes that the pain initially presented only with exertion, however over the past two weeks the chest pain became more frequent and developed at rest. On the evening of [**11-8**], he developed right sided chest pain while sitting at home. He presented to [**Hospital 487**] Hospital and was admitted for r/o MI. ECG on admission was unchanged, with negative troponin. However, while on the floor the patient developed [**11-2**] substernal chest pain with diaphoresis and ECG showed new RBBB with STE in V2-V3. He denies any nausea, vomiting, lightheadedness at that time. Pt was transferred to [**Hospital1 18**] on ASA, plavix, heparin gtt. . In cath lab, found to have 3V disease. LMCA with mild disease LAD 99% just beyond origin, TIMI 1 flow, LCx large vessel with complex disease - 80% at bifurcation of large OM, diffuse 70-80% distal, chronically occluded RCA. POBA to prox LAD lesion attempted as bridge to CABG but unable to restore TIMI 3 flow. Cypher stent placed to LAD. Transferred to CCU on integrillin, heparin gtt. Hemodynamics significant for elevated R and L sided filling pressures. Past Medical History: CAD s/p MI ([**2089**]) Hyperlipidemia HTN GERD DM, type 2 OSA (CPAP at home) Social History: Smokes 1.5 pks/day for 30years. Drinks alcohol occasionally. Denies drug use. Is employed for the city. Family History: Brother recently passed away during valvular surgery at age 55, father died of MI in his 70s. Physical Exam: VS: BP 139/91, HR 85, RR 17, O2sat 90% on 4L Gen: well appearing obese male, NAD HEENT: MMM, PERRL, EOMI Neck: no carotid bruit, no JVD but difficult to assess CV: nl s1s2, no m/r/g Resp: CTA Abd: obese, NT, ND Ext: 2+ pulses, no edema Pertinent Results: Initial OSH Labs: Trop: <0.01, CPK: 108 BUN: 15, Cr: 0.8 Na: 139, K: 4.0 ALT: 56, AST: 52 WBC: 8.7, Hct: 42.5, Plt: 234 . CK trend at [**Hospital1 18**]: [**2100-11-10**] 04:04AM BLOOD CK(CPK)-7361* [**2100-11-10**] 04:29PM BLOOD CK(CPK)-5392* [**2100-11-11**] 03:16AM BLOOD CK(CPK)-3511* [**2100-11-12**] 05:35AM BLOOD CK(CPK)-1172* . Studies: ECG: NSR at 84, RBBB, STE in V1-V2 . [**11-2**] Echo: Normal LV size and systolic performance. EF 55%, Trace MR. . Cardiac Cath: LMCA: mild disease LAD: 99% just beyond origin, TIMI 1 flow LCx: large vessel with complex disease - 80% at bifurcation of large OM, diffuse 70-80% distal RCA: total occlusion proximal Hemodynamics: RA 23, PA 57/34/44, PCW 36 Brief Hospital Course: Mr. [**Known lastname 68242**] is a 54 year old male with a history of inferior MI in 95 who presented with chest pain to OSH, found to have 3VD now s/p stent to LAD. . CARDIAC # Ischemia: Mr. [**Known lastname 68242**] presented with ST elevations across his precordium and received a stent in the LAD. He was found to have multivessel disease, and CABG was considered but deferred given his TIMI 1 flow necessitating stent placement. He was sent out of the cath lab on integrillin, plavix, and aspirin. Post-procedure, he developed hypotension (SBPs 70s, pt remained asymptomatic) likely [**2-25**] to overdiuresis, beta-blockade. His central monitoring showed lower PA pressures causing decreased preload in this pt with prior IMI. He received normal saline bolus with resolution of the hypotension. His CKs peaked at 7300, falling to 1100 within 3 days. He remained chest pain free post-procedure. As his lipid panel revealed increased cholesterol and triglycerides, he will likely need to start a fibrate or Omacor as an outpt as combination therapy with his statin. This was deferred during his hospitalization given his elevated LFTs post-MI. He was continued on ASA, plavix, atorvastatin 80 (held in setting of LFT elevation, then restarted prior to discharge). He was started on 12.5 metoprolol TID to decrease cardiac demand post MI, captopril 6.25 TID, then converted to Toprol XL 50 and lisinopril 5 prior to discharge. The plan is to defer further PCI to left circumflex and allow LV function to recover post MI. He will need an outpt stress test (in approx 1 month) to assess level of ischemia due to left circ 80% lesion, consider additional intervention. Smoking cessation counseling was provided. Patient states that he plans to never smoke again. Will follow up as outpt for this issue. . # LV function Markedly elevated R and L sided filling pressures, depressed cardiac index during cath. Diuresis during cath with subsequent hypotension compounded by beta-blockade. TTE revealed EF 30% w/ LV systolic dysfxn, akinetic apex, mild pulmonary artery systolic hypertension. Given his akinetic apex, he was started on heparin as bridge to coumadin. He was discharged on Lovenox with follow up in Cardiology clinic to determine his optimal coumadin dosing. He was instructed to be careful and to avoid any activities that would put him at risk for bleeding, given his ASA, Plavix, Lovenox and coumadin. He was instructed not to drink alcohol until he checks with his Cardiologist as an outpt first. . # Rhythm Post-cath was in NSR, ST-T change resolved, no RBBB. Changed to Toprol XL 50mg qd prior to discharge, which he tolerated well. . # PULMONARY h/o OSA, CXR w/ minimal pulmonary edema, otherwise unremarkable Was placed on BiPAP at night [**10-28**], brought in his own machine in from home. Weaned off oxygen prior to discharge. . # GI h/o GERD, mild transaminitis likely secondary to MI; GI was consulted, recommended checking his LFTs several weeks after discharge to confirm that they have returned to [**Location 213**]. They were trending down upon discharge. Continued on Protonix given GERD and anticoagulation. . # DM: Inadequately controlled as outpatient (A1c 8.2%), seen by [**Last Name (un) **] who recommended holding outpatient avandia as it is contraindicated in heart failure, starting metformin at low dose, continuing to monitor his renal fxn while in house. He was instructed to avoid dehydration as this could set him up for lactic acidosis while on metformin. His sliding scale was changed to humalog from regular insulin. He will need to call [**Last Name (un) **] to set up a follow up appt in their clinic after discharge. . CODE: Full Medications on Admission: Aspirin 325mg QD Atorvastatin 80mg QD Isosorbide dinitrate 10mg [**Hospital1 **] Lisinopril 20mg PO QD Avandia Nitroglycerin 2% oint Omeprazole Restoril Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 4. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Lovenox 120 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous twice a day for 5 days: continue until your INR > 2.0 for 2-3 days (discuss with your PCP). [**Hospital1 **]:*10 syringes* Refills:*1* 7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO at bedtime: goal INR [**2-26**]. Your INR should be checked twice weekly until > 2.0, then as directed by your PCP. [**Name Initial (NameIs) **]:*90 Tablet(s)* Refills:*2* 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). [**Name Initial (NameIs) **]:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 9. work restriction Please allow patient to return to light duty work < 3 times weekly following his hospitalization. Absolutely no lifting or physical activity until authorized by the patient's cardiologist. 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. [**Name Initial (NameIs) **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 11. Lancets Misc Sig: One (1) lancet Miscell. four times a day as needed for finger stick. [**Name Initial (NameIs) **]:*100 lancets* Refills:*2* 12. One Touch Ultra Test Strip Sig: One (1) strip Miscell. four times a day as needed for finger stick. [**Name Initial (NameIs) **]:*50 test strips* Refills:*3* Discharge Disposition: Home Discharge Diagnosis: Primary: ST elevation MI Coronary artery disease . Secondary: Diabetes mellitus Hypertension Hyperlipidemia Obstructive sleep apnea Discharge Condition: Stable. Discharge Instructions: You suffered from a serious heart attack in one of the major arteries supplying your heart. Other arteries were also noted to be diseased. Therefore, you will need close cardiac follow up within the next several months. We recommend that you see a cardiologist as soon as possible and you will need to get a stress test within a month of discharge. It is also very important that you take all of your medications. It is also extremely important that you no longer smoke cigarettes. . You are taking hte following new medications: Plavix 75mg daily, Lisinopril, and Toprol XL. You are also taking medications called coumadin and lovenox which act as a blood thinner. You will need to take this every day and get your INR checked regularly. Lovenox can be stopped when your INR is > 2.0 for 3 days. Please keep all outpatient appointments. Please follow up with the [**Hospital **] clinic for better diabetes control. If you begin to experience chest pain, shortness of breath, lightheadedness or any other concerning symptoms please call 911 or your physician [**Name Initial (PRE) 2227**]. Followup Instructions: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], the Cardiology Fellow who followed you while you were in the hospital, will call you soon after your discharge to confirm a follow up appointment with you ([**Telephone/Fax (1) 69101**]. Please call if you have not heard from him in the next several days. You will also need to follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Telephone/Fax (1) 41961**] this week for INR check and follow up. Please follow up with [**Last Name (un) **] diabetes center ([**Telephone/Fax (1) 17484**] for continued help in managing your diabetes.

[ "410.11", "327.23", "414.01", "401.9", "272.4", "250.00", "278.01", "458.29", "412", "530.81" ]

icd9cm

[ [ [] ] ]

[ "00.45", "00.40", "88.52", "37.23", "99.20", "88.56", "36.07", "00.66" ]

icd9pcs

[ [ [] ] ]

9083, 9089

3185, 6888

328, 353

9265, 9275

2459, 3162

10423, 11067

2092, 2188

7091, 9060

9110, 9244

6914, 7068

9299, 10400

2203, 2440

278, 290

381, 1852

1874, 1953

1969, 2076

9,402

171,096

2632

Discharge summary

report

Admission Date: [**2153-10-2**] Discharge Date: [**2153-10-6**] Date of Birth: [**2084-3-11**] Sex: F Service: MEDICINE Allergies: Aspirin / Aleve Attending:[**First Name3 (LF) 1055**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Capsule endoscopy History of Present Illness: 69-yo-woman w/ DM2, HTN, ESRD p/w chest pain x 4 hours. She was feeling well until last night, when she developed sudden onset substernal chest pressure at rest, [**9-3**] severity, radiating to the back, assoc w/ nausea but no vomiting, dyspnea, palps, or diaphoresis. The pain is not associated w/ eating, body position, or exercise. The pain did not respond to SL NTG x 4, prompting the pt to call EMS for transport to the ED. She denies any fever, chills, dyspnea, cough, abd pain, dysuria, melena, hematochezia. Her stool has been black chronically since starting Fe 3 months ago; there is no change in the nature of stools. She has no h/o CAD or smoking. In the [**Name (NI) **], pt had persistent CP. Was treated w/ plavix 75mg x1, metoprolol 5mg iv x1, 25mg po x1, and NTG SL x 2. The pt was never free of CP in the ED. Hct noted to be 10 points below baseline w/ melanic stool on exam, prompting NG lavage that was normal. She was transfused 2units PRBCs, and admitted to MICU for further care. Past Medical History: 1. diabetes mellitus type 2: c/b nephropathy, neuropathy 2. ESRD: s/p AV fistula placement [**7-30**], pending HD, makes urine 3. CHF: ECHO [**7-30**] w/ LVEF 55%, 3+MR, 2+TR, mod pulm art HTN, diastolic dysfunction; exercise MIBI [**4-29**] w/ no perfusion defects 4. hypertension 5. gout 6. Anemia: multifactorial in setting of ESRD w/ guaiac positive stool 7. Occult GI bleed: EGD [**7-30**] w/ mild gastritis (H. pylori negative); C-scope [**7-30**] w/ hyperplastic polyps Social History: Lives alone, has nurse [**First Name (Titles) **] [**Last Name (Titles) 13222**] visit and help with ADLs. Denies tobacco, EtOH, or IVDU. Family History: DM - daughter, son HTN - son [**Name (NI) **] CAD Physical Exam: Gen: elderly woman lying in bed in NAD HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, no JVD CV: reg s1/s2, no s3/s4/m/r Pulm: crackles at bases B, no wheezes Abd: obese, +BS, soft, NT Ext: warm, faint DP B, no edema Rectal: + melenic stool in vault per ED note Neuro: a/o x 3, CN 2-12 intact Pertinent Results: Admission Labs: [**2153-10-2**] 05:25AM WBC-8.4 RBC-2.03*# Hgb-6.2*# Hct-19.6*# MCV-97 MCH-30.5 MCHC-31.6 RDW-17.3* Plt Ct-338 [**2153-10-2**] 05:25AM Neuts-53.0 Lymphs-38.6 Monos-5.3 Eos-2.7 Baso-0.4 [**2153-10-2**] 05:25AM PT-13.5* PTT-28.8 INR(PT)-1.2 [**2153-10-2**] 05:25AM Glucose-113* UreaN-93* Creat-6.4* Na-141 K-4.9 Cl-107 HCO3-19* AnGap-20 [**2153-10-2**] 05:25AM Calcium-8.5 Phos-5.4* Mg-2.3 [**2153-10-2**] 06:45PM Ferritn-215* VitB12-268 Folate-10.0 . [**2153-10-4**] 05:05AM PTH-270* . [**2153-10-2**] 05:25AM CK(CPK)-117 CK-MB-3 cTropnT-0.03* [**2153-10-2**] 12:17PM CK(CPK)-140 CK-MB-9 cTropnT-0.12* [**2153-10-2**] 06:45PM CK(CPK)-214* CK-MB-22* MB Indx-10.3* cTropnT-0.51* [**2153-10-3**] 03:42AM CK(CPK)-214* CK-MB-20* MB Indx-9.3* cTropnT-1.01* [**2153-10-3**] 09:05AM CK(CPK)-185* CK-MB-13* MB Indx-7.0* cTropnT-1.00* . Imaging: CHEST X-RAY, PORTABLE AP: Comparison is made to prior study of [**2153-9-6**]. The cardiac silhouette is moderately enlarged. Aortic calcifications are present. There is mild vascular engorgement without frank pulmonary edema. The appearance of the vasculature has improved in the interval. There is no pneumothorax. No focal consolidations are seen. IMPRESSION:Improved congestive heart failure. . [**10-2**] EKG: Sinus rhythm - Diffuse ST-T wave abnormalities - cannot exclude in part ischemia - clinical correlation is suggested Since previous tracing of the same date, further ST-T wave changes present . Capsule endoscopy: Procedure Info & Findings: Findings: Good prep 1. Polypoid lesion in stomach 2. Erythema and congestion at gastric antrum 3. Duodenitis in duodenal bulb 4. Capsule did not reach the colon. . Summary & Recommendations: Summary: 1. Gastric polypoid lesion 2. Gastritis. 3. Duodenitis in duodenal bulb. 4. Small nonbleeding angioectasia small bowel, out of reach of enteroscope 5. No active bleeding. Please check KUB prior to any MRI Brief Hospital Course: # Chest pain: Likely secondary to demand ischemia, as supported by the pattern of pain similar to past anginal episodes and dynamic ST depressions on EKG in the setting of low HCT. Chest pain resolved with blood transfusions. Cardiac enzymes peaked on HD#2. Cardiology was consulted and determined that cath was not indicated at this time given recent GI bleed. Recommended follow up in 1 month to reassess for possible catheterization and ASA desensitization. Pt was restarted on her statin, metoprolol, and isosorbide dinitrate and remained hemodynamically stable. Patient was given one dose of plavix in ED, plavix was held during the rest of the admission with plans to restart when cleared by GI. . # GI bleed: Patient had guaiac positive stool on admission and HCT 19, most likely due to UGI/bowel bleed. Hct remained stable after 4 units PRBC and pt was hemodynamically stable. Pt was transferred out to floor on HD 2. Pt had capsule endoscopy, results returned after discharge, which showed a gastric polypoid lesion, gastritis, duodenitis in duodenal bulb and a small nonbleeding angioectasia in the small bowel. The capsule did not reach the colon, pt will need to have a KUB prior to any MRI. Patient was continued on protonix. Plavix was held during her hospitalization with plans to restart if the capsule endoscopy was normal. Patient will follow up with PCP to recheck CBC and plan further GI work up. Patient continued on B12 and folate for anemia. . # CHF: Patient has h/o diastolic dysfxn. Patient was given lasix as needed with blood transfusions. Patient was continued on isosorbide dinitrate and metoprolol once hemodynamically stable. Continued on Lasix 40 mg QD. . # CKD: She has ESRD nearing hemodialysis. AV fistula still maturing. Renal was consulted, no urgent indications for dialysis during this hospitalization. Continued calcium acetate and phoslo. Cr improved to 4.7 at discharge. Will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. . # DM2: Pt was given NPH for basal glucose control and covered w/ ISS. At discharge she was restarted on glipizide, will follow up with PCP for further management. Medications on Admission: 1. Allopurinol 100 mg p.o. every other day. 2. Calcitriol 0.5 mcg p.o. daily. 3. Phos-Lo two tabs t.i.d. with meals. 4. Glipizide 2.5 mg daily. 5. Hydralazine ten milligrams p.o. t.i.d. 6. Imdur 30 mg daily. 7. Lipitor 20 mg daily. 8. Lasix 40 mg daily. 9. Metoprolol 50 mg p.o. b.i.d. 10. Plavix on hold 11. Multivitamin daily. 12. Iron 150 mg p.o. b.i.d. 13. Protonix 40 mg daily. 14. Epogen - not yet started 15. Tylenol p.r.n. Discharge Medications: 1. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO once a day. 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Calcium Acetate 667 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Glipizide 2.5 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO once a day. 11. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 12. Ferrous Sulfate 134 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: PRIMARY: Chest pain secondary to demand ischemia Anemia GI Bleed Secondary: Discharge Condition: Stable Discharge Instructions: If you develop chest pain, shortness of breath, dizziness, lightheadness, or palpitations call your primary care doctor immediately or return to the emergency room. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction to no more than 1500 ml Followup Instructions: Please schedule a follow-up appointment with your primary care doctor ([**Last Name (LF) **],[**Known firstname **] L. [**Telephone/Fax (1) 7976**]) within one week of your discharge. --follow-up CBC, especially Hct --follow-up capsule endoscopy study results --restart plavix if capsule study is normal . You have a follow up appt scheduled with [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. on [**2153-10-30**] at 3:30. Completed by:[**2153-10-20**]

[ "530.81", "280.0", "250.60", "588.81", "274.9", "578.9", "357.2", "414.01", "585.6", "428.32", "428.0", "411.1", "424.0", "535.60", "403.91", "250.40", "211.1" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.19" ]

icd9pcs

[ [ [] ] ]

8129, 8186

4331, 6520

287, 307

8307, 8316

2395, 2395

8672, 9160

2013, 2065

7002, 8106

8207, 8286

6546, 6979

8340, 8649

2080, 2376

237, 249

335, 1341

2411, 4308

1363, 1842

1858, 1997

65,190

164,805

1963

Discharge summary

report

Admission Date: [**2192-11-26**] Discharge Date: [**2192-12-5**] Date of Birth: [**2113-3-13**] Sex: M Service: NEUROSURGERY Allergies: Aspirin Attending:[**First Name3 (LF) 78**] Chief Complaint: L acute on chronic SDH Major Surgical or Invasive Procedure: Left frontoparietal craniotomy and evacuation of subdural hematoma. History of Present Illness: 79 yo russian speaking only male c hx of CAD, COPD, asthma, afib with 7 day hx of increasing right sided weakness with acute worsening 2-3 hours ago. Patient states that he has felt unsteady over this time period and daughter states that he fell approximately 3 days ago and has been dragging his R leg over the last 1-2 days. Slurred speech per daughter tonight and he had difficulty holding on to a cup of water with his right hand. Patient has had no visual changes and denies headache. Past Medical History: 1) h/o CHF but no EF 2) CAD s/p MI x 2 and angioplasty, ? stent in L iliac. On coumadin and plavix but stopped for steroid injection planned for [**1-3**] 3) PVD 4) Afib 5) PUD/GERD 6) s/p cataract removal 7) s/p CCY (gallstones, porcelin gallbladder) 8) hernia repair 9) COPD/ Asthma 10)Nephrolithiasis 11) colonic polyps 12) DVT in L lower extr. 13) DCMP, CHF 14) L spine disc herniation Social History: Lives in [**Location 583**] with wife, denies tobacco, etoh and IVDU Family History: Noncontributory Physical Exam: PHYSICAL EXAM (upon admission) O: T:97.3 BP: 108/66 HR:60 R 18 O2Sats 98% 2L NC Gen: WD/WN, comfortable, NAD. HEENT: Pupils:PERRL 3mm bilat EOMs intact Lungs: CTA bilaterally. Cardiac: reg irregular. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused, multiple soft mobile lipomas throughout extremities and torso. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. A&Ox3 Orientation: Oriented to person, place, and date. Language: good comprehension and repetition, difficult to assess dysarthria [**2-21**] russian language. Naming intact. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally V, VII: slight R facial droop and sensation intact and symmetric. VIII: decreased on R side IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-23**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 4 4+ 4+ 4 5 4 5 4 5 5 5 5 5 5 Toes downgoing bilaterally Coordination: difficulty with finger-nose-finger on the right, slow rapid alternating movements on the right Pertinent Results: ADMISSION LABS: [**2192-11-25**] 11:40PM PT-27.9* PTT-26.4 INR(PT)-2.7* [**2192-11-25**] 11:40PM WBC-8.7 RBC-4.39* HGB-13.9* HCT-39.0* MCV-89 MCH-31.7 MCHC-35.7* RDW-13.9 [**2192-11-25**] 11:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2192-11-25**] 11:40PM cTropnT-<0.01 [**2192-11-25**] 11:40PM GLUCOSE-119* UREA N-24* CREAT-1.2 SODIUM-130* POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-25 ANION GAP-11 DISCHARGE LABS: IMAGING: CTA HEAD W/O CONTRAST [**2192-11-26**]: 1. Large left chronic subdural hematoma, heterogeneous in attenuation but containing acute blood products, measuring 3.3 cm in maximum depth. There is resultant rightward subfalcine herniation and shift of midline structures to the right, by 1.5 cm at the level of foramen of [**Last Name (un) 2044**] and 1 cm at the septal level. 2. CTA demonstrates a soft plaque at the right proximal ICA without evidence of flow-limiting imaging stenosis. CTA head demonstrates no focus of active bleeding ("spot sign"), dural AVF, AVM or aneurysm larger than 2mm. 3. Stable appearance of likely right-sided Zenker's diverticulum in the superior mediastinum, at the thoraic inlet. 4. Multilevel cervical spondylosis. Brief Hospital Course: Mr. [**Known lastname 10816**] was admitted to the neurosurgery service to the ICU. He was started on Keppra due to question of subclincal seizures given his transient right arm weakness. His INR was reversed, surgery was delayed while the subdural became more chronic in nature. A speech and swallow was completed and was approved for a regular diet. He underwent a left sided craniotomy on [**2192-11-30**] with Dr. [**First Name (STitle) **]. Post-operative course was uneventful. Patient was written for transfer to the SDU from the ICU on [**12-1**] but remained in the ICU due to no beds in the SDU. On [**11-1**] the patient was transfered to the floor without a stepdown bed given his stable examination and neurologic status. On [**11-1**] his Foley catheter was discontinued and his oxygen was weaned. The patient was cleared for home with physical therapy on [**12-5**] and he was discharged stable without issue. Medications on Admission: Medications prior to admission: Singulair 10 mg Tab 1 Tablet(s) by mouth once a day Plavix 75 mg Tab 1 Tablet(s) by mouth DAILY (Daily) Hydrocodone-Acetaminophen 5 mg-500 mg Tab 1 Tablet(s) by mouth once or twice daily as needed for for severe pain only Xopenex HFA 45 mcg/Actuation Aerosol Inhaler 1 puff inhaled every 6 hours as needed for shortness of breath/wheeze Furosemide 20 mg Tab 1 Tablet(s) by mouth once a day Alprazolam 0.25 mg Tab 1 Tablet(s) by mouth daily Lisinopril 10 mg Tab 1 Tablet(s) by mouth once a day Simvastatin 80 mg Tab 1 Tablet(s) by mouth daily at bedtime Omeprazole 20 mg Cap, Delayed Release Capsule(s) by mouth once a day Isosorbide Mononitrate SR 30 mg 24 hr Tab 1 Tablet(s) by mouth once a day dose change. to replace 60 mg tabs Prednisone 10 mg Tab 1 Tablet(s) by mouth once a day Amitriptyline 25 mg Tab 1 Tablet(s) by mouth daily at bedtime Docusate Sodium 100 mg Cap 3 Capsule(s) by mouth daily Trazodone 50 mg Tab 1 Tablet(s) by mouth once a day Warfarin 5 mg Tab Take 1 Tablet(s) by mouth daily or as directed by [**Hospital 197**] Clinic Warfarin 7.5 mg Tab Take 1 Tablet(s) by mouth daily or as directed by coumadin clinic metoprolol succinate ER 25 mg 24 hr Tab Oral 1 Tablet Sustained Release 24 hr(s) Once Daily nitroglycerin 0.3 mg Sublingual Tab Sublingual as needed Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 2. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): ** RESTART THIS MEDICATION on [**2192-12-7**] **. 3. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Acute on Chronic SDH Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? You were on a medication called Coumadin (Warfarin) which was held during your hospitalization. Please restart this medication IF/WHEN your primary care physician deems appropriate. ** Please RESTART your home Plavix dose on [**2192-12-7**] ** ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. Please continue Keppra dose until follow-up appointment CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ?????? You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Please have your STAPLES REMOVED in 5 days after discharge at your primary care physician's office.

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Discharge summary

report

Admission Date: [**2109-4-1**] Discharge Date: [**2109-5-10**] Date of Birth: [**2055-7-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Heart Murmur Major Surgical or Invasive Procedure: [**2109-4-1**] - Aortic Valve Replacement (23mm CE Magna Pericardial), Ascending Aorta and Hemiarch Replacement (24mm Gelweave Graft). [**2109-4-10**] - Sternal rewiring and dedridement [**2109-5-1**] GJ tube placement History of Present Illness: 53 y/o male who was noted to have a heart murmur on routine physical exam in [**12-25**]. Underwent an echo which revealed severe AS with dilated aorta and EF 65-70%. Subsequently had cardiac cath which showed no coronary disease. Also underwent chest CT which showed a dilated ascending aorta measured at 5.1 x 4.9cm. Now referred for cardiac surgery. Past Medical History: Gout, Arthritis, h/o Hepatitis A, s/p Vasectomy Social History: Denies tobacco use. Admits to rare ETOH use. Family History: NC Physical Exam: VS: 93 134/97 75" 235# Gen: WDWN male in NAD Skin: W/D intact HEENT: EOMI, PERRL NCAT Neck: Supple, FROM, -JVD, -Carotid bruit Chest: CTAB -w/r/r Heart: RRR w/ [**2-21**] holosystolic murmur Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**2109-5-6**] 05:25AM BLOOD WBC-2.6*# RBC-3.25* Hgb-9.5* Hct-28.0* MCV-86 MCH-29.1 MCHC-33.7 RDW-14.1 Plt Ct-237 [**2109-5-5**] 05:08AM BLOOD WBC-5.3 RBC-3.58* Hgb-10.1* Hct-31.0* MCV-87 MCH-28.3 MCHC-32.7 RDW-14.4 Plt Ct-291 [**2109-4-4**] 12:30AM BLOOD WBC-19.2* RBC-3.02* Hgb-9.5* Hct-26.3* MCV-87 MCH-31.6 MCHC-36.3* RDW-12.3 Plt Ct-208 [**2109-4-3**] 05:55AM BLOOD WBC-14.8* RBC-3.29* Hgb-10.2* Hct-29.0* MCV-88 MCH-31.0 MCHC-35.3* RDW-12.9 Plt Ct-144* [**2109-5-6**] 05:25AM BLOOD Glucose-104 UreaN-36* Creat-2.6* Na-138 K-3.6 Cl-105 HCO3-22 AnGap-15 [**2109-5-5**] 05:08AM BLOOD Glucose-119* UreaN-29* Creat-2.5* Na-139 K-4.2 Cl-103 HCO3-22 AnGap-18 RADIOLOGY Final Report CHEST (PA & LAT) [**2109-5-5**] 3:14 PM CHEST (PA & LAT) Reason: PNA [**Hospital 93**] MEDICAL CONDITION: 53 year old man with WITH FEVRS TO 105 / R/O PNA REASON FOR THIS EXAMINATION: PNA PA AND LATERAL CHEST, [**5-5**] HISTORY: High fever, rule out pneumonia. IMPRESSION: PA and lateral chest compared to [**5-4**]: Small bilateral pleural effusion unchanged since [**5-4**]. No consolidation or other evidence of pneumonia. Heart size normal. Upper lungs clear. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: SUN [**2109-5-5**] 9:27 PM RADIOLOGY Final Report CT CHEST W/O CONTRAST [**2109-5-5**] 2:31 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Reason: r/o infectiond NO CONTRAST [**Hospital 93**] MEDICAL CONDITION: 53 year old man with wit fevers to 105 / now 103 / post avr (tissue) with asc ao hemiarch repair. Also has acute renal failure creat 1.0 to 2.5 NO CONTRAST REASON FOR THIS EXAMINATION: r/o infectiond NO CONTRAST CONTRAINDICATIONS for IV CONTRAST: ARF WITH CREAT OF 2.5 CT TORSO ON [**2109-5-5**] CLINICAL HISTORY: Fevers, question source of infection. TECHNIQUE: Helical acquisition of CT images performed from the thoracic inlet through the ischial tuberosities following administration of oral contrast only, via GJ tube. IV contrast unable to be administered due to poor renal function. Comparison made to recent CT of [**2109-4-19**]. FINDINGS: Left-sided PICC line extends to the cavoatrial junction. Prior aortic valve replacement is again seen, with high density surrounding the ascending aorta, and multiple surgical clips, all stable and post-operative. Previously described gas- and fluid-containing collections at the sternotomy site are again seen, decreased in size when compared to prior. There is mild persistent stranding in the subcutaneous fat of the anterior mediastinum. Bilateral small pleural effusions are seen. There is no focal airspace consolidation. Respiratory motion limits evaluation of the underlying parenchyma. Below the abdomen, non-contrast evaluation of the liver, spleen, pancreas, and adrenal glands reveals no abnormalities. There are two small subcentimeter hypodensities within the liver, likely benign cysts and unchanged. There is biliary sludge within a non-distended gallbladder. There is a new 4mm round high density focus within the proximal left ureter, compatible with ureteral calculus, with mild associated fullness of the more central collecting system. A caliceal diverticulum versus dilated calix is also seen with layering milk of calcium at the left lower pole. Right collecting system is decompressed. No additional stones are seen. Colon is decompressed. No pelvic mass or lymphadenopathy. Bladder, seminal vesicles, and prostate are unremarkable with periurethral prostatic calcifications. No abscess or drainable fluid collection. There is stranding in the left groin with surgical clips likely from recent procedure. IMPRESSION: 1. Slightly increased pleural effusions with improved left base airspace consolidation when compared to prior study. 2. Improved postoperative gas/fluid collections in the anterior mediastinum. 3. New 4 mm left proximal ureteral calculus with only minimal associated left hydroureteronephrosis. 4. No abscess or drainable fluid collection within the abdomen or pelvis. No discrete source for the patient's fevers. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**] RADIOLOGY Final Report VIDEO OROPHARYNGEAL SWALLOW [**2109-4-24**] 2:28 PM VIDEO OROPHARYNGEAL SWALLOW Reason: eval swallowing function [**Hospital 93**] MEDICAL CONDITION: 53 year old man s/p AVR REASON FOR THIS EXAMINATION: eval swallowing function OROPHARYNGEAL VIDEO FLUOROSCOPY INDICATION: 53-year-old man post cardiac surgery. FINDINGS: Oral and pharyngeal swallowing video fluoroscopy was performed today in collaboration with speech and language pathology. Various consistencies of the barium were administered. ORAL PHASE: There is moderate impairment of bolus formation with prolonged mastication of the solids. There is mild reduction in bolus control with premature spillover before the swallow with liquids. Mild reduction of AP tongue movement and oral transit times for ground solids was seen. Mild coating of residue remains in the oral cavity after the swallow. PHARYNGEAL PHASE: There is a delay in initiation in the swallow, intermittently severe. When started, palatal elevation was mildly reduced, laryngeal elevation and laryngeal valve closure are moderately reduced. Mild coating of residue remained in the valleculae after the swallow. No residue was seen in the piriform sinuses. ASPIRATION/PENETRATION: Patient had penetration before the swallow with thin and nectar-thick liquids secondary to swallow delay and aspiration due to not being able to consistently clear the penetration with thin liquids. The aspiration was silent. IMPRESSION: Mild-to-moderate oral and moderate-to-severe pharyngeal dysphagia with intermittent aspiration with liquids secondary to delayed and premature spillover. For further details and treatment recommendations, please see speech pathology note dated [**2109-4-24**]. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**] Approved: MON [**2109-4-29**] 12:00 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 77633**], [**Known firstname 4075**] [**Hospital1 18**] [**Numeric Identifier 77634**]TTE (Complete) Done [**2109-4-19**] at 3:37:11 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] [**Street Address(2) 15115**] [**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2055-7-11**] Age (years): 53 M Hgt (in): 75 BP (mm Hg): 130/90 Wgt (lb): 225 HR (bpm): 75 BSA (m2): 2.31 m2 Indication: Endocarditis ICD-9 Codes: 424.1, 424.0 Test Information Date/Time: [**2109-4-19**] at 15:37 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2008W033-0:30 Machine: Vivid [**6-23**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.9 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 60% to 70% >= 55% Left Ventricle - Lateral Peak E': 0.11 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.11 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 8 < 15 Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Ascending: 2.6 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A ratio: 1.00 Mitral Valve - E Wave deceleration time: 248 ms 140-250 ms Findings LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR well seated, normal leaflet/disc motion and transvalvular gradients. No masses or vegetations on aortic valve. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No mass or vegetation on mitral valve. Normal mitral valve supporting structures. No MS. Normal LV inflow pattern for age. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or vegetation on tricuspid valve. Normal tricuspid valve supporting structures. No TS. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. No vegetation/mass on pulmonic valve. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60-70%) There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2109-4-9**], a pericardial effusion is no longer present. IMPRESSION: no obvious vegetations seen If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2109-4-19**] 16:04 [**Numeric Identifier 77635**] G TUBE PLACMENT, ALL INCL. [**2109-5-1**] 9:37 AM Reason: for feeding contiues to fail swallow Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 53 year old man with s/p asc aorta replacement REASON FOR THIS EXAMINATION: for feeding contiues to fail swallow INDICATION: 53-year-old man status post ascending aortic replacement. Failed swallow test. Need for feeding tube. RADIOLOGISTS: The procedure was performed with Dr. [**Last Name (STitle) 24949**] as well as Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6330**] and Dr. [**First Name8 (NamePattern2) 6339**] [**Last Name (NamePattern1) 19420**] (both attending radiologists, present and supervising throughout). PROCEDURE: The risks and benefits of the procedure were explained to the patient and written informed consent was obtained. The patient was placed supine on the angiographic table and the abdomen was prepped and draped in standard sterile fashion. A preprocedure timeout was performed using two patient identifiers. After insufflation of the stomach via a NG tube, under fluoroscopic guidance and injection of local anesthesia, two T-fasteners were deployed in the stomach. A 19-gauge needle was then advanced into the stomach with the angle pointing towards the pylorus. A 0.035 Bentson guidewire was subsequently advanced through the needle and coiled within the stomach. Exchange was made for a 5 Fr Cobra catheter and then a 5 Fr Sos Omni catheter to maneuver across the pylorus and into the duodenum. T A stiff Amplatz wire was then passed to the jejunum. The stomach tract was dilated with a 14 French dilator. A 20 French peel- away sheath was then advanced over the wire into the stomach and the inner dilator was removed and a 16 French GJ tube ([**Doctor Last Name 9835**]) was placed in the jejunum. Injection through the tube confirmed the proper location with the tip in the jejunum. The gastrostomy was secured to the skin with a flexi track. The patient tolerated the procedure well and there were no immediate complications. Conscious sedation was provided using divided doses of a 100 mcg of fentanyl and a single dose of 1 mg of Versed, during a total intraservice time of 30 minutes. The patient's vital parameters were continuously monitored throughout the procedure. IMPRESSION: Successful placement of a 16 French [**Doctor Last Name 9835**] percutaneous gastrojejunostomy tube with tip in the jejunum. The tube is ready for use. The T-fastener sutures should be removed in [**6-27**] days as detailed in the provider or entry system. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 46933**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: FRI [**2109-5-3**] 7:55 AM Brief Hospital Course: Mr. [**Known lastname **] was a same day admit after undergoing all pre-operative work-up as an outpatient. On [**2109-4-1**] he was brought directly to the operating where he underwent a aortic valve replacement and ascending aorta with hemiarch replacement. 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 but somewhat confused and was extubated. He was then transferred to the step down unit for further recovery. Later on postoperative day one, Mr. [**Known lastname **] developed acute onset of short term memory loss and had a seizure. He was returned to the intensive care unit for further care. The neurology service was consulted. A CT scan of his head was normal without any acute changes. Dilantin was loaded and keppra was started for his seizure. Given his mild respiratory distress and fever, it was presumed that he aspirated during his seizure, vancomycin, levofloxacin and flagyl were started. An EEG showed no epileptiform features and no electrographic seizure activity however was suggestive of a mild encephalopathy suggesting dysfunction of bilateral, subcortical, or deep midline structures. He was sedated and reintubated for aggitation. Thiamine and folate were started as acute alcohol withdrawal was suspected. Tube feeds were started for nutritional support. His white count continued to decrease however his fevers persisted. A CT of his abdomen was obtained to rule out an abdominal pathology. This revealed a large pericardial effusion and moderate-to-large mediastinal fluid collection with probable dehiscence of the sternotomy. In the setting of continued fevers, infection cannot be excluded and clinical correlation is recommended. There were also large bilateral pleural effusions, left greater than right, and lower lobe atelectasis. Tiny hypodense liver lesion too small to characterize and unchanged were also noted. Mr. [**Known lastname 77636**] wife admitted that he consumes roughly 30 beers daily thus strengthening the diagnosis of alcohol withdrawal. He was again extubated on [**2109-4-8**] however needed to be reintubated shortly after due to large amounts of secretions. Given his mediastinal and pericardial fluid collection in the presence of a partially dehissed sternum, Mr. [**Known lastname **] was returned to the operating room for debridement. His sternum was washed out and rewired on [**2109-4-10**]. His effusions were also drained. He returned to the intensive care unit for monitoring. He underwent a bronchoscopy for a left lower lobe collapse and thick oral secretions. Minimal secretions were suctioned however serratia was found on culture. He was seen by ID and Zosyn was started. The neurology service continued to follow him for memory loss. Keppra was continued for his seizure activity. He was evantually and successfully weaned from ventilation. Speech and swallow was consulted and followed him. Recommendation was to continue tube feeds at this time until his confusion clears. A NG Tube was placed for feeding. Mr. [**Known lastname **] was transferred to the step down unit for continued recovery. His white blood cell count climbed and vancomycin was restarted for preseumed mediatinitis. He remained confused despite a normal brain MRI. A video swallow was performed which showed aspiration with thin and thick liquids, with significant impairment in initiation of pharyngeal swallow. A dobhoff tube was placed under fluorsoscpy as he had manually removed his NG tube. Aggressive physical therapy continued. He was seen by neuropthomology for his supranuclear gaze palsy and will follow up with them in [**1-20**] months. PICC line was placed on [**4-23**]. Video swallow performed on [**4-24**] showed improvement and he was cleared for nectar thick liquids and pureed solids, he continued on 16 hours of tube feeds. He was again seen by speech and swallow on [**4-26**] and found to be aspirating more and he was again made NPO. He was seen by GI for PEG placement evalution. On [**5-1**] PEG placed and within the next 24 hours tube feeding was started along with supervised feedings. PICC line placed on [**5-2**]. [**5-4**] Mr [**Known lastname **] [**Last Name (Titles) 28316**] a temperature 103 then to 105. He was again pan cultured. His creatinine also increased from 1.0 to 2.0 then to 2.5. His NSAIDs were dc'd and free water increased. Caspofungin was started per ID to treat [**Female First Name (un) **] in blood from [**5-5**]. PICC was dc'd. He was seen by opthamology and there were no signs of fungal endopthalmitis. Rash was noted, and urine eos were increased, therefore zosyn was discontinued. Speech and swallow evalution on [**5-9**] showed improvement and his diet was advanced to thin liquids and ground solids. PICC line was replaced on [**5-10**] and he was ready for discharge to rehab. Medications on Admission: none Discharge Medications: 1. Colace 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO twice a day. 2. PICC line 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. 3. Sarna Anti-Itch 0.5-0.5 % Lotion [**Month/Year (2) **]: One (1) Topical three times a day as needed for itching. 4. Vancomycin 1,000 mg Recon Soln [**Month/Year (2) **]: One (1) Intravenous once a day: continue until [**5-29**]. 5. Caspofungin 50 mg Recon Soln [**Month/Year (2) **]: One (1) Intravenous once a day: continue until [**5-19**]. 6. Levetiracetam 500 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO twice a day. 7. Metoprolol Tartrate 25 mg Tablet [**Month/Day (4) **]: 1.5 Tablets PO three times a day: 37.5mg three times daily . 8. Atorvastatin 10 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day. 9. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (4) **]: One (1) Injection three times a day. 10. Aspirin 325 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day. 11. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day. 12. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: Four (4) Inhalation four times a day as needed for shortness of breath or wheezing. 13. Outpatient Lab Work weekly (tuesday) CBC w/ Diff, LFT, Chem 7, vanco trough fax to [**Hospital **] clinic [**Telephone/Fax (1) 432**] 14. insulin sliding scale with humalog Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 61-109 mg/dL 0 Units 0 Units 0 Units 0 Units 110-130 mg/dL 3 Units 3 Units 3 Units 3 Units 131-150 mg/dL 5 Units 5 Units 5 Units 5 Units 151-180 mg/dL 7 Units 7 Units 7 Units 7 Units 181-210 mg/dL 9 Units 9 Units 9 Units 9 Units 211-240 mg/dL 11 Units 11 Units 11 Units 11 Units 241-280 mg/dL 13 Units 13 Units 13 Units 13 Units 15. Lantus 100 unit/mL Solution [**Telephone/Fax (1) **]: Thirty Five (35) units Subcutaneous once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Aortic Stenosis/Aortic Aneurysm s/p Aortic Valve Replacement, Ascending Aorta and Hemiarch Replacement PMH: Gout, Arthritis, h/o Hepatitis A PSH: Vasectomy Discharge Condition: Fair 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) Call with any questions or concerns. Followup Instructions: Dr. [**First Name (STitle) **] in 2 weeks Dr. [**Last Name (STitle) 696**] when discharged from rehab Dr. [**First Name (STitle) 2429**] when dsicharged from rehab Dr. [**First Name (STitle) **] [**Name (STitle) **] (Neuro-opthamology) 1-2 months Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2109-5-27**] 9:00 Will need outpatient work-up for CPAP at night when mental status clears. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2109-5-10**]

[ "996.76", "285.9", "427.1", "E879.6", "303.91", "998.31", "518.0", "799.02", "507.0", "E849.7", "070.1", "441.2", "291.81", "E878.8", "746.4", "274.0", "780.39", "423.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "34.79", "96.6", "57.95", "35.21", "96.04", "38.45", "88.72", "44.39", "33.23", "38.93", "38.91", "89.14", "39.61", "94.62" ]

icd9pcs

[ [ [] ] ]

22524, 22603

15132, 20101

332, 553

22802, 22809

1414, 2170

23552, 24147

1084, 1088

20156, 22501

12296, 12343

22624, 22781

20127, 20133

22833, 23529

1103, 1395

280, 294

12372, 15109

581, 935

957, 1006

1022, 1068

82,478

107,004

41278

Discharge summary

report

Admission Date: [**2115-3-19**] Discharge Date: [**2115-3-26**] Date of Birth: [**2062-8-25**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Shellfish / Percocet / Codeine / Sulfa (Sulfonamide Antibiotics) / Ceclor / Darvocet-N 100 / Flexeril / Dilaudid / Valium / Zithromax / Ace Inhibitors / doxicycline / Cardizem / Toprol XL / Verapamil / Catapres / Atacand / Norvasc / Levaquin / Cipro / Floxin / Prednisone / Adhesive / Latex Attending:[**Attending Info 65513**] Chief Complaint: Elective Surgery Major Surgical or Invasive Procedure: TAH-BSO debulking of ovarian cancer History of Present Illness: 52 year old female with h/o multiple drug allergies, complex pelvic mass now s/p TAH-BSO for excision and staging. . Patient initally presented to PCP [**Name Initial (PRE) **] abdominal pain and anorexia several weeks prior to this admission. Pelvic ultrasound positive for a 7cm cystic mass posterior to the uterus. MRI showed a 9cm cystic mass arising from the right ovary with <1.5cm nodes in the perirectal areas and some nodes anterior to the IVC. CA-125 was 46. Notably, she also has complete duplication of her lower gynecologic tract including a vertical vaginal septum and a didelphic uterus/cervix. She presented for surgery. Past Medical History: Asthma, mild Hypertension GERD s/p Nissen Seasonal allergies Back pain Carpal tunnel surgery Ulnar neurosurgery Achilles tendon repair Nissen fundoplication Cholecystectomy Lithotripsy Social History: She smoked, but quit 15 years ago. Denies alcohol or drug abuse. She works in the Police Department. Family History: Breast cancer in paternal aunt and grandmother. Ovarian cancer, none. Uterine or cervical cancer in her sister. Physical Exam: Exam upon admission to ICU: Vitals: afebrile, 88 87/49 99% on Assist Control (500/5/16bpm/50%O2) General: intubated, spontaneously moving all extremities HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear Neck: Supple, no JVD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: midline incision w bandage c/d/i, soft, non-distended, quiet bowel sounds, no guarding GU: +foley Ext: cool, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION EXAM: [**2115-3-19**] 10:46PM TYPE-ART PO2-158* PCO2-46* PH-7.33* TOTAL CO2-25 BASE XS--1 [**2115-3-19**] 10:46PM LACTATE-3.7* [**2115-3-19**] 10:26PM GLUCOSE-171* UREA N-15 CREAT-0.7 SODIUM-142 POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-23 ANION GAP-14 [**2115-3-19**] 10:26PM CALCIUM-8.4 PHOSPHATE-4.0 MAGNESIUM-1.8 [**2115-3-19**] 10:26PM WBC-17.3*# RBC-4.54 HGB-12.9 HCT-38.8 MCV-86 MCH-28.5 MCHC-33.3 RDW-13.5 [**2115-3-19**] 10:26PM NEUTS-92* BANDS-0 LYMPHS-5* MONOS-3 EOS-0 BASOS-0 [**2115-3-19**] 08:28PM TYPE-ART PO2-135* PCO2-39 PH-7.40 TOTAL CO2-25 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2115-3-19**] 07:05PM TYPE-ART PO2-187* PCO2-40 PH-7.40 TOTAL CO2-26 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2115-3-19**] 07:05PM HGB-11.4* calcHCT-34 [**2115-3-19**] 04:14PM GLUCOSE-115* LACTATE-1.8 NA+-138 K+-2.9* CL--103 [**2115-3-19**] 04:14PM HGB-11.3* calcHCT-34 DISCHARGE LABS: [**2115-3-21**] 06:20AM BLOOD WBC-12.8* RBC-4.07* Hgb-11.6* Hct-34.2* MCV-84 MCH-28.4 MCHC-33.9 RDW-14.2 Plt Ct-200 [**2115-3-22**] 06:20AM BLOOD WBC-9.5 RBC-3.56* Hgb-10.8* Hct-30.0* MCV-84 MCH-30.4 MCHC-36.1* RDW-14.1 Plt Ct-179 [**2115-3-23**] 05:40AM BLOOD WBC-8.9 RBC-3.71* Hgb-10.6* Hct-31.2* MCV-84 MCH-28.6 MCHC-34.1 RDW-14.1 Plt Ct-184 [**2115-3-24**] 05:30AM BLOOD WBC-7.4 RBC-3.90* Hgb-11.2* Hct-32.5* MCV-83 MCH-28.7 MCHC-34.5 RDW-14.0 Plt Ct-230 [**2115-3-25**] 06:10AM BLOOD WBC-6.8 RBC-3.81* Hgb-11.4* Hct-33.6* MCV-88 MCH-29.8 MCHC-33.9 RDW-13.8 Plt Ct-222 [**2115-3-26**] 06:20AM BLOOD WBC-9.0 RBC-4.26 Hgb-12.7 Hct-35.7* MCV-84 MCH-29.8 MCHC-35.6* RDW-14.2 Plt Ct-291 [**2115-3-21**] 06:20AM BLOOD PT-13.9* PTT-22.9 INR(PT)-1.2* [**2115-3-22**] 06:20AM BLOOD Glucose-99 UreaN-8 Creat-0.5 Na-142 K-3.5 Cl-104 HCO3-30 AnGap-12 [**2115-3-23**] 05:40AM BLOOD Glucose-83 UreaN-10 Creat-0.5 Na-141 K-3.5 Cl-103 HCO3-29 AnGap-13 [**2115-3-24**] 05:30AM BLOOD Glucose-89 UreaN-7 Creat-0.5 Na-137 K-3.4 Cl-101 HCO3-28 AnGap-11 [**2115-3-25**] 06:10AM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-138 K-3.9 Cl-104 HCO3-26 AnGap-12 [**2115-3-26**] 06:20AM BLOOD Glucose-108* UreaN-8 Creat-0.6 Na-140 K-3.8 Cl-104 HCO3-25 AnGap-15 [**2115-3-21**] 03:34AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2115-3-21**] 3:34 am URINE Source: Catheter. **FINAL REPORT [**2115-3-22**]** URINE CULTURE (Final [**2115-3-22**]): NO GROWTH. Brief Hospital Course: 52 year old female with h/o multiple drug allergies, complex pelvic mass now s/p TAH-BSO. Please see operative note for details. . [**Hospital Unit Name 153**] Course: The patient was transferred to the [**Hospital Unit Name 153**] after during her TAH-BSO. She required 2 U PRBCs intraoperative. Her vitals on arrival with SBP 70s s/p this blood and 6L LR. Her hypotension was thought to be secondary to third spacing in the setting of a protracted abdominal surgery v. medication effect from propofol. BP improved throughout her stay. She received another 1 U PRBCs in the ICU, with HCT stable around 36-38. She arrived in the [**Hospital Unit Name 153**] intubated but was successfully extubated. Her WBC post op was 17 but she remained afebrile so this was thought to be due to a stress response to protracted surgery. She received amp/gent/flagyl intra-operatively but no additional antibiotics in the [**Hospital Unit Name 153**]. She was kept NPO as there was concern for ileus post surgery secondary to mobilization of bowl. IV PPI was given for history of GERD. She was transferred to the floor the afternoon of POD#1. She was put on a morphine PCA for pain control. Her diet was advanced on POD#4 after she had flatus, then to regular on POD#6. Her Hct was stable. She did have a temperature to 101 on POD#1, and a urine culture was done and came back normal. Her pain medications were switched to PO. She became ambulatory. She was discharged home in good condition on POD #7. Medications on Admission: Vitamin D Asmanex Triamterene/HCTZ 37.5/25mg po daily Protonix 40mg po daily Claritin Singulair 10mg po daily Xopenex - hasn't used in months Discharge Medications: 1. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: Three (3) ML Inhalation q 6 hours () as needed for prn SOB/wheezing. 2. morphine 10 mg/5 mL Solution Sig: 2.5-5 ml PO Q4H (every 4 hours) as needed for pain: each mL has 2mg of morphine. Do not take more than 5 mL at once. Disp:*500 ml* Refills:*0* 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. acetaminophen 650 mg/20.3 mL Solution Sig: 20.3 mL PO Q6H (every 6 hours). Disp:*2436 mL* Refills:*2* 5. ibuprofen 100 mg/5 mL Suspension Sig: Thirty (30) mL PO Q6H (every 6 hours). Disp:*500 mL* Refills:*2* 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 7. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Asmanex Twisthaler 110 mcg (30 doses) Aerosol Powdr Breath Activated Sig: One (1) daily Inhalation daily (). 9. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Ovarian cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Nothing in your vagina for 3 months. No heavy lifting for 6 weeks. You may shower, but no baths for 3 weeks. Continue to take acetaminophen and ibuprofen around the clock. You make take liquid morphine on top of this as needed for pain. Please also take Colace, a stool softener, twice daily while taking these medications. You may take Milk of Magnesia for constipation. Please stay active while at home. Please follow-up with your primary care doctor to discuss management of your other medications. Restart all your home medications. Hold your blood pressure medication if you feel dizzy or light-headed. Followup Instructions: Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2115-4-1**] 11:30 - Staple removal Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2115-4-8**] 9:00 - Post-op follow-up Please call Dr.[**Name (NI) 89880**] office for an appointment to discuss chemotherapy. His number is ([**Telephone/Fax (1) 34323**]. [**Name6 (MD) 35354**] [**Name8 (MD) **] MD [**MD Number(2) 65515**] Completed by:[**2115-3-30**]

[ "183.0", "998.11", "530.81", "E878.6", "998.2", "493.90", "752.89", "401.9", "518.0" ]

icd9cm

[ [ [] ] ]

[ "40.3", "68.49", "39.32", "65.61", "54.4" ]

icd9pcs

[ [ [] ] ]

7535, 7541

4780, 6270

580, 617

7600, 7600

2294, 3209

8387, 8949

1634, 1749

6463, 7512

7562, 7579

6296, 6440

7751, 8364

3226, 4757

1764, 2275

524, 542

645, 1288

7615, 7727

1310, 1497

1513, 1618

25,116

143,666

620+55227

Discharge summary

report+addendum

Admission Date: [**2194-11-2**] Discharge Date: [**2194-11-11**] Date of Birth: [**2115-11-26**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4765**] Chief Complaint: STEMI and possible Aortic Dissection Major Surgical or Invasive Procedure: Cardiac catheterization with placement of 2 bare-metal stents to PDA History of Present Illness: 78 yo F w/ s/p CABG in [**2178**] w/ 2 vision stents, who initially presented to [**Hospital3 **] on [**11-1**] by ambulance with generalized weakness, worse on the left side. EMTs noted slight facial droop on the L side w/ weakend L sided grip and left arm drifting. CT Scan showed no evidence of an acute process. At the OSH, her TropI were 0.02 --> 0.04 --> 0.49 and with the next series 2.55, 7.59, 11.85. Last troponin at 0945 on [**11-2**] 15.52. She received morphine, lovenox, plavix and aspirin and it was decided that she should be transfered to [**Hospital1 18**] for cardiac cath. She developed scapular pain, along with an oxygen requirement and had a widened pulse pressure, so there was concern for aortic dissection. Upon transfer she went for CTA to rule out aortic dissection, which showed some evidence of LLL consolidation, and was given 1 dose vanc/cefepime empirically. She was also found to have ST elevations on EKG in leads III and AVF and went to the cath lab for evaluation. Of note, she has been off of her aspirin and plavix due to recent carpal tunnel release on [**2194-10-30**]. . In the cath lab, 100% occlusion of the PDA was seen and 2 BMS were placed in the vein graft in the PDA. The last hour of the procedure, pt was complaining of lower back pain (chronic) and was in a lot of discomfort. She was given fentanyl and versed, and became hypoxic to mid 80s (down from 94% at presention to cath lab). She became hypotensive and it was noted that she was in a.fib with RVR. Lopressor 2.5mg IV and amiodarone 150mg IV were administered, and then pt was cardioverted with DCC (200J), which restored her to sinus rhythm. She received a total of 100mg fentanyl and 2mg versed. The swan and venous sheath remain in place. The arterial sheath has been removed. She came up to the floor on dopamine drip and integrilin and was placed on a hi-flow neb mask, with O2 sats 88-92%. Past Medical History: CAD s/p CABG [**78**] (LIMA-LAD, SVG-OM, SVG-Dx, SVG-PDA) HTN Hyperlipidemia s/p umbilical hernia repair s/p Colonoscopy with polypectomy [**2189-3-2**] h/o DVT h/o partial hysterectomy s/p right carpal tunnel release, [**2194-10-30**] Social History: Has fourteen children. - Tobacco history: 100 pack year, quit [**2176**] - ETOH: none - Illicit drugs: none Family History: Brother died of [**Name (NI) 4766**], Brother died of [**Name (NI) 4767**], Mother with Breast Cancer - No family history of arrhythmia, cardiomyopathies; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM VS: T= 103.6 BP= 105/40 (4 extremities: L leg 82/44, R leg 90/54, L arm 101/40, R arm 100/40) HR= 90 RR=23-26 O2 sat= 95% on NRB GENERAL: appears fatigued, lying in bed comfortable, non-rebreather in place. HEENT: MMM, OP clear, EOMI, PERRL. NECK: JVP not elevated. CARDIAC: regular rate and rhythm, 2/6 systolic murmur best heard at LUSB, PMI not displaced. no s3 or s4 appreciated. LUNGS: decreased BS throughout, crackles at left lower lung base. expiratory wheeze heard throughout lungs. ABDOMEN: soft, NT/ND, +BS. no palpable aorta, no HSM. EXTREMITIES: no clubbing or cyanosis. scar from previous left saphenous vein harvest noted. 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+ NEURO (Pre-cath): alert, oriented to person, place and year. CN II-XII intact with no facial droop noted. bilateral upper extremities with 5/5 strength and sensation intact and equal. bilateral lower extremities with 5/5 strength in dorsifelxion and ankle flexion with sensation intact and equal. . DISCHARGE PHYSICAL EXAM Vitals - Tm/Tc: 98.6/97.9 HR: 89 (83-94) BP: 131/63 (104-131/56-80) RR: 20 02 sat: 94 RA (93-100 RA, 94-96 2L) In/Out: Last 24H: [**2213**]/3100 (net ~-1L); BMx2 (Guaiac negative) Last 8H: 0/600 Weight: 70.2 (bedscale) from 70.8 kg GENERAL: Alert, mentating, appropriate. NAD, lying in bed. HEENT: MMM, OP clear NECK: JVP at 6 cm. CARDIAC: regular rhythm, 2/6 systolic murmur best heard at LUSB, PMI not displaced. No S3/S4. LUNGS: decreased breath sounds b/l at bases R>L with minimal crackles. ABDOMEN: Soft, NT/ND, +bowel sounds. EXTREMITIES: no clubbing or cyanosis. Trace bilateraly pedal edema. PULSES: Radial 2+ DP 1+ PT 1+ bilaterally Pertinent Results: ADMISSION LABS [**2194-11-2**] 08:37PM BLOOD WBC-12.4*# RBC-3.61* Hgb-12.3 Hct-33.7* MCV-93 MCH-33.9*# MCHC-36.4* RDW-13.1 Plt Ct-159 [**2194-11-2**] 08:37PM BLOOD Neuts-87.0* Lymphs-8.7* Monos-3.9 Eos-0.2 Baso-0.2 [**2194-11-2**] 08:37PM BLOOD PT-12.8 PTT-22.1 INR(PT)-1.1 [**2194-11-2**] 08:37PM BLOOD Glucose-142* UreaN-11 Creat-0.8 Na-140 K-3.5 Cl-101 HCO3-28 AnGap-15 [**2194-11-2**] 08:37PM BLOOD CK-MB-26* MB Indx-4.7 cTropnT-1.19* [**2194-11-2**] 08:37PM BLOOD CK(CPK)-550* [**2194-11-2**] 08:37PM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9 . DISCHARGE LABS [**2194-11-10**] WBC 7.3, RBC 2.77, HGB 9.0, MCV 96, MCH 32.5, MCHC 33.8, RDW 12.8, Plt Ct 289 [**2194-11-8**] PT 12.7, PTT 26.1, INR 1.1 [**2194-11-10**] Glucose 99, UreaN 14, Creat 0.6, Na 139, K 4.1, Cl 103, HCO3 28 [**2194-11-10**] Calcium 8.6, Phos 3.8, Mg 2.2 [**2194-11-6**] Iron 14, calTIBC 181, Ferritn 270, TRF 139 . MICROBIOLOGY [**2194-11-2**] BLOOD CX (final): No growth [**2194-11-2**] URINE CX: PROBABLE ENTEROCOCCUS. ~5000/ML. [**2194-11-2**] MRSA Screen: No MRSA isolated [**2194-11-3**] SPUTUM CX: gram stain showed extensive contamination with upper respiratory secretions [**2194-11-4**] URINE CX (final): No growth [**2194-11-4**] BLOOD CX (final): No growth [**2194-11-5**] SPUTUM CX: gram stain showed extensive contamination with upper respiratory secretions . IMAGING [**2194-11-2**] CARDIAC CATH: COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated coronary artery disease. The LMCA was angiographically-free of flow-limiting stenoses. The LAD was diffusely diseased proximally and mid with serial focal lesions of 50% proximal and 70% x 2 mid lesions (just beyond the take-off of the small diagonal and septal branches). It filled antegrade with TIMI 3 flow. No retrograde LIMA filling/competitive flow noted. The LCx was known to be chronically occluded, with faint filling of tiny vessels noted via L -> L collaterals. The RCA was not selectively engaged since it is known to be occluded. 2. Selective vein graft angiography demonstrated a proximal total occlusion of the SVG-RCA graft. A stenotic lesion proximally was noted to be followed by a thrombosis of the graft segment beyond the stents. The SVG-Diag was patent. The SVG-OM was occluded as was previously known. 3. Selective arterial conduit angiography demonstrated an atretic LIMA-> LAD. 4. The patient was complaining of lower back pain (chronic) at the conclusion of the left heart catherization, and was in a great deal of discomfort. She was given more Versed and Fentanyl, and became hypoxic to the mid-80s (down from 94% at presentation to the cath lab) on 100% NRB. She also became hypotensive; rhythm soon after noted to be atrial fibrillation with RVR. Lopressor 2.5 mg IV and Amiodarone 150 mg IV were administered followed by DCCV at 200 J, which restored NSR. 5. Resting hemodynamics during hypotension while patient was in atrial fibrillation revealed mildly elevated right-sided filling pressures with a RVEDP of 11 mmHg, and moderately elevated left-sided filling pressures with a PCWP of 19 mmHg. Her cardiac index was reduced in the setting of atrial fibrillation with rapid ventricular rate (using an assumed O2 consumption). There was also low-normal systemic systolic arterial pressures noted at the start of her catherization, with central aortic pressure of 101/46, mean 68 mmHg. . FINAL DIAGNOSIS: 1. Successful primary angioplasty (thrombectomy, PTCA, and bare-metal stenting) of the SVG-> RCA with restoration of TIMI 3 flow. Resistent lesion at the proximal SVG was dilated with 4.5v balloon at high pressure and a 4.0 angiosculpt balloon. 2. Mildly elevated right-sided pressures, and moderately elevated left-sided pressures. 3. Systemic arterial pressures noted to be low-normal. 4. Cardiac index borderline while patient in atrial fibrillation with RVR. 5. Brief hemodynamic compromise due to rapid atrial fibrillation treated successfully with DCCV, beta blocker, and amiodarone. 6. Successful deployment of 6F Angioseal to the R common femoral artery. . [**2194-11-2**] CTA CHEST W&W/O C&RECONS, NON-CORONARY: There is no mediastinal hemorrhage or pneumomediastinum. There is no pericardial and no pleural effusion. Coronary artery bypass grafts are seen. There is moderate atherosclerotic calcification of the thoracic aorta with soft and calcified plaques. No evidence of acute aortic syndrome including no evidence of dissection. The ascending aorta measures 3.5 cm, not meeting criteria for aneurysm formation. Multiple mediastinal lymph nodes are seen, not meeting size criteria for pathologic enlargement. There is no evidence of pulmonary embolism. Normal proximal supraortic vasculature. Moderate centrilobular emphysema of the lungs is demonstrated. There is opacification of the entire left lower lobe and opacification of the posterior part of the superior segment of the right lower lobe and the basal segments of the right lower lobe. Diagnosis includes aspiration pneumonia and/or atelectasis. There is no axillary or hilar lymphadenopathy. Status post sternotomy with intact sternal wires. There are no suspicious lytic or sclerotic bony lesions at the thoracic spine. . [**2194-11-2**] ECG: Sinus rhythm. Coved ST segment elevation in the inferior leads (lead III greater than lead II) with associated Q waves and biphasic T waves. ST segment depression in leads I and aVL consistent with reciprocal changes from inferior myocardial infarction in evolution. Compared to the previous tracing of [**2189-3-6**] ST segment elevation is new, although Q waves were seen in II, III and aVF on prior tracing. . [**2194-11-3**] ECG 2:15am: Sinus rhythm with atrial premature beats. ST segment changes as previously described with concomitant anteroseptal ST segment depression which may be due to posterior wall myocardial ischemia or concomitant anteroseptal myocardial ischemia. Compared to tracing #1 anteroseptal ST segment depression is new and atrial premature beats are now present. . [**2194-11-3**] ECG 7:44am: Sinus rhythm. ST segment elevation in the inferior leads with biphasic T waves in leads III and aVF. Anteroseptal ST segment depression. Atrial premature beats. Compared to tracing #2 the findings are similar and are consistent with inferior myocardial infarction in evolution with possible posterior wall involvement. . [**2194-11-3**] ECHO 1:04am: Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with akinesis of the basal 2/3rds of the inferior wall. The remaining segments contract normally (LVEF = 50-55 %). The aortic valve is thickened. Significant aortic stenosis cannot be excluded, but unlikely to be severe (limited 2D imaging of the valve and no Doppler). No aortic regurgitation is seen. No mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Regional left ventricular systolic dysfunction c/w CAD. No significant pericardial effusion. Possible mild aortic valve stenosis. Compared with the prior study (images reviewed) of [**2189-3-5**], inferior dysfunction is more severe. . [**2194-11-3**] ECHO 10:35am: 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 estimated right atrial pressure is 5-10 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferolateral wall. The remaining segments contract normally (LVEF = 55 %). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction c/w CAD. Pulmonary artery hypertension. Mild mitral regurgitation. Small secundum type atrial septal defect . [**2194-11-4**] CHEST (PORTABLE AP): Patient is status post-median sternotomy for CABG. Left PICC line ends at lower SVC. Bilateral diffusely increased lung opacities new since recent chest CT from [**2194-11-2**], likely represents moderately severe pulmonary edema. Left lower lung opacity reflects a combination of moderate effusion and atelectasis. Minimal atelectasis is also seen in the right lung base. Pleural effusion, if any, is minimal on the right side. Concurrent pneumonia cannot be ruled out in the appropriate clinical setting. . [**2194-11-4**] US SIMPLE/SING ABSC/CYST DRAIN/INCISION PORT: Transverse and sagittal images were obtained of the subcutaneous tissues in the posterior sacral region at the area of the patient's discomfort. At this region there is no suspicious soft tissue mass and no fluid collection is identified. . [**2194-11-5**] ECG: Normal sinus rhythm. Compared to tracing #1 the ST segment elevation in leads II, III and aVF is less prominent as are the reciprocal changes in the lateral precordial leads. Series of tracings is consistent with an acute evolving inferoposterior myocardial infarction. . [**2194-11-5**] CHEST (PORTABLE AP): In comparison with study of [**11-4**], there is continued substantial pulmonary edema with cardiac enlargement, bilateral pleural effusions (worse on the left), and compressive atelectasis at the bases. In the appropriate clinical setting, supervening pneumonia would have to be considered. . [**2194-11-6**] CHEST (PORTABLE AP): There remains a moderate cardiomegaly with evidence for prior CABG. Sternal wires are intact. Pulmonary edema is present to a moderate degree, which appears stable. Moderate bilateral effusions are unchanged. Left lower lobe collapse is also unchanged. No pneumothorax is present. Brief Hospital Course: 78 yo F w/ s/p CABG in [**2178**] w/ 2 vision stents who p/w concern for aortic dissection and inferior STEMI, now s/p 2 BMS in the vein graft in the PDA, with LLL pneumonia. . . ACTIVE ISSUES # CAD s/p STEMI: Pt w/ known three vessel disease, s/p CABG in [**2178**] and 2 vision stents, admitted with evidence of inferior STEMI on EKG with STE in III and aVF and reciprocal depressions in I and aVL. Cath demonstrated total proximal occlusion of SVG-RCA, which was stented with BMS. Based on the site of her infarction, the patient may be preload-dependent. Towards the end of the cardiac catheterization, pt went into atrial fibrillation with RVR and was given Lopressor 2.5mg IV and Amiodarone 150mg IV. She was then cardioverted with DCC (200J), which restored her to sinus rhythm. She came back up to the floor on dopamine, which was subsequently weaned over the next few days. She was continued on her home clopidogrel 75 mg PO daily and atorvastatin 80mg daily, but aspirin was decreased to 81 mg and metoprolol succinate decreased to 50 mg daily. Once she was weaned off dopamine, she was started on lisinopril 5mg daily. PICC was placed so that the femoral venous sheath could be pulled and she could still receive dopamine infusion and IV antibiotics for her pneumonia (see below). Last day of antibiotics was Monday [**2194-11-10**] and the PICC line was pulled before discharge. . # Hypoxia: Likely multifactorial from probably decreased baseline pulmonary function, based on extensive smoking history, exacerbated acutely by pneumonia and acute pulmonary edema in the setting of her MI. She was monitored for respiratory failure, evaluated, and treated with a non-rebreather mask as needed. Supplemental oxygen was eventual weaned off with acceptable maintenace of oxygen saturations. Pneumonia was treated with antibiotics, as described below. At the OSH, BNP was 889. During this admission, the patient was given furosemide, which effectively decreased her pulmonary edema. Her hypoxia was also reponsive to nebulizers and inhalers. Before discharge, she was oxygenating well on room air. . # Left-lower lobe consolidation: Evidence of entire LLL consolidation and basal segments of RLL shown on CTA chest, which likely represented pneumonia, and was present upon admission. Not likely HAP as pt was in OSH only since [**11-1**] and CXR only showed b/l lower base atelectasis. She was POD#2 s/p carpal tunnel surgery upon admission, after which she received percocet, unsure of how much she was taking, so there could be question of aspiration, now on NRB. She was febrile to 103.6 initially w/ WBC 12.4 and left shift neut 87.0% and she spiked again to 102.8 on HD#2. She was put on vancomycin, cefepime, and azithromycin on HD#1 for a total 8 day course to cover for possible HAP and atypical pneumonia. Her WBC normalized and was 7.3 on the day of discharge. . # Erythematous lesion on back: Pt has history of chronic back pain and she was quite uncomfortable due to immobility secondary to the venous sheath status post cardiac catheterization. It was initially unclear if this was an abscess or beginning of a pressure wound. Ultrasound performed over the sacral area showed no suspicion for a soft tissue mass or fluid collection. Her pain was controlled with morphine, tramadol, lidocaine patch, and hot compresses. . # Possible TIA - She presented to OSH w/ left sided weakness with some slight facial droop on the L side w/ weakened L sided grip and left arm drifting per EMTs. Neuro consult at OSH reported no focal deficits, CNs intact, normal sensation, but noted proximal weakness creating a dysmetric response. They recommended elective MRI or followup CT to see if anything evolves on the right side and cartoid ultrasonography w/ antiplatelet therapy. There were no focal deficits on physical exam here. She was continued on aspirin and plavix as above. . # HTN: Despite her history of hypertension, she was relatively hypotensive with a widened pulse pressure. Aortic dissection was ruled out with CTA. There was concern for possible sepsis (LLL consolidation and high WBC w/ left shift) v. cardiogenic shock (recent myocardial infarction). She was initially started on 12.5mg metoprolol [**Hospital1 **] (with uptitration to 25mg [**Hospital1 **]), and then was started on lisinopril 5mg daily once her BP tolerated it. Her home nifedipine was held in favor of lisinopril and metoprolol. . . CHRONIC ISSUES # HL: Pt was continued on home atorvastatin 80mg daily for her hyperlipidemia and for cardioprotection. Lipid panel was great. . . TRANSITIONAL ISSUES 1.) Recommend pulmonary function testing to evaluate extent of COPD/emphysema and treatment implications Medications on Admission: Metoprolol 150mg PO BID Plavix 75mg PO daily Nifedipine 60mg PO daily Lipitor 80mg PO daily Aspirin 325mg daily MVI Calcium Tylenol Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] - [**Location (un) **] Discharge Diagnosis: Primary diagnoses: Inferior STEMI Pneumonia ?TIA . Secondary diagnoses Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure to participate in your care here at [**Hospital1 1535**]. You were admitted after you had a heart attack. In the cardiac catheterization lab, two bare metal stents were placed in one of the blood vessels supplying your heart to improve its circulation. You were also found that have a pneumonia, for which you were treated with intravenous antibiotics. During your hospitalization, you experienced shortness of breath that was probably secondary to your pneumonia, along with extra fluid that had accumulated in your lungs. Additional treatments for this shortness of breath included a medication that pulls fluid off of the lungs and nebulizer/inhaler treatments to open your airways. You improved steadily and were breathing comfortably at the time of discharge. Please note, the following changes have been made to your medications: 1.) START lisinopril 5 mg by mouth daily 2.) START tiotropium inhaler 1 cap inhaled daily 3.) START ferrous sulfate 300 mg by mouth daily 4.) DECREASE metoprolol succinate to 50 mg by mouth daily 5.) DECREASE aspirin to 81 mg by mouth daily 6.) STOP nifedipine It is important that you follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 4768**], and your cardiogist, Dr. [**First Name (STitle) **], after this hospitalization. Please keep the appointments that have been made for you, as listed below. Wishing you all the best! Followup Instructions: Name: [**Last Name (LF) 1112**],[**First Name3 (LF) **] D Location: [**Location (un) **] FAMILY PRACTICE Address: [**Location (un) 4769**], [**Location (un) **],[**Numeric Identifier 4770**] Phone: [**Telephone/Fax (1) 4771**] ***Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge Department: CARDIAC SERVICES When: THURSDAY [**2194-12-4**] at 1:40 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2194-11-11**] Name: [**Known lastname 565**],[**Known firstname **] M Unit No: [**Numeric Identifier 566**] Admission Date: [**2194-11-2**] Discharge Date: [**2194-11-11**] Date of Birth: [**2115-11-26**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 567**] Addendum: Addendum to Brief Hospital Course: . # Question of Aortic Dissection: Upon arrival, pt had scapular pain, an oxygen requirement, along with a widened pulse pressure. There was concern for a possible aortic dissection, which was ruled out with CTA Chest as it showed no evidence of dissection. Discharge Disposition: Extended Care Facility: [**Location (un) 176**] - [**Location (un) 568**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 569**] MD [**MD Number(1) 570**] Completed by:[**2194-11-11**]

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icd9pcs

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9648

Discharge summary

report

Admission Date: [**2157-9-3**] Discharge Date: [**2157-9-17**] Date of Birth: [**2109-6-6**] Sex: M Service: MEDICINE Allergies: lisinopril Attending:[**First Name3 (LF) 2901**] Chief Complaint: CHF exacerbation Major Surgical or Invasive Procedure: Right basilic PICC placement History of Present Illness: 48yoM with h/o diastolic HF, CAD, morbid obesity, OSA on CPAP, HTN/HL, brought in by EMS with severe SOB. Pt was coughing yesterday and was up all night coughing, and was unable to catch his breath. Called EMS, found to have HTN to >200's, very SOB, and with mild CP, tachypnea to the 40's. EMS gave him CPAP, 2 sprays nitroglycerin. In the ED he was tachypneic to the 40's but 100% on CPAP, 160/100. His CPAP settings were increased to 23/18 home settings and he received 40 mg IV Lasix, 4 mg IV morphine. His respiratory status improved, RR decreased to 20s, SBP decreased to 110s-120s and he calmed down and looked better. His CXR was poor quality but called as moderate pulmonary edema and likely effusions. He had not much UOP to initial 40 mg IV Lasix, so given another 80mg IV Lasix with about 350 UOP before last signout. Vitals before transfer: 56 115/64 23 97% on 100% FiO2 15/12. He was weaned down 85% FiO2 before transfer. On arrival, pt is in moderate respiratory distress, and tachypneic. . Pt endorses taking his medications and "doing his exercises." ROS as above otherwise, fever from 99.3 to 99.9 at home, occasional dizziness, and dry cough since last Wednesday and thought he was getting a cold, but denies orthopnea, PND, BLE edema, chest pain (other than above), palpitations. Also negative for h/a's, myalgias, sinus congestion, sore throat, n/v/d/c/abd pain, dysuria. Otherwise negative. Past Medical History: -Morbid Obesity (BMI>70) -HTN -HLD -OSA on nocturnal bipap -tobacco abuse -heart failure with preserved ejection fraction Social History: SOCIAL HISTORY -Tobacco history: active smoker, 25 pack-year -ETOH: was heavy alcohol user, 1 pint hard alcohol/day, quit cold [**Country 1073**] Father's Day this year -Illicit drugs: None -Herbal Medications: None - Patient has no stable home, stays at friends' [**Name2 (NI) **], currently separated from wife Family History: Multiple grandparents with DM and MI Physical Exam: Physical Exam on Admission: 101.9 p89 146/85 24 84% --> 96-98% Morbidly obese M, tachypneic to mid 30's with CPAP mask on, able to speak short sentences, moderately distressed. EOMI, no scleral icterus, mouth exam deferred due to CPAP. Unable to examine jugular veins at present time Poor to fair air movement, difficult to hear breath sounds but no gross crackles. + expiratory rubbing atelectatic sounds Unable to hear S1/S2 at all due to habitus and loud breath sounds Obese abd NT ND, benign BLE surprisingly with none to only very trace pitting edema. Extremities are all warm distally and proximally. Bilateral DP's and radials are palpable CN 2-12 grossly intact, he is moving all extremities, conversant and alert, mood/affect appropriately distressed Physical Exam on Discharge: VS: T 98.1 BP 90s/50s - 130s/80s HR 70s RR 20 97% RA GENERAL: obese 48 yo M in no acute distress HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, unable to assess JVD. CHEST: CTABL no wheezes, no rales, no rhonchi, distant BS CV: S1 S2 very distant [**1-26**] body habitus, could not appreciate murmurs. ABD: very obese with mult skin folds. Pos BS. No rebound/guarding. EXT: wwp, [**12-26**]+ edema, non pitting. right > left (pt states this is chronic) DPs, PTs 1+. NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. SKIN: LUE with outlined boundaries from thrombophlebitis at old IV site, slightly tender still on medial and ant aspect of forearm. Improved since yesterday. PSYCH: A/O, cooperative and pleasant. Pertinent Results: Labs on Admission [**2157-9-3**] 10:51PM TYPE-ART PO2-77* PCO2-43 PH-7.41 TOTAL CO2-28 BASE XS-1 [**2157-9-3**] 10:51PM GLUCOSE-115* LACTATE-1.0 K+-3.2* [**2157-9-3**] 10:51PM freeCa-1.15 [**2157-9-3**] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2157-9-3**] 03:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2157-9-3**] 03:00PM URINE RBC-8* WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [**2157-9-3**] 03:00PM URINE HYALINE-5* [**2157-9-3**] 03:00PM URINE MUCOUS-RARE [**2157-9-3**] 10:00AM LACTATE-1.4 K+-3.8 [**2157-9-3**] 09:47AM GLUCOSE-125* UREA N-9 CREAT-1.0 SODIUM-138 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 [**2157-9-3**] 09:47AM estGFR-Using this [**2157-9-3**] 09:47AM CK(CPK)-56 [**2157-9-3**] 09:47AM CK-MB-2 proBNP-850* [**2157-9-3**] 09:47AM cTropnT-<0.01 [**2157-9-3**] 09:47AM WBC-8.1 RBC-4.81 HGB-14.8 HCT-42.3 MCV-88 MCH-30.8 MCHC-35.1* RDW-14.2 [**2157-9-3**] 09:47AM NEUTS-70.5* LYMPHS-16.5* MONOS-10.4 EOS-2.1 BASOS-0.5 [**2157-9-3**] 09:47AM PT-14.5* PTT-24.1 INR(PT)-1.3* [**2157-9-3**] 09:47AM PLT COUNT-243 [**2157-9-3**] 03:00PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2157-9-3**] 03:00PM URINE RBC-8* WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 [**2157-9-3**] 10:51PM BLOOD Type-ART pO2-77* pCO2-43 pH-7.41 calTCO2-28 Base XS-1 . Labs on discharge [**2157-9-17**] 04:53AM BLOOD WBC-7.7 RBC-4.78 Hgb-13.8* Hct-42.4 MCV-89 MCH-28.8 MCHC-32.4 RDW-13.9 Plt Ct-228 [**2157-9-17**] 04:53AM BLOOD Glucose-136* UreaN-37* Creat-1.5* Na-140 K-4.6 Cl-104 HCO3-24 AnGap-17 [**2157-9-12**] 03:35AM BLOOD %HbA1c-6.3* eAG-134* . [**2157-9-3**] ECG: rate 60's normal QRS axis, difficult baseline but likely NSR due to regular RR; poor RWP, no clear ischemic changes. Compared to previous, nonspecific T waves changes are improved to normal appearing . CHEST (PORTABLE AP) Study Date of [**2157-9-3**] IMPRESSION: Findings consistent with moderate pulmonary edema. . CHEST (PA & LAT) Study Date of [**2157-9-15**] There is a right-sided PICC ending about 2-3 cm past the atriocaval junction. Recommend pulling this back by 2-3 cm. The cardiomediastinal silhouette is enlarged. There is bibasilar atelectasis with signs of pulmonary edema. Portable TEE (Complete) Done [**2157-9-13**] No thrombus/mass is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular vegetation or paravalvar abscess seen. UNILAT UP EXT VEINS US LEFT Study Date of [**2157-9-11**] IMPRESSION: Superficial thrombophlebitis involving the left forearm vein. No evidence of DVT in the left upper extremity. Micro- [**2157-9-10**] 5:45 am BLOOD CULTURE **FINAL REPORT [**2157-9-13**]** Blood Culture, Routine (Final [**2157-9-13**]): STAPH AUREUS COAG +. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 32647**], [**2157-9-10**]. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. Aerobic Bottle Gram Stain (Final [**2157-9-11**]): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2157-9-11**]): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. [**2157-9-10**] 9:43 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2157-9-13**]** Blood Culture, Routine (Final [**2157-9-13**]): STAPH AUREUS COAG +. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 32647**], [**2157-9-10**]. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. Aerobic Bottle Gram Stain (Final [**2157-9-11**]): GRAM POSITIVE COCCI IN CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2157-9-11**]): GRAM POSITIVE COCCI IN CLUSTERS. [**2157-9-10**] 8:50 am BLOOD CULTURE **FINAL REPORT [**2157-9-13**]** Blood Culture, Routine (Final [**2157-9-13**]): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final [**2157-9-11**]): Reported to and read back by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] @ 00:23A [**2157-9-11**]. GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2157-9-11**]): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. [**2157-9-11**] 3:32 pm BLOOD CULTURE **FINAL REPORT [**2157-9-15**]** Blood Culture, Routine (Final [**2157-9-14**]): STAPH AUREUS COAG +. SENSITIVITIES PERFORMED ON CULTURE # 330-7879T [**2157-9-10**]. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. Aerobic Bottle Gram Stain (Final [**2157-9-12**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2157-9-12**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Brief Hospital Course: 48yoM with h/o diastolic HF EF >55%, morbid obesity, OSA on home CPAP who presents with acute shortness of breath and CXR concerning for pulmonary edema. . 1. Acute on chronic diastolic heart failure: Upon arrival to the CCU the pt was on BiPAP for respiratory distress. CXR showed bilateral pulmonary edema. He was started on a Lasix IV drip as well as hydrochlorothiazide. He continued to diurese well. His weight decreased by approximately 30lbs during this admission. He was weaned off all supplemental O2 and at time of discharge he was sating well on room air. We changed his home diuretic from furosemide to torsemide 60mg daily. He was euvolemic on exam prior to discharge. He was continued on Aspirin 81mg, Pravastatin 40mg, Atenolol 100mg and Losartan 100mg daily. He was told to monitor his weight daily and try to limit fluid intake to 1.5L per day. 2. Bacteremia: Pt developed fevers, leukocytosis to 13 and a superficial thrombophlebitis/cellulitis around an IV site. The IV was pulled out and blood cultures were obtained. They were positive [**3-28**] for MSSA bacteremia. He initially was placed on Vancomycin but then narrowed to Nafcillin 2gm IV q4h. Once on antibiotic therapy his fevers and leukocytosis resolved. Infectious disease was made aware of his infection, they also agreed that the most likely source was the superficial thrombophlebitis/cellulitis site. A TEE was obtained which showed no evidence of masses/vegetations on any heart valves. A PICC line was placed for home administration of Nafcillin. His last day of antibiotic treatment will be [**2157-9-29**]. . 3. OSA on home Bipap: Home settings are 23/18, currently tolerating well. Will continue to use Bipap at night with sleep. . 4. Hypertension- We controlled the pt's blood pressure effectively with Losartan 100mg daily and Atenolol 100mg daily. We stopped amlodipine and Imdur due to episodes of hypotension. 5. Coronary Artery Disease- We continued Aspirin 81mg, Losartan 100mg, Pravastatin 40mg and Atenolol 100mg daily. 6. [**Name (NI) 32648**] Pt has follow up appointments with Dr. [**First Name (STitle) 437**] and his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11616**]. He was given an out pt lab script for a Chem-7 and CBC to be checked on [**2157-9-19**]. The results should be faxed to Dr. [**Last Name (STitle) 11616**]. Medications on Admission: 1. aspirin 81 mg 2. furosemide 40 mg daily 3. nicotine 21 mg/24 hr Patch 24 hr 4. atenolol 50 mg daily 5. amlodipine 10 mg daily 6. pravastatin 40 mg daily 7. losartan 100 mg daily 8. isosorbide mononitrate 120 mg ER daily 9. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath Discharge Medications: 1. potassium chloride 10 mEq Capsule, Extended Release Sig: Four (4) Capsule, Extended Release PO once a day. Disp:*120 Capsule, Extended Release(s)* Refills:*2* 2. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 4. ipratropium bromide 0.02 % Solution Sig: One (1) vial Inhalation every six (6) hours. 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 6. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 7. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) bag Intravenous Q4H (every 4 hours): Last day is [**2157-9-29**]. Disp:*78 doses* Refills:*0* 8. Outpatient Lab Work Please check chem-7, CBC on [**2157-9-19**] with results to Dr. [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 11616**] at Phone: [**Telephone/Fax (1) 7976**] Fax: [**Telephone/Fax (1) 13238**] 9. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day for 6 weeks. 11. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Acute on chronic systolic congestive heart failure Septicemia Hypertension Morbid Obesity Coronary artery disease Sleep Apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had an acute exacerbation of your congestive heart failure. You were admitted for intensive diuresis with lasix to remove the extra fluid. We have removed a total of 25 pounds and your weight at discharge is 512 pounds. One of your IV lines became infected and you had bacteria in your blood. You need to have intravenous antibiotics for a total of 2 weeks. Please call Dr. [**First Name (STitle) 437**] for any symptoms of shortness of breath or swelling as well. . We made the following changes in your medicines: 1. STOP taking amlodipine, furosemide, and imdur 2. Start taking nafcillin for the infection in your blood. The last day will be [**2157-9-29**] 3. START taking Torsemide to get rid of extra fluid 4. START Potassium to make up for potassium losses from the diuretics 5. Increase Atenolol to 100 mg daily Followup Instructions: . Department: CARDIAC SERVICES When: MONDAY [**2157-9-26**] at 3:00PM With: DR. [**Known firstname **] [**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: [**Hospital1 7975**] INTERNAL MEDICINE When: FRIDAY [**2157-9-30**] at 11:15 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "278.01", "V85.45", "428.33", "999.39", "999.2", "451.82", "428.0", "305.1", "038.11", "401.9", "584.9", "327.23" ]

icd9cm

[ [ [] ] ]

[ "88.72", "38.93" ]

icd9pcs

[ [ [] ] ]

14523, 14594

10519, 12871

286, 317

14764, 14764

3860, 10496

15763, 16533

2255, 2293

13265, 14500

14615, 14743

12897, 13242

14915, 15740

2308, 2322

3105, 3841

230, 248

345, 1764

2336, 3077

14779, 14891

1786, 1909

1925, 2239

18,458

167,538

1359

Discharge summary

report

Admission Date: [**2154-3-18**] Discharge Date: [**2154-4-2**] Date of Birth: [**2085-7-22**] Sex: M Service: GOLD SURGERY HISTORY OF PRESENT ILLNESS: This is a 68-year-old male with a chief complaint of presentation of epigastric pain times four hours. The patient related a history of waking up from sleep by sharp, nonradiating, constant epigastric pain. The patient stated that over the past week prior to admission, he had some recurrent episodes of hiccups and difficulty swallowing liquids and solids. The patient denied any vomiting, abdominal pain, chills, or chest pain. The patient denied any fevers. Normal bowel movement the evening prior to admission with no blood or melena. The patient stated that he has a history of metastatic endocrine tumor of pancreas which has been asymptomatic, and he has lost about ten pounds over the last six months and developed bilateral lower extremity edema over the past week prior to presentation. The patient has a history of peptic ulcer disease status post surgery in [**2143**] at the [**Hospital1 2025**]; procedure type was unclear, but may be a [**Name (NI) 8274**]. PAST MEDICAL HISTORY: Thymic carcinoid in [**2138**] status post resection, status post radiation therapy in [**2138**] at [**Hospital1 2025**]. Metastatic neuroendocrine tumor, possible metastasis from above, now new primary in the pancreas with bony mets to these areas, right shoulder, pelvis, bilateral femurs. The patient has been followed for the slowly progressing tumor by Dr. [**First Name (STitle) **]. He also has coronary artery disease status post stent to left anterior descending in [**2146**]. [**Year (4 digits) 8274**] procedure for peptic ulcer disease. Insulin-dependent diabetes mellitus. Hypercholesterolemia. MEDICATIONS ON ADMISSION: Aspirin, Lovastatin, Lopressor, Multivitamin, Insulin. ALLERGIES: Penicillin. SOCIAL HISTORY: No alcohol use. Intermittent smoking history. PHYSICAL EXAMINATION: Vital signs: On presentation exam revealed a temperature of 96??????, afebrile, vital signs were stable except for tachycardia. General: The patient was alert and oriented but ill-appearing. Lungs: Clear to auscultation bilaterally. Heart: Tachycardiac. No murmurs, rubs, or gallops. Abdomen: Nondistended, soft, tender to percussion and palpation. There was a diffusely present mass of the epigastrium. Rectal: Negative mass. Heme positive. LABORATORY DATA: White count 6, hematocrit 37, down to 30.1 on presentation, platelet count 600 from 186 on his last presentation a year ago; LFTs with an ALT of 69, AST 29, alkaline phosphatase 122, total bilirubin 0.4. Chest x-ray revealed free air under the right diaphragm, recommended exploratory laparotomy. PREOPERATIVE DIAGNOSIS: The patient went to the Operating Room with perforated viscus. POSTOPERATIVE DIAGNOSIS: The patient went to the Operating Room with perforated viscus. OPERATION PERFORMED: Exploratory laparotomy, Roux-en-Y gastroenterostomy. FINDINGS: Perforation of base of gastroenterostomy, anastomotic ulceration, free air, free gastric fluid throughout, no evidence of wide-spread malignancy. HOSPITAL COURSE: The patient was taken to the SICU where he was maintained intubated and sedated. On postoperative day #1, the patient was weaned off Levofloxacin. A Swan was placed, and fluid boluses were given due to the patient's low urine output. Levofloxacin was added. The patient was given 2 U packed red blood cells. The patient otherwise continued to be monitored and was stable. Chest x-ray on postoperative day #3 revealed a wet read. The patient was given Lasix on postoperative day #4 supplemented with diuresis, and the patient's fluid positive status. TPN was recommended the following day for the patient's nutritional status. Cardiology was consulted due to the patient's worsening pulmonary status and question of congestive heart failure. The patient was started on Enalapril secondary to these results. The patient responded well to Lasix and began to diurese. The patient continued to diurese well. He was placed on Insulin for sugar control. The patient was extubated on postoperative day #10 and started on Diamox and was diuresed at that point. The patient was transported to the floor later on that day. He received physical therapy for strengthening, balance training, mobility training, and postural drainage Otherwise the patient on the floor was stable. The rest of his hospital stay was uncomplicated. His p.o. intake began to improve gradually, as he was started on regular diet, and a calorie count revealed that the patient took in 50-60% of estimated caloric need and 40% of estimated protein need. The plan was for the patient to be discharged on TPN, which he will received half bag with the eventual goal of weaning the patient off TPN completely, as his p.o. intake improves. The patient will be discharged to a long-term care facility where he will receive physical therapy. The patient is to follow-up with Dr. [**Last Name (STitle) **] within two weeks. DISCHARGE MEDICATIONS: Heparin, Albuterol p.r.n., Protonix 40 mg 1 tab q.d., Percocet p.r.n., Captopril 25 mg 1 tab b.i.d., Insulin according sliding scale, Ambien 5 mg 1 tab p.o. h.s., Lasix 20 mg 1 tab t.i.d., Lopressor 50 1 tab b.i.d. with hold parameters, TPN electrolytes. DISCHARGE DIAGNOSIS: Perforated viscus status post exploratory laparotomy, bowel resection, and Roux-en-Y gastroenterostomy. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8275**] Dictated By:[**Name8 (MD) 8276**] MEDQUIST36 D: [**2154-4-2**] 09:16 T: [**2154-4-2**] 09:34 JOB#: [**Job Number 8277**]

[ "414.01", "428.0", "V45.82", "198.5", "197.1", "157.2", "250.00", "531.50", "997.4" ]

icd9cm

[ [ [] ] ]

[ "99.15", "99.04", "54.4", "43.7", "45.62", "38.93" ]

icd9pcs

[ [ [] ] ]

5117, 5373

5395, 5757

1820, 1901

3194, 5093

1989, 3176

173, 1154

1177, 1793

1918, 1966

4,787

148,689

2555

Discharge summary

report

Admission Date: [**2127-6-7**] Discharge Date: [**2127-6-14**] Date of Birth: [**2044-1-3**] Sex: M Service: MEDICINE Allergies: Meropenem / Penicillins Attending:[**First Name3 (LF) 800**] Chief Complaint: GI Bleed. Major Surgical or Invasive Procedure: [**2127-6-7**] Transfusion of one unit of packed red blood cells [**2127-6-13**] Colonoscopy History of Present Illness: Mr. [**Known lastname 12731**] is an 83 year old male with past medical history of atrial fibrillation, ESRD on HD, history of gastrointestinal bleeding, . . Today, while at rehabilitation at [**Hospital1 **], he was noted to have several bowel movements with bright red blood and clots, at least three witnessed episodes of about 200 cc total. Around that time, his systolic blood pressure was reported to be in the 70's. He was given 1000 cc of NS prior to transfer. He initially presented to [**Hospital6 12736**], where he received one unit of PRBC's and two liters of IVF. His HCT there was found to be 26.7. . In the ED, initial vital signs were notable for a blood pressure of 89/52. At time of arrival to [**Hospital1 18**], he had received four liters of IVF. NG placement for lavage was attempted, however patient refused. While in the ED at [**Hospital1 18**], he had no further episodes of bleeding, however rectal exam was notable for bright red blood. Due to concerns over some possible guarding, at CT abdomen was completed. GI was consulted from the ED as well. In the [**Hospital1 18**] ED, he received one unit of PRBC and 500 cc of NS. . He also received 1 gram of vancomycin, 400 mg of IV ciprofloxacin, and 500 mg of IV flagyl after his urine was noted have an appearance "of pus." . On the floor, he reports that he feels "okay," and has no complaints. Past Medical History: - ESRD on HD Tuesday/Thursday/Saturday - Atrial fibrillation, not on anticoagulation - h/o GI bleeds, diverticulitis - C. Diff colitis - h/o CVAs (two, with residual right-sided weakness) - h/o nephrolithiasis w/ stent and nephrostomy tube - CAD s/p MI - Sleep apnea (not on CPAP) - Depression - PFT's [**2117**] with mild restrictive ventilatory defect - Anemia with h/o iron deficiency - Recent fall with C2 dens fracture with anterior displacement ([**4-/2127**]) - Numerous line infections, most recently MRSA [**4-/2127**] which was treated with Vancomycin until [**2127-5-10**] (also with MRSA [**8-/2125**], ESBL E. Coli [**9-/2125**], [**11/2125**], [**6-/2126**], and [**7-/2126**]) - Delirium during hospital admissions - COPD and restrictive lung disease - Common bile duct stone s/p stenting [**10/2126**] - Urinary tract infections, including VRE and Klebsiella, with urosepsis Social History: Patient recently has been at rehabilitation since fall and C2 fracture. Lives with wife [**Name (NI) **], daughter lives downstairs, h/o smoking [**12-21**] PPD for 50 years, quit 20 years ago, occasional beer, none recently, no drugs. Family History: Non-contributory. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on admission: [**2127-6-7**] 04:00PM PT-14.5* PTT-34.1 INR(PT)-1.3* [**2127-6-7**] 04:00PM PLT COUNT-252 [**2127-6-7**] 04:00PM NEUTS-86.3* LYMPHS-9.3* MONOS-3.6 EOS-0.7 BASOS-0.2 [**2127-6-7**] 04:00PM WBC-10.8 RBC-3.21* HGB-9.4* HCT-30.4* MCV-95 MCH-29.4 MCHC-30.9* RDW-18.8* [**2127-6-7**] 04:00PM ALBUMIN-2.3* CALCIUM-8.7 PHOSPHATE-2.6*# MAGNESIUM-1.8 [**2127-6-7**] 04:00PM cTropnT-0.04* [**2127-6-7**] 04:00PM ALT(SGPT)-6 AST(SGOT)-13 LD(LDH)-129 ALK PHOS-116 TOT BILI-0.4 [**2127-6-7**] 04:00PM estGFR-Using this [**2127-6-7**] 04:00PM GLUCOSE-92 UREA N-27* CREAT-3.4*# SODIUM-137 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14 [**2127-6-7**] 04:08PM LACTATE-0.7 [**2127-6-7**] 05:50PM URINE RBC-[**11-8**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [**2127-6-7**] 05:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN->300 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0 LEUK-LG [**2127-6-7**] 05:50PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025 MICROBIOLOGY: - [**2127-6-7**] Blood culture - no growth - [**2127-6-7**] Blood culture - no growth - [**2127-6-7**] Urine culture - Klebsiella oxytoca KLEBSIELLA OXYTOCA sensitivities: AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING/STUDIES: ECG [**2127-6-7**]: Baseline artifact. Sinus versus ectopic atrial rhythm. Borderline P-R interval prolongation. Left axis deviation. Consider left anterior fascicular block of right bundle-branch block type. Since the previous tracing of [**2127-4-29**] the rate is slower and the axis is less left superior. The QRS complex is narrower. ST-T wave abnormalities are improved. CXR [**2127-6-7**]: FINDINGS: Portable AP view of the chest was obtained. A dialysis catheter is again noted with its tip in the region of the superior vena cava. There is a vascular stent traversing the left brachiocephalic vein. Low lung volumes limit the evaluation. Cardiomegaly is again noted with scattered bilateral reticular lung opacities, which appear grossly stable compared with multiple prior exams. Possibility of mild congestion cannot be entirely excluded, though there is no overt CHF. A small left-sided pleural effusion cannot be excluded as well. Mediastinal contour is grossly stable. No pneumothorax is seen. Bony structures are unchanged with degenerative changes of the left shoulder and right humeral head prosthesis. Degenerative changes are also noted in the spine. IMPRESSION: Cardiomegaly, possible mild fluid overload. CT abdomen/pelvis [**2127-6-7**]: IMPRESSION: 1. No evidence for mesenteric ischemia. 2. Colonic diverticulosis, without evidence for diverticulitis. 3. Stable focal dissections in distal abdominal aorta and left common iliac extending in to the proximal left external iliac artery. Stable fusiform aneurysm of the left common iliac artery. 4. Thickened bladder wall. Correlate clinically with evidence of urinary tract infection. 5. Heterogeneous renal enhancement, compatible with multiple small renal cysts in the setting of hemodialysis, unchanged from prior study. 6. Nodular liver again suspicious for cirrhosis. Stable pneumobilia suggesting prior biliary intervention. Colonoscopy [**2127-6-13**]: severe diverticulosis Brief Hospital Course: Mr. [**Name14 (STitle) 12946**] is an 83 year old male with past medical history of ESRD on HD, atrial fibrillation, HD line infections, and prior GI bleeds who presented with bright red blood per rectum. #) Bright red blood per rectum: Concerning for lower GI bleed (though cannot exclude upper source), given history of similar episodes in past. Last colonoscopy was [**2123**], at which time diverticulosis was seen along with an abnormal patch of mucosa in the rectum and a rectal polyp. EGD in [**2122**] was normal. Differential included repeat diverticular bleed, AVM, malignancy, among other causes. NG lavage refused by patient. The patient received 1 unit of pRBCs on arrival, with subsequent stabilization in Hct to ~30. IV PPI was started, 2 large bore IVs placed. GI team was consulted, and did not see any urgent need to scope. The patient was transferred to the medicine floor. Spine consult was called prior to EGD, with recommendation for keeping head in neutral position throughout procedure. Colonoscopy was performed which revealed severe diverticulosis which was deemed causative factor for bleed and EGD therefore not indicated. Hct trend stable at time of discharge. #) ESRD: Received HD while an inpatient. There was initial concern for fluid overloaded state given all 4L IVF given on the floor and 2 units of PRBC's that he received. He was taken to HD on [**6-9**] (instead of usual [**6-10**]). He was continued on nephrocaps, calcium acetate, midodrine prior to dialysis, and darboetin weekly. Last HD was on morning of discharge, [**6-14**] with plan to resume HD on tuesday, thursday, saturday schedule. #) History of recurrent UTI's: Urine analysis on arrival was concerning for infection. He has a history of numerous pathogens that are resistent (VRE, ESBL klebiella). He received vanco/cipro/flagyl in ED, and was continued on cipro/daptomycin in MICU while awaiting culture data; culture grew sensitive Klebsiella oxytoca. He was started on a 7 day course of Bactrim. He had no fever, hypothermia, or leukocytosis to suggest SIRS/sepsis (initial hypotension was attributed to bleeding episodes). #) Atrial fibrillation: Not on anticoagulation for history of bleeding. Rate well controlled. #) Coronary artery disease: Aspirin was initially held, then restarted once Hct became stable just prior to MICU callout. #) Hyperlipidemia: Atorvastatin continued. #) Access: PICC line placed #) Contact: Wife [**Name (NI) **] [**Name (NI) 12731**] - home ([**Telephone/Fax (1) 12947**], cell ([**Telephone/Fax (1) 12948**] #) Code: Full (discussed with patient) Medications on Admission: (per documentation from Spaudling) - Acetaminophen 975 mg TID - ASA 81 mg - Atorvastatin 10 mg - Calcium acetate 1334 mg TID - Ciprofloxacin 250 mg after hemodialysis - Cyanocobalamin 100 mcg daily - Darbepoetin alfa 200 mcg qWednesday - Ferrous sulfate 325 mg daily - Miconazole powder - Midodrine 10 mg M/W/F 1 hour prior to dialysis - Nephplex tablet daily (Nephrocap) - Omeprazole 20 mg daily - Tiotropium 10 mcg daily - Tramadol 25 mg [**Hospital1 **] - Trazodone 25 mg QHS - Oxycodone 2.5 mg prior to PT - Albuterol nebulizer PRN - Docusate 100 mg [**Hospital1 **] - Polyethylene glycol 17 grams PRN - Senna PRN Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO Tues-Thurs-Sat: Gibe one hour prior to dialysis. 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**12-21**] Inhalation Q6H (every 6 hours) as needed for shortness of breath. 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 days: Please take medication through [**6-15**] to complete treatment for UTI. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **] Discharge Diagnosis: PRIMARY: - Gastrointestinal bleed - Hypotension - Urinary tract infection SECONDARY: - End-stage renal disease on dialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were transferred to [**Hospital1 69**] after several episodes of rectal bleeding. You received 1 unit of blood after your arrival, and your blood levels stabilized. You were seen by the gastroenterology service, and underwent a colonoscopy which showed extensive diverticulosis. A urine test showed evidence of infection, so you were started on antibiotics. A hepatitis panel was checked for you before your return to our outpatient dialysis unit which was all negative. We have made the following changes to your medication regimen: - BEGAN TAKING Bactrim for UTI. You will continue to take this medication for a total of 7days with the last day being [**6-15**]. Please continue to take your medications as prescribed. Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**] When: MONDAY [**2127-7-21**] at 1:30 PM With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1579**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2127-6-14**]

[ "562.10", "V45.11", "599.0", "285.9", "569.0", "041.3", "427.31", "412", "311", "585.6", "578.9", "272.4", "496", "414.01" ]

icd9cm

[ [ [] ] ]

[ "45.25", "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

11335, 11429

7062, 9665

291, 387

11597, 11597

3493, 3498

12524, 13035

2974, 2993

10333, 11312

11450, 11576

9691, 10310

11773, 12501

3008, 3474

242, 253

415, 1791

3512, 7039

11612, 11749

1813, 2705

2721, 2958

29,504

181,564

7257

Discharge summary

report

Admission Date: [**2130-6-28**] Discharge Date: [**2130-7-6**] Date of Birth: [**2052-7-23**] Sex: M Service: MEDICINE Allergies: Antihistamines Attending:[**First Name3 (LF) 3984**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: lumbar puncture History of Present Illness: 77M with CLL, CAD, afib, CRI, DM1 presents with 2 days of worsening confusion. He is normally completely oriented and sharp. Over the course of 2 days, his mental status declining from mistaking the time of day to the point that he was noted to have 2 sets of clothes on. His family reports that the patient only c/o fatigue, decreased appetite the week leading up to the hospitalization. He had no fever, chills, HA, abdominal sxs, respiratory sxs, sick contacts. [**Name (NI) **] had seen his PCP, [**Name10 (NameIs) 1023**] took a CXR that was reportedly clear and recommended CT torso, which the pt declined. When the pt did not improve, his family brought him to ED where his vitals were 97.3, 95, 129/61, 19, 96% RA. He received a CXR, a CT head, and labs which were all unrevealing. LP was deferred initially due to elevated INR. On HD#2, the pt underwent LP by the neurology consult service and was found to have 2375 WBCs which were 99% lymphocytes, protein of 212, and glucose of 128. Neurology felt this was c/w meningitis, possibly carcinomatous. He was started on vanc/ceftriaxone/amp/acyclovir. Oncology was consulted and reviewed the CSF with Heme path and felt that the CSF was c/w reactive lymphocytosis, NOT carcinomatous meningitis, (flow cytometry showed 99% reactive lymphocytosis and 1% CLL cells). During this hospitalization his mental status has deteriorated rapidly. Pt's family reported that he walked into the ED and was able to answer questions appropriately. This gradually deteriorated to only recognizing his family members on the floor to keeping his eyes shut, moaning, and grimacing on arrival to the ICU. Past Medical History: PMH: 1.) CLL - diagnosed in [**2122**] - s/p intermittent chlorambucil and Epo 2.) DM I, insulin-pump 3.) afib, s/p cardioversion 4.) HTN 5.) CAD 6.) Hyperuricemia 7) Pneumonia 8) CKD ([**Year (4 digits) 5348**] cr. 1.6-1.8) 9) LE edema . PSH: 1.) s/p sx for tooth infection with abscess ([**2123**]) 2.) fx of right shoulder Social History: Lives in [**Location 620**] with his wife. Independent with ADLs. Former pipe and cigar smoker. Quit 8 years ago. Never smoked cigarettes. Social EtOH. Swimmer and tennis player. No recent travel within the last 6 months. Family History: Mother died of MI in 90s. Further fam hx unknown . Physical Exam: Vitals: T: 100.4, P: 86, BP: 108/71, O2: 96% RA General: eyes shut, moaning, groaning, tremulous HEENT: eyes shut tight, exudates bilaterally, MM dry Neck: No LAD or thyromegaly appreciated Heart: [**Last Name (un) **], 2/6 SEM noted Lungs: coare rhonchi bilaterally Abd: +BS, soft, NT/ND, no masses or HSM noted Ext: [**2-8**]+ LE edema, family states chronic Neuro: Unresponsive to commands, does not open eyes, moans, withdraws to pain in all 4 extremities, good muscle tone in all 4 extremities, DTR 2+ in bilateral patella and biceps, tremulous in all 4 extremities (worse than [**Month/Day (2) 5348**] per family). No asterixis or clonus. Equivocal babinski. Skin: No rashes Pertinent Results: Admission labs: [**2130-6-28**] 11:20AM WBC-65.8*# RBC-4.27* HGB-11.6* HCT-35.4* MCV-83 MCH-27.1 MCHC-32.7 RDW-16.6* [**2130-6-28**] 11:20AM NEUTS-10* BANDS-0 LYMPHS-80* MONOS-5 EOS-1 BASOS-0 ATYPS-4* METAS-0 MYELOS-0 [**2130-6-28**] 11:20AM PLT SMR-NORMAL PLT COUNT-194 [**2130-6-28**] 11:20AM PT-24.8* PTT-28.2 INR(PT)-2.4* [**2130-6-28**] 11:20AM GLUCOSE-289* UREA N-43* CREAT-1.8* SODIUM-135 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-24 ANION GAP-17 [**2130-6-28**] 11:20AM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-2.1 [**2130-6-28**] 11:20AM ALT(SGPT)-12 AST(SGOT)-19 LD(LDH)-463* CK(CPK)-69 ALK PHOS-95 TOT BILI-1.0 [**2130-6-28**] 11:20AM TSH-5.7* [**2130-6-28**] 11:20AM DIGOXIN-0.8* . CXR [**2130-6-27**]: Significant interval decrease in the moderate right pleural effusion. Unchanged right middle and lower lobe atelectasis. . Sinus CT [**2130-6-28**]: 1. Chronic sinus disease with opacification and remodeling of the left sphenoid sinus and posterior ethmoid air cells, with the appearance of a mucocele in an Onodi cell in the region of the left orbital apex. 2. Right second bicuspid ([**Doctor First Name **] #4) periapical abscess, with reactive changes in the floor of that maxillary antrum. . Head CT [**2130-6-28**]: 1. No evidence of hemorrhage or vascular territorial infarction. 2. Global atrophy. 3. Chronic left sphenoid and ethmoid sinusitis, better evaluated on concurrent maxillofacial CT. . Head MRI [**2130-6-30**]: 1. No enhancing brain parenchymal lesion or acute infarcts identified. 2. Tiny right frontoparietal subdural hematoma with maximum width of approximately 3 mm with pachy-meningeal enhancement, which could be secondary to the subdural collection or secondary to lumbar puncture. 3. Subtle leptomeningeal signal at the right frontal convexity on FLAIR images without enhancement is as a non-specific finding and could be due to vascular enhancement or an early sign of leptomeningeal disease. 4. Mild-to-moderate changes of small vessel disease. 5. Soft tissue changes due to inspissated secretions in the left posterior ethmoid air cells and left sphenoid sinus, which could be secondary to obstructive sinusitis. Brief Hospital Course: 77-year-old man with a with history of CLL, atrial fibrillation, type 1 diabetes mellitus presented with 2 days of worsening confusion and disorientation. . # Acute mental status changes: Lumbar puncture, neuroimaging studies, metabolic work-up, extensive infectious disease work-up revealed no apparent etiology for his altered mental status. Infectious Diseases, Hematology-Oncology, Neurology were consulted. He was empirically treated with broad-spectrum antimicrobials as well as IVIG for hypogammaglobulinemia. However, his clinical status continued to deteriorate, and the family decided to changed his code status to DNR/DNI and comfort measures only. The patient expired on [**2130-7-6**]. Medications on Admission: Enalapril 5mg Coumadin 2mg Lasix 20mg Allopurinol 300mg Ambien 5mg Spironolactone/HCTZ 25/25 mg daily Digoxin 250 mcg every other day Novolog Pump Discharge Disposition: Expired Discharge Diagnosis: Expired. Discharge Condition: Expired. Discharge Instructions: Expired. Followup Instructions: Expired. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "522.5", "427.31", "279.00", "473.9", "790.6", "204.10", "V66.7", "428.0", "585.9", "250.00", "049.9", "V15.82", "270.6", "403.90" ]

icd9cm

[ [ [] ] ]

[ "99.14", "96.71", "96.04", "96.6", "03.31" ]

icd9pcs

[ [ [] ] ]

6458, 6467

5560, 6260

296, 313

6519, 6529

3358, 3358

6586, 6723

2589, 2641

6488, 6498

6286, 6435

6553, 6563

2656, 3339

235, 258

341, 1984

3374, 5537

2006, 2333

2349, 2573

3,212

101,466

26204

Discharge summary

report

Admission Date: [**2177-2-1**] Discharge Date: [**2177-2-25**] Date of Birth: [**2119-4-5**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: intra cranial bleed Major Surgical or Invasive Procedure: Right occipital craniotomy for cerebellar bleed evacuation. History of Present Illness: Pt is a 57y/o M who was in his USOH until this morning when he was noted to have a HA and then collapsed. He was responsive at the scene (GCS 15) and taken by EMS to OSH where his mental status deteriorated and he was intubated. CT revealed a 4.3 cm hemorrhage in the R cerebellum. He was then transferred to [**Hospital1 18**] for further management. Past Medical History: HTN, nasal polyps. Social History: Occasional cigars, no cigarette smoking hx; occasional etoh on weekends, no other drugs, no supplements. Lives with wife, works in research and development for electronics company. Family History: unknown Physical Exam: PE:HR 62, BP 193/106, RR 14 on CMV, SaO2 100% on FiO2 100% Gen: Intubated in NAD HEENT: no signs of trauma, no racoon eyes, no battle sign, anicteric sclera CV: rrr Pulm: LCTA b/l Abd: soft NT ND BS present Neuro: Moves only lower extremities. Withdrawls lower extremities to pain but does not follow commands. Pupils fixed and constricted ~2mm. No dolls eye reflex, corneal reflex present only on the left side. Pertinent Results: [**2177-2-1**] 03:15PM PT-12.2 PTT-20.8* INR(PT)-1.0 [**2177-2-1**] 03:15PM PLT COUNT-275 [**2177-2-1**] 03:15PM NEUTS-90.5* BANDS-0 LYMPHS-6.3* MONOS-2.9 EOS-0.1 BASOS-0.1 [**2177-2-1**] 03:15PM WBC-18.1* RBC-4.79 HGB-15.0 HCT-41.7 MCV-87 MCH-31.2 MCHC-35.9* RDW-12.9 [**2177-2-1**] 03:15PM GLUCOSE-206* UREA N-21* CREAT-1.0 SODIUM-145 POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-21* [**2177-2-1**] 03:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG Brief Hospital Course: [**Known firstname **] [**Known lastname 64942**] is a 57 year-old male with right cerebellar bleed initially he was lucid at the scene then quickly detorioted requiring intubation where he admitted to neuro ICU unit, started on dexamethasone and dilantin. He was taken to OR on [**2177-2-1**] for occipital craniotomy for right cerebellar hematoma evacuation with a ventriculostomy placement without intraoperative complications. Patient transferred back to ICU for hemodynamic and neurologic monitoring. Immediate post-op neuro exam: pupils were reactive bilaterally, no eye opening, extensor posturing on bilateral upper extremities, with a flexion on bilateral lower extremities. Post operative MRI requested on postop day two to evaluate for infarction, given that his neurologic exam was not improving. MRI of the brain showed no infarct besides some compression of the brainstem at the level of the pons, therefore neurology consulted regarding "locked in syndrome". Neurology team felt that patient demonstrated some elements of locked in syndrome with preserved vertical eye movements and blinking, and comprehension without motor activity. If the compression of the brain stem is related to cerebral edema there is a chance for him to regain his fucntions as edema resolves. Neurology recommended a repeat MRI to evaluate cerebral edema on [**2-5**] without significant change in the appearance of edema, no mannitol was given. Over subsequent hospital stay, his neuroloigcal status slowly but gradually improved. [**2177-2-6**] IVC filter palced for DVT prophylaxis since he cannot be anticoagulated and possible prolonged hospitalization/rehabilitation without any complication. On [**2177-2-8**] patient started spiking fever up to 103 which continued until [**2177-2-18**] without a clear source all of his cultures were negative, HBV/HCV neg, ([**2-8**])CSF negative, except sputum culture grew E COLI. Empiric triple antibiotic coverage initiated, and infectious disease consulted. Patient had bouts of diarrhea requiring rectal bag, cdiff was negative several assays. ID recommeneded continue metronidazole total of 14 days despite negtive c-diff on stool. His external ventricular drain removed on [**2177-2-10**]. Serial Head CT' obtained to evaluate interval change in brain. On [**2-11**] head CT showed Status post removal of the right-sided ventricular catheter without evidence for hydrocephalus seen. Resolving right-sided cerebellar and intraventricular hemorrhage. Persistent low density in the right cerebellar hemisphere, which could either represent a small evolving infarct or residual edema.Suboccipital craniectomy staples removed on [**2177-2-11**]. [**2177-2-12**] patient had bedside trache placement Size#8 without any complications, gradually weaned FiO2 as tolarated. PEG palced on [**2177-2-19**] with out a complication, able to tranfer stepdown floor on [**2-20**].on [**2-21**] LENI Right upper and BLE lower neg for DVT, changed to floor status on [**2-22**]. Upon discharge, patient had almost full strength and use of his left side, right side had decreased strength (about 1-2/4), nystagmus had disappeared, had good eye movement, was OOB to chair for a good portion of the day, communicated via mouth wording followed commands, was on 35% trahc collar mask and was at full strength tube feeds. PT & OT re-evaluated patient just before discharge for rehab recommendations. Patient evaluated by speech pathologist regarding [**Last Name (un) 64943**] muir valve, which was failed this may be due to the trach being too large to get adequate airflow to the vocal cords, &/OR upper airway edema, &/OR impaired vocal cord mobility or closure. His trache needs to down sized at rehab in order to use [**Last Name (un) 64943**] muir valve, if problem is continued should followed with ENT. Patient will f/u with stroke team as an outpt, and f/u w/[**Doctor Last Name **] 3 months in office. Medications on Admission: Toprol, HCTZ, Lisinopril Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection twice a day. 5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 7. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every 8 hours) as needed. 8. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days: needs through wed [**2-26**]. 12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Intraparenchymal cerebellar hemorrhage with incipient herniation. Discharge Condition: good Discharge Instructions: please seek medical attention if you experience fever > 101.5, severe nausea/vomitting/pain/dizziness; new or increased numbness/tingling/paralysis please take new medications as directed please keep foloow-up appointment please work with physical therapy to improvement range of motion, strength, speech Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 3months with Ct call [**Telephone/Fax (1) 1669**] for appt. Follow up with stroke neurology call [**Telephone/Fax (1) 7207**] for appt. Completed by:[**2177-2-25**]

[ "431", "787.91", "780.6", "401.9", "518.81", "348.4", "790.5" ]

icd9cm

[ [ [] ] ]

[ "01.24", "01.39", "38.93", "31.1", "02.2", "43.11", "88.51", "01.18", "02.12", "96.6", "38.7" ]

icd9pcs

[ [ [] ] ]

7183, 7253

2056, 6000

337, 398

7364, 7371

1501, 2033

7727, 7942

1041, 1051

6076, 7160

7275, 7343

6026, 6053

7395, 7704

1066, 1482

278, 299

426, 783

805, 825

841, 1025

2,958

119,050

54250

Discharge summary

report

Admission Date: [**2180-4-16**] Discharge Date: [**2180-4-25**] Date of Birth: [**2108-4-21**] Sex: M HISTORY OF PRESENT ILLNESS: Briefly, this is a 71-year-old male with a history of non-Hodgkin lymphoma diagnosed in [**2170**], status post CHOP treatment, in remission, also with hypertension who presented to the Emergency Department with The patient reported that the abdominal pain, fevers, and sweats began approximately three weeks prior to admission. The pain was noted to be in his abdomen just below his rib cage; mostly localized near his umbilicus. The patient was noted to be dull and constant and without significant change during eating. The patient did notice some anorexia and also feverish on and off and had chills and sweats at night. He saw his primary care provider approximately one week prior to admission who put the patient on Prevacid. Shortly after that, he developed diarrhea which seemed to get worse when he ate. The last two days prior to admission, the patient had been on business in [**Location (un) 5354**]. The pain was disabling. He called his physician who told him to return to [**Location (un) 86**] to seek treatment. On review of systems, it was noted the patient had approximately a 13-pound weight loss. Given the patient's abdominal pain, a CT scan was obtained in the Emergency Department which revealed a thrombus of the superior mesenteric vein. PAST MEDICAL HISTORY: 1. Non-Hodgkin lymphoma; treated in [**2170**] with seven cycles of CHOP; noted to be remission. 2. High cholesterol. 3. Hypertension. MEDICATIONS ON ADMISSION: 1. Lipitor 10 mg p.o. q.d. 2. Avapro (question dose). 3. Prevacid (question dose). ALLERGIES: He has no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, in the Emergency Department, the patient had a temperature of 99.8, pulse was 85, blood pressure was 134/57, respiratory rate was 16, oxygen saturation was 96. Generally, he was noted to be alert and oriented times three, in no apparent distress. His head and neck examination showed moist mucous membranes without scleral icterus. His neck had no jugular venous distention. No thyroid was palpable. The lungs were clear to auscultation bilaterally. His cardiovascular examination showed an irregular rhythm, a soft 2/6 systolic ejection murmur. His abdomen was soft, nontender, and nondistended, without hepatosplenomegaly. His lower extremities demonstrated no cyanosis, clubbing or edema. Lymph nodes demonstrated no neck, axillary, or groin lymphadenopathy. PERTINENT LABORATORY DATA ON PRESENTATION: On admission the patient was noted to have white blood cell count of 15.7, hematocrit was 28.7, and platelet count of 213. The differential on the patient's white blood cell count showed 84.5 neutrophils, 11.1 lymphocytes, 4.3 monocytes, 0.1 eosinophils, 0.1 basophils. The patient's coagulations showed a slightly elevated INR of 1.3. The patient's urinalysis was negative on admission. Electrolytes on admission demonstrated sodium was 133, potassium was 3.7, blood urea nitrogen was 23, creatinine was 1.2. The patient's liver function tests were essentially normal with a total bilirubin of 1.4, and a lipase of 35, transaminase was slightly elevated. Albumin was 3.7, calcium was 9.4, phosphorous was 3.6, magnesium was 1.6. HOSPITAL COURSE: The patient was admitted for workup of the abdominal mass noted on CT scan, for treatment of diarrhea, and for evaluation of superior mesenteric vein clot. The patient was begun on a heparin drip for anticoagulation. On admission, the Medicine Service and the Vascular Surgery Service were consulted. A CT scan was reviewed. It was thought superior mesenteric vein thrombosis necessitated a heparin drip for anticoagulation. The patient would need a hypercoagulable state workup. The Vascular Surgery Service also recommended a CT angiogram of the abdomen to be obtained to delineate the pancreatic area given a small amount of stranding seen around the pancreas, there was a question it may be an abdominal mass versus a recurrent of his non-Hodgkin lymphoma. On [**2180-4-17**] the patient was admitted to the General Medicine Service. His abdominal examination was felt to be benign. There was no obvious reason for the superior mesenteric vein thrombosis. Overnight from [**4-16**] to [**4-17**], there was a small amount of mild epigastric tenderness noted. On [**2180-4-17**] the patient's hematocrit was noted to be decreased to a value of 25. It was decided at that point to transfuse 2 units of packed red blood cells to the patient; although, there was no hematuria or bright red blood per rectum, and there was no obvious source for his bleeding. On [**2180-4-17**], a CT angiogram was obtained. This CT angiogram demonstrated a prominent periaortic lymph node in the chest which were consistent with old lymphomatotic disease. There was also a large lymph node in the right inguinal region which was immediately adjacent to the femoral artery and vein which was not producing any venous occlusion. There was noted to a large infiltrate of soft tissue density within the mesentery with encasement and thrombosis of the superior mesenteric vein. The infiltrate of soft tissue could be lymphoma neural residual which would cause thrombosis of the superior mesenteric vein. Alternatively, the changes could be inflammation secondary to the venous occlusion. The presence of multiple lymph nodes within the retroperitoneum was noted which also favor lymphoma with secondary thrombosis. A deep venous thrombosis was noted within the pancreas, but there were no other secondary signs of pancreatitis, although there was a small amount of stranding on the original CT scan when the patient was admitted. There was no evidence of small bowel inflammation or ischemia. Overnight from [**4-17**] to [**4-18**], the patient was thought to be clinically improving somewhat. On [**4-18**], the patient continued to do well with no dramatic changes in his laboratory values. It was noted that 4/8 bottles from his blood cultures from the [**4-16**] were growing gram-negative rods in the anaerobic bottles. The urine culture was negative, as was his stool Clostridium difficile culture. On the [**4-18**], the patient was continued on his heparin drip; however, it was decided to start anticoagulation of the patient with Coumadin on [**4-18**]. The patient was transfused an additional unit of packed red blood cells at this time. The patient was on levofloxacin on day three of admission. It was decided given his positive blood cultures to add ceftazidime q.8h. until the sensitivities and speciation were obtained. On [**2180-4-18**], the Blue Surgical Service of Dr. [**Last Name (STitle) **] was consulted to see the patient by the Vascular Surgery Service given a question of soft tissue density within enhancement and thrombosis of the superior mesenteric vein. Of note, the portal vein was patent on the CT scan, however. At that time, the medical history was reviewed by the Blue Surgery Service. As noted, the patient was a 71-year-old male with a past history of non-Hodgkin lymphoma and superior mesenteric vein thrombosis of unclear etiology. On [**2180-4-19**], per the Blue Surgery Service, it was felt the patient would benefit from going to the angiography suite for thrombolysis of the clot in the superior mesenteric vein, and the patient was to be transferred to the Intensive Care Unit status post procedure with continuous infusion of t-PA to keep the superior mesenteric vein open. On [**2180-4-19**], the patient underwent a retrograde thrombolytic therapy procedure. During this procedure, a successful transhepatic recanalization of the superior mesenteric vein using angioplasty and thrombolysis was done. An infusion catheter was placed in the superior mesenteric vein for overnight infusion of t-PA. Following this procedure, the patient was noted to have a hematocrit of 29.2. The patient was transferred status post procedure to the Trauma Surgery Intensive Care Unit. The patient's t-PA drip was noted to be going at 0.5 mg per hour in addition to 200 units of heparin being transfused intravenously per hour. This procedure was complicated by a transient occlusion with thrombolysis catheter which demonstrated a kinking of the catheter within the sheath. This kink was unclotted, and free flow of thrombolysis resumed. The patient continued to do well on [**4-19**] following this procedure. His vital signs were noted to be stable with a slight increase in hematocrit. Overnight from [**2180-4-19**] to [**2180-4-20**], the patient did well. His antibiotics included ceftazidime, Flagyl, and Levaquin. There were no events overnight. On [**4-20**], the patient's thrombolysis with t-PA was continued. The patient returned to Interventional Radiology on [**4-20**] for assessment of his superior mesenteric vein thrombus. The patient's returned imaging demonstrated a patent portal vein. The patient returned to the Surgical Intensive Care Unit following this re-imaging on [**4-20**]. On [**4-20**], in the Intensive Care Unit, the patient continued to do relatively well. On [**4-20**], an Infectious Disease consultation was obtained by the Surgical Intensive Care Unit team given the patient's positive blood cultures from admission as well as continued fevers while on intravenous antibiotics. The assessment was this was a 71-year-old patient with non-Hodgkin lymphoma in remission with a superior mesenteric vein thrombus and with anaerobic gram-negative rod bacteremia. They felt he was improving on broad spectrum antibiotics. The focus of infection in the microbiologic growth implicated a gut flora. It was felt that his current regimen would cover gut anaerobes and aerobic bacteria; but, however, was suboptimal for enterococcus, but since there was no enterococcus isolated so far, and the patient appeared to be better, there was no need to change his antibiotic regimen. Infectious Disease recommended awaiting the speciation of the final gram-negative rod from the blood cultures in order to consolidate antibiotic therapy into a single [**Doctor Last Name 360**]. On [**4-20**], the patient was also seen by the Angiography Service at the hospital. Status post procedure, the patient was found to be comfortable and doing well off t-PA and catheter removal by the Angiography Service. Overnight from [**4-20**] to the [**4-21**], the patient continued to well. His temperature maximum was 100.4, and his urine output was adequate, and his potassium was 4.7. On [**4-21**], the General Surgery Service recommended repletion the patient's electrolytes and to begin another heparin drip to elevate the patient's PTT to a value of 60 to 80. The patient was transferred out of the Intensive Care Unit on [**4-21**] to the Surgery Service. On [**4-21**], the Gastrointestinal Service was consulted. They reviewed the patient's history and medical course. Their recommendations were for the patient undergo a colonoscopy as well as a esophagogastroduodenoscopy. The patient's heparin was held at 6 a.m. for these procedures. On [**4-21**], the anaerobic organism in the patient's blood culture was speciated as Bacteroides fragilis in groups. At this time, it was decided to switch the patient to monotherapy of Unasyn 3 g intravenously q.6h. The prescription was called into the pharmacy. Overnight from [**2180-4-21**] to [**2180-4-22**], the patient continued to do well. His colonoscopy was scheduled for the [**2180-4-23**]. On colonoscopy, the colonoscope revealed two small hyperplastic polyps within the rectum, and the colonoscopy was otherwise normal from the cecum to the terminal ileum. The patient also received an esophagogastroduodenoscopy on [**2180-4-24**]. On this study, a small hiatal hernia was seen. The patient was noted to also have a normal stomach and normal duodenum. Following the procedure, the patient continued to do well. He was without complaints. He was afebrile. Vital signs were otherwise stable with good urine output. On [**4-25**], the patient was also scheduled to undergo a ultrasound-guided biopsy of his lymph nodes. He underwent a successfully fine-needle aspirate of a pelvic lymph node with cytology present. Following this procedure, the patient did well. It was decided to discharge the patient home on [**4-25**]. CONDITION AT DISCHARGE: Condition on discharge was good. MEDICATIONS ON DISCHARGE: Discharge medications included Lovenox, Coumadin, and Augmentin. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [**Last Name (STitle) 141**] on [**Last Name (LF) 2974**], [**2180-4-27**], for an INR check. DISCHARGE DIAGNOSES: 1. Question recurrent Hodgkin's disease; status post fine-needle aspirate of pelvic lymph node with cytology positive for malignant cells, consistent with involvement by Hodgkin's disease. 2. Status post CHOP therapy times seven cycles for non-Hodgkin lymphoma. 3. Non-Hodgkin lymphoma diagnosed in [**2170**]. 4. Hypertension. 5. Hypercholesterolemia. 6. Superior mesenteric venous thrombosis; status post thrombus embolization with t-PA. DISCHARGE STATUS: The patient was to be discharged to home and to follow up wit his oncologist, Dr. [**Last Name (STitle) 141**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Name8 (MD) 16207**] MEDQUIST36 D: [**2180-7-21**] 14:41 T: [**2180-7-28**] 07:00 JOB#: [**Job Number **]

[ "401.9", "557.0", "202.80", "038.8" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.10", "45.23", "40.11", "88.64" ]

icd9pcs

[ [ [] ] ]

12795, 13622

12552, 12619

1611, 3358

3377, 12476

12491, 12525

12641, 12774

147, 1424

1446, 1585

8,256

151,306

26064+57478

Discharge summary

report+addendum

Admission Date: [**2106-1-14**] Discharge Date: [**2106-2-18**] Date of Birth: [**2083-3-3**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p Motor Vehicle Crash Major Surgical or Invasive Procedure: Left Chest tube placement Diaphragmatic Repair & Reduction of Herniated Bowel Pelvic Pinning External fixation tib/fib fractures Family History: Noncontributory Pertinent Results: [**2106-1-14**] 10:43PM TYPE-ART RATES-20/ TIDAL VOL-650 PEEP-10 O2-50 PO2-125* PCO2-46* PH-7.34* TOTAL CO2-26 BASE XS--1 INTUBATED-INTUBATED [**2106-1-14**] 10:43PM LACTATE-3.8* [**2106-1-14**] 05:54PM GLUCOSE-134* UREA N-12 CREAT-1.0 SODIUM-144 POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-23 ANION GAP-15 [**2106-1-14**] 05:54PM ALT(SGPT)-225* AST(SGOT)-439* ALK PHOS-32* AMYLASE-250* TOT BILI-1.1 [**2106-1-14**] 05:54PM WBC-11.0# RBC-4.11*# HGB-12.6*# HCT-33.5* MCV-81*# MCH-30.6 MCHC-37.6* RDW-14.3 [**2106-1-14**] 05:54PM PLT SMR-LOW PLT COUNT-89* [**2106-1-14**] 05:54PM PT-13.4* PTT-26.0 INR(PT)-1.2 [**2106-1-14**] 05:54PM FIBRINOGE-258 Brief Hospital Course: [**Hospital1 18**] ED called re trauma transfer from [**Location (un) 8641**]. Surgical team notified. Reported 22 M involved in high impact MVC, hypotensive, responded to volume resuscitation. Further report stated relatively stable during transport. Trauma stat called at 11:58pm. Palpable groin pulses, HR~100, SBP 90's. Fast initially negative. No pericardial effusion. CXR from [**Location (un) **] definitive for left diaphragm rupture. Patient transferred to OR for exploratory laparotomy. In the OR (see operative report for full details), left diaphragm laceration with herniation of stomach and small bowel. Abdomen showed a large retroperitoneal hematoma. L diaphragm was repaired with a running prolene suture. L chest tube placed and L abdomen left open. Orthopaedics followed for external fixation of pelvis, femur, and bilateral tibia/fibula fractures. Postoperatively patient was transfered to the trauma ICU intubated and sedated. Urology was consulted for left renal laceration and concern for ureteral injury secondary to hematuria. Patient was again taken to the OR on [**2106-1-15**] for ex-lap, sub-xiphoid pericardial window, and delayed abdominal closure and concomitant traction pin placement, I and D of tibial and femoral wounds, and ORIF of left SI joint. Vascular was consulted for a concern re: questionable ischemic L leg. Brisk cap refill, and triphasic distal AT and PT signals were seen. There was no evidence of RLE ischmia. Patient continued to improve in the TSICU, sedation and ventilator was slowly was weaned. Nutrition was mainatined with tube feeds and TPN. Patient was treated on short course of zosyn for gram negative rods in the sputum. On [**2106-1-28**] he was again taken to the operating room with orthopaedic surgery for repeat I and D of his leg wound, removal of the external fixator, and ORIF of his left ankle pilon fracture. He was transfered to the floor, worked with the physical therapist and made progress. He progressed to a regular diet, slide board transfers and remained non-weight bearing in bilateral lower extremities. Medications on Admission: denies Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*60 * Refills:*2* 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Fentanyl 100 mcg/hr Patch 72HR Sig: Two (2) Patch 72HR Transdermal Q72H (every 72 hours): Decrease to 1 patch after 1 week. Disp:*30 Patch 72HR(s)* Refills:*0* 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: 15-30 MLs PO Q6H (every 6 hours) as needed for constipation. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Home Health Hospice Discharge Diagnosis: Polytrauma patient s/p MVC: -Anterior-posterior compression type 3 pelvic fracture with vertical shear of the left hemipelvis. -Left transverse acetabular fracture. -Left distal tibia-fibular fracture, pilon, open, Gustilo grade 1. -Left subtrochanteric femur fracture. -Right tibia and fibula shaft fracture. -Retroperritoneal Hematoma -Left diaphragmatic rupture -retroperitoneal hematoma -mesenteric injury -small bowel deserosalization -Lobar atelectasis and pericardial effusion following multiple trauma. Discharge Condition: Stable NWB bilateral lower extremities Discharge Instructions: Follow up in Trauma Clinic in [**4-17**] weeks, please call clinic to schedule: [**Telephone/Fax (1) 6439**]. Follow up in [**Hospital **] Clinic in 1 month, please call cliic to schedule Take all of your medications as precscribed Return to the Emergency Department if you develop fever, chills, abdominal pain, nausea, vomiting, redness or drainage from wound, questions or concerns. Followup Instructions: Call [**Telephone/Fax (1) 6439**] to schedule appointment in [**4-17**] weeks in Trauma Clinic. Call [**Telephone/Fax (1) 1228**] for an appointment in [**Hospital **] Clinic in 2 weeks with Dr. [**Last Name (STitle) 1005**]. Call [**Telephone/Fax (1) 1237**] to schedule appointment in 1 month in [**Hospital **] Clinic. Completed by:[**2106-2-5**] Name: [**Known lastname 11418**],[**Known firstname **] Unit No: [**Numeric Identifier 11419**] Admission Date: [**2106-1-14**] Discharge Date: [**2106-2-18**] Date of Birth: [**2083-3-3**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3524**] Addendum: Addendum from [**Date range (1) 11420**]/06: Pt was not discharged on [**2-5**] for further work-up of low grade temperature and malaise. [**2-5**]- There was a family meeting and there were concerns over the disposition of the patient. Family wanted more options presented to them regarding dispostion prior to leaving the hospital. [**2-7**]- CXR LLL opacity; manubrium anteriorly displaced, WBC 10, UA neg [**2-8**]- US B/L LE showed DBT BLE. Essentially only the R CF [**Last Name (un) 11421**] is patient. Hep gtt started for PTT goal of 60-80 sec. Sputum Cx inadequate. Wanted to rule in/out based on low grade fever and opacity on CXR. Started vanco empircally for h/o MRSA; case management to see today, PICC placed but needs adjustment. [**2-9**]- Urine Cx grew out enterococcus. Sensitivities pending. RUE PICC repositioned. Still NWB BLE. Ortho follow up is with Dr. [**Last Name (STitle) 83**] with films. Short leg cast adjusted. Vascular surgery concurs with heparin and coumadin for the DVTS. There is nothing to do per thoracics on manubrium's displacement. Pt placed on bowel regimen. Pt c/o firm lump L antecubital PIV site which has not worsened. [**2-10**] Started SSI (BS 300). Blood sugars have been stable since. [**2-11**] VRE in urine S to linezolid, PTT 59.4, coumadin started, good BM, NWB x 5 weeks, cannot go to rehab b/c of WB, once INR thera -> can go home. last PTT 62.3. [**2-12**] To be re-evaluated by Physical therapy on Monday, decreased fentanyl to 100, prn ativan. Neurology consulted for b/l finger tingling-> MRI C-spine read neg. Pt is to follow-up in neurology clinic if bilateral finger tingling persists >1 mos. 5mg coumadin x1. [**2-13**] MRI C-spine neg. Ortho placed walking boot RLE to dorsiflex foot. coumadin 5. [**2-14**] Continue bowel regimen. Plan for CXR and US DVT tomorrow, coumadin 5. [**2-15**] Pt had 400cc emesis. KUB wnl. US BLE no sig change, CXR clear lungs. INR therapeutic at 2.1, heparin gtt discontinued. cont coumadin 5, spiked temp to 101.1, sent Cx. [**2-16**] no events today. coumadin 1mg. [**2-17**] d/c'd stitches and PICC, coumadin 2mg. needs PT scripts and PCP to follow FS. Urine Culture negative on [**2-16**]. Pt is ready to go home with services tomorrow. [**2-18**] Pt is tolerating PO food. Pain is controlled. Pt is non-weight bearing bilateral lower extremities. Pt is to go home with physical therapy and visiting nursing aid until patient can go to rehab when weight bearing status improves. Chief Complaint: s/p Motor Vehicle Crash Major Surgical or Invasive Procedure: PICC placed on [**2106-2-8**]. History of Present Illness: 22M s/p MVC presumed unrestrained driver ejected from auto. Taken to [**Hospital 6534**] hosp fully awake but c/o B-LE pain. On CXR at [**Location (un) 6534**], found to have L-hydroPTX; CT placed on left then became HoTN req'ing Neo & 2U PRBCS c intubation. [**Location (un) 11422**] gave 4 more UPRBCs, stopped Neo. Pt HD after. L diaphragmatic tear w/ herniated bowel s/p reduction and primary repair (also pelvic fx s/p R perc pin, b/l LE tib/fib fx s/p ex fix, L femur fx, small bowel injury/repair, perinephric/zone 2 retroperitoneal hematoma. Past Medical History: none Social History: Works for a food distributing company. single occ tobacco (pt counseled on quitting tobacco), occ ETOH, no SA Pt is right handed. Family History: Noncontributory Physical Exam: 96.0 133 98/61 intubated on AC 1/550x18/5 RR, tachy CTA B with CT on left soft abd, FAST exam neg guiac neg, moderate rectal tone pelvis stable open fracture L ankle Lac over L knee Urine dip + for large blood Back:no step offs, no lac's unable to obtain BLE DP or PT. via doppler palp femoral pulses non-palp popliteal pulses. Pertinent Results: [**2106-1-14**] 12:10AM URINE RBC->50 WBC-0 BACTERIA-OCC YEAST-NONE EPI-[**4-18**] [**2106-1-14**] 12:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2106-1-14**] 12:10AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 418**]-1.008 [**2106-1-14**] 12:10AM FIBRINOGE-52* [**2106-1-14**] 12:10AM PT-20.8* PTT-82.5* INR(PT)-3.1 [**2106-1-14**] 12:10AM PLT COUNT-173 [**2106-1-14**] 12:10AM WBC-16.1* RBC-3.76* HGB-11.6* HCT-32.9* MCV-87 MCH-30.8 MCHC-35.3* RDW-13.8 [**2106-1-14**] 12:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2106-1-14**] 12:10AM URINE GR HOLD-HOLD [**2106-1-14**] 12:10AM URINE HOURS-RANDOM [**2106-1-14**] 12:10AM URINE HOURS-RANDOM [**2106-1-14**] 12:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2106-1-14**] 12:10AM AMYLASE-128* [**2106-1-14**] 12:10AM UREA N-11 CREAT-1.2 [**2106-1-14**] 12:15AM freeCa-0.78* Brief Hospital Course: Please see addendum Medications on Admission: none Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*60 * Refills:*2* 2. 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* 3. Fentanyl 100 mcg/hr Patch 72HR Sig: Two (2) Patch 72HR Transdermal Q72H (every 72 hours): Decrease to 1 patch after 1 week. Disp:*30 Patch 72HR(s)* Refills:*0* 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: 15-30 MLs PO Q6H (every 6 hours) as needed for constipation. 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 9. Outpatient Physical Therapy Please evaluate for home safety. 10. Outpatient [**Name (NI) **] Work PT with INR two times per week as patient is on Coumadin. INR should be between 2.0 - 3.0. 11. VNA Cardiac Evaluation Respiratory Evaluation Incision Evaluation Follow progress of bilateral lower extremity edema from DVTs. Please check PT with INR 2x per week as patient is on coumadin. 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for when pt approaches the tylenol limit of 4g/day.: please take when you have taken 8 tablets of Vicodin on any given day. Disp:*40 Tablet(s)* Refills:*0* 13. Home physical therapy out of bed 2 times a day. therex. stretching 3times/day. Discharge Disposition: Home With Service Facility: Home Health Hospice Discharge Diagnosis: s/p Motor Vehicle Crash -Anterior-posterior compression type 3 pelvic fracture with vertical shear of the left hemipelvis. -Left transverse acetabular fracture. -Left distal tibia-fibular fracture, pilon, open, Gustilo grade 1. -Left subtrochanteric femur fracture. -Right tibia and fibula shaft fracture. -Retroperritoneal Hematoma -Left diaphragmatic rupture -retroperitoneal hematoma -mesenteric injury -small bowel deserosalization Lobar atelectasis and pericardial effusion following multiple trauma. Vancomycin Resistant Enterococcus urinary tract infection s/p linezolid treatment Methycillin Resistant Staphaureus sputum culture. Bilateral lower extremity deep venous thrombosis. Discharge Condition: Stable NWB bilateral lower extremities Discharge Instructions: Please follow up with your primary care provider for management of your anticoagulation on coumadin. Please skip your coumadin dose today [**2106-2-18**]. Resume coumadin on [**2106-2-19**]. Follow up in [**Hospital 11423**] clinic in 2 weeks. You should get a chest xray the same day. Follow up in Trauma Clinic in [**4-17**] weeks. Follow up in [**Hospital 11424**] Clinic in 2 weeks with follow up xrays as well. AP pelvis, L femur, bilateral tib/fib, L ankle films. Follow up in [**Hospital **] Clinic in 1 month. Follow up in [**Hospital 1976**] Clinic in [**3-20**] weeks. Follow up in [**Hospital 2996**] Clinic in 1 month if hand tingling persists. You are not to bear weight on either of your feet. Please take newly prescribed medications as instructed. Regular diet as tolerated. You may shower. You should contact your MD if you experience: * Increasing pain * Fever (>101.5 F) or Vomiting * Inability to eat or drink * Reddness/swelling/discharge from wounds * Anything that concerns you. Followup Instructions: Please follow up with your primary care provider to manage your anticoagulation on coumadin. Please also have that provider evaluate your heart rate and blood sugars. Call [**Telephone/Fax (1) 1477**] to schedule appointment in 2 weeks in [**Hospital 11423**] Clinic. You should report 45 before appointment to [**Hospital Ward Name **] [**Location (un) **] for chest xray. The clinic is on the [**Location (un) 11425**] of [**Hospital Ward Name **]. Call [**Telephone/Fax (1) 8472**] to schedule appointment in [**4-17**] weeks in Trauma Clinic. Call [**Telephone/Fax (1) 809**] for an appointment in [**Hospital 11424**] Clinic with Dr. [**Last Name (STitle) 83**]. Please be seen in clinic in 2 weeks. Call [**Telephone/Fax (1) 283**] to schedule appointment in 1 weeks in [**Hospital **] Clinic with Dr. [**Last Name (STitle) **]. Call [**Telephone/Fax (1) 190**] to schedule appointment in 1 month in [**Hospital 2996**] clinic if the tingling in your hands continue to be of concern. Please call [**Telephone/Fax (1) 6842**] to schedule an appointment in [**3-20**] weeks with Urologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**] Completed by:[**2106-2-18**]

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58

Discharge summary

report

Admission Date: [**2132-4-10**] Discharge Date: [**2132-4-12**] Date of Birth: [**2062-5-2**] Sex: M Service: [**Year (4 digits) 662**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 663**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: 69 yo man with dementia (AAO x 1 and communicative at baseline), hx stroke with dense L hemiplegia, hx of GIB [**2121**] secondary to duodenal ulcer, who was BIBA for unresponsiveness. Per his wife, his caretaker moved him to his wheelchair. Around 9am, he lost consciousness and was noted to be diaphoretic and more rigid. He was moved to his bed, where he remained unresponsive with coffee ground emesis in his mouth. EMS was called and pt regained consciousness in the ambulance. In the ED, initial VS were: T 97.1, P 84, BP 126/90, RR 18, O2sat 95 RA. NG lavage was grossly positive with bright red blood, clots, and coffee grounds. Pt was guaiac negative. Hct 44, Plt 214, INR 1. Two 18 gauge PIVs placed for access, and patient typed & crossed for 2 units; given 2.5 L NS GI evaluated him with a plan to scope him in ICU while intubated. VS on transfer: P 88, BP 113/55, RR 20, O2sat 95RA. On the floor, pt responds to simple questions and denies any pain but unable to provide history. Per his wife, he had been in his USOH and not complaining of abdominal pain, n/v, diarrhea, hematochezia, or melena. He does not take NSAIDs or ASA; drinks tea but not coffee; does not eat a particularly acidic or spicy diet. He is not on a PPI. He did have a GI bleed in [**2114**] d/t duodenal ulcer; he was treated for H. pylori infection at that time. Past Medical History: Dementia of unclear etiology Phasic neurogenic overactivity Right ICH [**2124**] left hemiparesis H/o GIB secondary to duodenal ulcer in [**2114**] H/o H. Pylori infection in [**2114**] Raynaud's syndrome Sleep apnea Social History: Retired professor [**First Name (Titles) **] [**Last Name (Titles) **]. Originally from [**Country 651**]. Currently has 2 caretakers around-the-clock given dementia. Wife is a physician at [**University/College **]. EtOH: None Tobacco: None Illicits: None Family History: No known h/o significant GI bleed, PUD, gastric cancer. Physical Exam: (Per Admitting Resident) Vitals: T 98.7, P 91, BP 155/88, RR 12, O2 sat 98 RA General: Sleeping but arousable to voice, [**Last Name (un) 664**], confused but can answer simple yes-no questions, NAD HEENT: Sclera anicteric, MMM, visualized oropharynx clear, NGT in place with coffee grounds in tubing Neck: Supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-distended, bowel sounds present, pt appears comfortable and does not grimace but says "yes" to tenderness diffusely (including over extremities) GU: Foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AAO x 1, exam limited by cooperation Pertinent Results: Admission Labs [**2132-4-10**] 11:28AM BLOOD WBC-4.7 RBC-4.66 Hgb-15.2 Hct-44.3 MCV-95 MCH-32.7* MCHC-34.3 RDW-13.3 Plt Ct-214 [**2132-4-10**] 11:28AM BLOOD Neuts-45.4* Lymphs-49.6* Monos-3.1 Eos-1.3 Baso-0.6 [**2132-4-10**] 11:28AM BLOOD PT-11.9 PTT-25.7 INR(PT)-1.0 [**2132-4-10**] 11:28AM BLOOD Glucose-153* UreaN-17 Creat-1.2 Na-138 K-3.6 Cl-104 HCO3-23 AnGap-15 [**2132-4-10**] 11:28AM BLOOD ALT-24 AST-21 CK(CPK)-91 AlkPhos-66 TotBili-0.7 [**2132-4-10**] 11:28AM BLOOD Lipase-29 [**2132-4-10**] 11:28AM BLOOD cTropnT-<0.01 [**2132-4-10**] 11:28AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0 Discharge Labs [**2132-4-12**] 05:40AM BLOOD WBC-8.5 RBC-4.08* Hgb-13.8* Hct-39.3* MCV-96 MCH-34.0* MCHC-35.3* RDW-13.3 Plt Ct-175 [**2132-4-12**] 05:40AM BLOOD PT-13.0 PTT-29.0 INR(PT)-1.1 [**2132-4-12**] 05:40AM BLOOD Glucose-93 UreaN-13 Creat-1.1 Na-137 K-4.0 Cl-104 HCO3-24 AnGap-13 [**2132-4-12**] 05:40AM BLOOD Calcium-8.5 Phos-2.2* Mg-1.9 Urine Studies [**2132-4-11**] 10:38AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022 [**2132-4-11**] 10:38AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2132-4-11**] 10:38AM URINE RBC-0-2 WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0-2 [**2132-4-11**] 10:38AM URINE CastHy-0-2 [**2132-4-10**] 12:50PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.020 [**2132-4-10**] 12:50PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-8.0 Leuks-NEG [**2132-4-10**] 12:50PM URINE RBC-0 WBC-0-2 Bacteri-MANY Yeast-NONE Epi-0 [**2132-4-10**] 12:50PM URINE AmorphX-MANY [**2132-4-11**] 10:38 am URINE CULTURE (Final [**2132-4-12**]): STAPHYLOCOCCUS SPECIES. ~5000/ML. ENTEROCOCCUS SP.. ~4000/ML. ======================================= HELICOBACTER PYLORI ANTIBODY TEST (Final [**2132-4-11**]): POSITIVE BY EIA. ======================================= EGD ([**2132-4-9**]) Old blood and clots were seen throughout stomach. Copious irrigation of clots was performed. There were multiple punctate areas of red blood in the fundus. These were washed and were not actively bleeding. Other findings: Significant erythema was noted in the duodenum c/w duodenitis. Duodenum was carefully inspected and no ulcer was seen. Scope was advanced to D3 where bile was seen. Impression: Old blood and clots were seen throughout stomach. Copious irrigation of clots was performed. There were multiple punctate areas of red blood in the fundus. These were washed and were not actively bleeding. Significant erythema was noted in the duodenum c/w duodenitis. Duodenum was carefully inspected and no ulcer was seen. Scope was advanced to D3 where bile was seen. Otherwise normal EGD to second part of the duodenum Recommendations: No active bleeding was seen. Bleeding may have been due to punctate areas in fundus, gastritis, or unseen [**Doctor First Name 329**] [**Doctor Last Name **] or ulcer, although no definitive cause was found. IV PPI twice daily. Serial hct; transfuse as needed. Patient will need outpatient H. Pylori testing with either breath test or stool antigen. ======================================= ECG - Sinus rhythm. Baseline artifact. Normal tracing. Compared to the previous tracing of [**2125-2-12**] there is variation in precordial lead placement. Early repolarization pattern persists as recorded previously without diagnostic interim change. The tracing is normal. CXR - FINDINGS: In comparison with the study of [**12-18**], the tip of the NG tube lies within the lower esophagus and should be advanced at least 12-15 cm. ET tube tip is about 7 cm above the carina. Lungs remain clear. CXR - FINDINGS: As compared to the previous radiograph, the nasogastric tube has been advanced. The tip of the tube now projects over the proximal parts of the stomach. There is no evidence of complications, notably no pneumothorax. Brief Hospital Course: 69M with history of CVA, GI bleed due to duodenal ulcer admitted with upper GI bleed. # GI bleed: He was admitted to the medical ICU for further management. There he underwent upper endoscopy under intubation. There was no active source of bleeding identified although it was hypothesized that bleeding may have been due to punctate areas in the fundus, gastritis, or unseen [**Doctor First Name 329**] [**Doctor Last Name **] tear. Testing for H. pylori serology was positive. He was extubated post-procedure. He remained hemodynamically stable without evidence of active bleeding. Serial hematocrits were obtained, which were stable in the high thirties. He was started on high dose proton pump inhibitor twice daily. He was discharged with prescriptions for a PPI [**Hospital1 **] x 1 week, followed by a two-week course of a Prevpac, for treatment of his H. pylori. He was also instructed to call for a GI follow-up appointment. # Fever: Prior to being called out of the MICU, the patient was found to have a temperature of 100.3. There was no clear source of infection clinically. Urine and blood cultures were obtained and did not reveal significant growth (there was a small amount of bacteria on the urine cx). Potentially, this fever represented atelectasis in the setting of his ICU stay. He remained afebrile throughout the rest of his hospitalization. # Dementia: He was continued on aricept and citalopram. Mental status remained at baseline, per the patient's wife. # OSA: He was continued on home CPAP. # Neurogenic bladder: Foley in place while he was in the MICU. Per wife, scheduled voiding at home. Foley was d/c'ed prior to d/c. Medications on Admission: Citalopram 30 mg daily Donepezil 10 mg daily Discharge Medications: 1. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 7 days. Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Prevpac 500-500-30 mg Combo Pack Sig: One (1) tablet PO twice a day for 2 weeks: Please take as directed. Please start when week-long course of omeprazole is complete. Disp:*1 pack* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis -Upper Gastrointesinal Bleed -Helicobacter Pylori Infection Secondary Diagnosis -Dementia -Sleep Apnea -History of Gastrointesinal Bleed [**1-29**] Duodenal Ulcer -History of Previous Helicobacter Pylori Infection Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You presented to the emergency department after you were found to be unresponsive at home. At that time, you were also found to have bloody emesis. You were admitted to the ICU and underwent an EGD, which showed no obvious source of bleeding. Your hematocrit was followed and remained stable. You were also found to be positive for H. pylori, a bacteria known to be related to ulcers. You are being discharged with prescriptions for antacid medications as well as treatment for the H. pylori. CHANGES TO YOUR MEDICATIONS: - START omeprazole 20 mg twice a day for 1 week - After you have completed the week-long course of omeprazole, START Prevpac twice a day for 2 weeks. - You should continue your other medications as you were taking them previously. It was a pleasure taking part in your medical care. Followup Instructions: You should follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**], within [**12-29**] weeks of discharge. You can contact Dr.[**Name2 (NI) 666**] office at [**Telephone/Fax (1) 250**] to arrange a follow-up appointment. You also need to follow-up in the [**Hospital **] clinic within 1-2 weeks after your discharge. You can contact the [**Hospital **] clinic at ([**Telephone/Fax (1) 667**] to set up an appointment.

[ "787.22", "438.9", "535.40", "438.20", "327.23", "331.0", "041.86", "294.10", "578.0", "443.0", "535.60" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

9344, 9350

7062, 8725

339, 368

9627, 9627

3152, 7039

10592, 11045

2292, 2350

8821, 9321

9371, 9606

8751, 8798

9761, 10255

2365, 3133

10284, 10569

291, 301

396, 1761

9642, 9737

1783, 2001

2017, 2276

1,329

139,888

51372

Discharge summary

report

Admission Date: [**2152-9-19**] Discharge Date: [**2152-10-3**] Date of Birth: [**2096-10-16**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: Patient is a 55 year-old male with a history of rheumatic heart disease status post AVR, MVR and also a history of coronary artery disease status post coronary artery bypass graft, atrial fibrillation, hepatitis C, and cirrhosis who presents with fever and change in mental status. Patient was in his usual state of health until about three weeks prior to admission when he had a respiratory infection with a cough, sore throat. Complained of fever and chills. This resolved in four days, however, four or five days prior to admission patient then developed chest congestion with cough productive of yellow sputum. No blood. Fevers, chills to 103.8 F at home. The patient was noted by his wife to have decreased mental status. He was incoherent and non-communicative, coughing and retching. The morning of admission the patient had a temperature of 104.0 F and was weaker and incontinent of stool at home. On the way to the hospital the patient was incontinent of urine and became combative and incoherent. Per the patient's wife, the patient had been complaining of a diffuse abdominal pain for the last couple of days. ED COURSE: In the ED the patient had a temperature of 101.9 F; pulse of 90; a blood pressure 96/50; respirations at 28; saturating 93 - 95% on room air. Blood cultures were sent. Lumbar puncture was performed. A urinalysis and culture sent as well. The patient was given 1 gram of vancomycin and two grams of ceftriaxone and Gentamicin 80 milligrams. PAST MEDICAL HISTORY: 1. Remarkable for rheumatic heart disease, status post AVR and MVR in [**2146**]. 2. Coronary artery disease status post two vessel coronary artery bypass graft in [**2146**]. Postoperative course was complicated by a sternal wound infection. 3. MSSA bacteremia in [**2148**] that was treated as an endovascular infection. 4. Paroxysmal atrial fibrillation. 5. Seizure disorder. 6. Hepatitis C, status post Ribavirin and treatment, which has unfortunately advanced to cirrhosis. 7. Ventral hernia and has Grade I - II esophageal varices on most recent esophagogastroduodenoscopy in [**2150**]. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Patient lives with his wife in [**Name (NI) 38**]; formerly was a smoker and had heavy alcohol consumption; occasional marijuana use. [**Name (NI) **] wife denies any history of intravenous drug use. MEDICATIONS ON ADMISSION: 1. Nadolol 20 milligrams p.o. once a day. 2. Dilantin 300 milligrams p.o. once a day. 3. Amiloride/hydrochlorothiazide [**3-/2100**] once a day. 4. Advair p.r.n. 5. Celexa 40 milligrams p.o. once a day. 6. Coumadin. PHYSICAL EXAMINATION: When evaluated by the MICU Team patient's physical exam was as follows. Patient had a temperature of 105.0 F; pulse of 89, blood pressure was 111/51, breathing at 24, pulse oximetry 99% on two liters. Head, eyes, ears, nose and throat: Patient had mildly icteric conjunctivae. Extraocular movements are intact. His oropharynx is clear with no erythema. His neck had no lymphadenopathy and there was no noted jugular venous distention. Patient's chest exam was clear to auscultation bilaterally. Cardiovascular exam regular rate with mechanical S1, S2, no murmurs were appreciated. Abdominal exam was remarkable for mild distention but soft and mild diffuse tenderness that did not localize. Patient was noted to have hepatosplenomegaly and a ventral hernia. Patient's extremities had trace peripheral edema, palpable DP pulses bilaterally. No splinter hemorrhages or [**Last Name (un) 1003**] lesions were noted. Neurologic: The patient was oriented only to name but had no obvious focal neurologic deficits and no noted asterixis. LABORATORY ON ADMISSION: Patient had a white count of 8.5, hematocrit 41.2, platelets of 54, all of these were within baseline for the patient with the exception of his hematocrit which was evaluated from his baseline which is usually in the low 30's. Chemistries were remarkable for a BUN and creatinine of 31 and 1.8, the 1.8 is elevated from the patient's usual baseline creatinine of 01.0. Patient's LFTs were elevated with an ALT of 71, and AST of 106, alkaline phosphatase 115, total bilirubin of 2.5, LDH of 493. All of these are within patient's normal baseline range. Urinalysis was nitrite positive with a trace of protein, glucose and ketone negative. A small bilirubin, 11 - 20 red blood cells, no white blood cells. Patient's CSF first tube had 3 white blood cells, 1 red blood cell with a differential of 7 polys, 33 lymphs, 45 monos, protein was 22 and glucose was 80. Gram stain was negative for PMNs and no microorganisms were noted. Patient's first ABG on four liters nasal cannula was 7.33 with a Pco2 of 49 and Po2 of 150. Patient's tox screen was negative and his ammonia level was 24. EKG: Showed normal sinus rhythm with left axis deviation otherwise unremarkable. Patient had a head CT Scan which showed no acute intracranial processes. Chest x-ray showed no gross infiltrate or effusions. A right upper quadrant ultrasound which showed no fluid or abscess throughout the gallbladder. In short this is a 55 year-old male with rheumatic heart disease, status post AVR, MVR, coronary artery disease, status post coronary artery bypass graft, paroxysmal atrial fibrillation and HCV cirrhosis who presented with fever, mental status changes prior to admission. HOSPITAL COURSE BY ISSUE: 1) INFECTIOUS DISEASE - because of the patient's previous history of Staphylococcus aureus bacteremia and his mechanical valves, suspicion of endocarditis was quite high in this patient. Patient had multiple blood cultures sent on the day of admission. Four out of four bottles of which grew coag positive Staphylococcus aureus was later identified as being methicillin-sensitive Staphylococcus aureus. Patient's urine culture was also remarkable for growing methicillin-sensitive Staphylococcus aureus, however, Infectious Disease Service felt that this was likely a flow over from the blood into the urine. Patient had a TEE the day after admission which showed no evidence of valvular abscess or endocarditis. Patient had multiple blood cultures over the course of this hospital stay all of which remained negative after the initially positive blood culture on the 5th. Patient also had a bone scan to rule out osteomyelitis. Bone scan unfortunately was unremarkable. Because no source was located on this patient for his bacteremia, the patient was treated with oxacillin for presumed endovascular infection. Patient will complete a six week course of antibiotics for his staphylococcus aureus bacteremia. 2. GASTROINTESTINAL - patient had a history of Hepatitis C cirrhosis with a history of Grade I and II varices on his previous esophagogastroduodenoscopy in [**2150**]. Patient had an occult positive blood stool after transfer to the floor. However, he had a nasogastric lavage which was unremarkable and which returned only clear fluid. After initial drop in hematocrit from 41 to the low 30's the patient's hematocrit stabilized in the range of 30 - 31. Thus it was felt that there was no need at this time for esophagogastroduodenoscopy or colonoscopy to evaluate the occult blood. Patient had later stools during his hospitalization that were occult blood negative. Thus it seems likely that the cause of his occult blood was nasal trauma secondary to nasogastric tube insertion. Patient was evaluated by the Hepatic Service here in the hospital and will be scheduled for repeat EGD to evaluate his varices at some point in the near future. Patient received multiple fluid boluses over the course of his admission and developed notable ascites. His belly was much more distended than on arrival after fluid boluses for previous episodes of hypotension and hydration secondary to fever. Because of this, patient was started on Lasix and aldactone. Patient had a brisk diuresis which was limited by an increase in the creatinine. Patient developed abdominal pain in the setting of ascites which was localized to his right lower quadrant near McBurney's point. Patient had no rebound tenderness, however, because of his profound tenderness a CT Scan was obtained to rule out acute appendicitis. CT Scan showed no evidence of acute appendicitis but did raise the possibility of diverticulitis thus patient was started levo and Flagyl to treat a presumed diverticulitis. Patient did have a therapeutic paracentesis during his stay which showed a white blood cell count of 175 and a red blood cell count of 25,000. The red blood cell count was likely due to traumatic tap. Additionally patient had a gram stain of his peritoneal fluid which showed no organisms. 3. HEMATOLOGY - patient had a hematocrit that was stable in the range of 30 - 31 after his initial drop with hydration from 41 - 31. Following his therapeutic paracentesis, the patient developed a sizable hematoma on his right flank as well as a two point drop in hematocrit. The patient was thus transfused two units of packed red blood cells and his hematocrits add up appropriately. Patient's hematocrit remained stable throughout the rest of the course of his admission and his hematoma did not expand further beyond the borders initially marked. Patient also had thrombocytopenia. Patient's baseline platelet level is usually in the 50's. He was somewhat lower at the beginning of his admission thus Heparin flushes were held and a HIT antibody was sent. His HIT antibody was subsequently found to be nonreactive. Patient's platelets remained stabilized around 40 throughout the course of his admission. Patient was on Coumadin on admission, anticoagulated for his mechanical valves. During his admission, his Coumadin was held and he was anticoagulated with Heparin. Until such time his diagnostic procedures were finished at which point and time the patient was started back on his Coumadin. Patient's INR was 4.0 on the day prior to discharge. 4. CARDIOVASCULAR: The patient has a history of coronary artery disease. He was continued on aspirin throughout the course of his admission. The patient did develop some demand ischemia and a troponin leak secondary to rapid atrial fibrillation which he developed during his hospital course. The troponin leak resolved once his rate was returned to within normal limits. Pump wise, this patient has a normal ejection fraction, however, he did have some question of failure when he developed rapid atrial fibrillation likely secondary to diastolic dysfunction. Patient responded well to diuresis and had no further signs of failure or shortness of breath once his heart rate was controlled. Rhythm wise, the patient had been in sinus on admission, however, during his hospital course he suddenly developed atrial fibrillation with rapid ventricular response up to the 200's. He had no initial response to Lopressor thus he was started on a diltiazem drip and transferred to [**Hospital Ward Name 19024**] more intense monitoring. He was seen by Cardiology who recommended not employing antiarrhythmics at this time but rather increasing his dose of nadolol and stopping the diltiazem. This was done, however, patient became hypotensive several hours after being given his beta blocker and required fluid boluses and transient dopamine for which he was transferred back to the Intensive Care Unit overnight. Patient was rapidly weaned off of dopamine although his rate remained difficult to control without beta blockers. He remained on diltiazem and diltiazem drip until he underwent DC cardioversion, prior to discharge after which he remained in normal sinus rhythm throughout the course of his stay. 5. RENAL - patient had a creatinine of 1.8 on admission which improved down to 1.2 with hydration. His creatinine fluctuated over the course of his hospital stay depending on his fluid status. At the time of discharge, his creatinine again, was 1.8, this was following a brisk diuresis to relieve his ascites and it was felt that the patient's creatinine would turn back towards the baseline, post diuresis. 6. PULMONARY - patient had adequate O2 saturations during his admission but did have a history of using Advair and several times during admission he was noted to have bilateral wheezing. Whether this was due to cardiac or pulmonary causes was not clear. Patient was started on Atrovent nebulizer which seemed to relieve his wheezing as the diuresis. Patient would likely benefit from pulmonary function tests in the near future if he has not had them already. 7. NEUROLOGICALLY: The patient had a history of seizure disorder. He was initially somnolent with mental status changes and incontinent of urine and stool as he defervesced and was started on antibiotics. His mental status improved markedly and at one point during his hospital admission shortly after leaving the ICU for the first time, this patient did have notable asterixis. He was treated with lactulose and his mental status returned to baseline. Patient was maintained on Dilantin throughout the course of his hospitalization. DISPOSITION: Patient was discharged in good condition on [**2152-10-3**] home. DISCHARGE STATUS: Patient will follow up with Dr. [**Last Name (STitle) **] for primary care. DISCHARGE DIAGNOSES: 1. MSSA bacteremia. 2. Presumed endovascular source. 3. HCV cirrhosis. 4. Rheumatic heart disease, status post AVR / NVR. 5. Coronary artery disease, status post coronary artery bypass graft. 6. Atrial fibrillation. 7. Seizure disorder. MEDICATIONS ON DISCHARGE: 1. Lasix 40 milligrams p.o. q. day. 2. Oxicillin 2 grams IV q. six hours times four more weeks. 3. Aspirin 81 milligrams p.o. q. day. 4. Aldactone 100 milligrams p.o. q. day. 5. Dilantin 300 milligrams p.o. q. day. 6. Protonix 40 milligrams p.o. q. day. 7. Atrovent metered dose inhaler two puffs inhaled q.i.d. 8. Coumadin 2.5 milligrams p.o. q. day. 9. Levaquin 500 milligrams p.o. q. day times 10 days. 10. Flagyl 500 milligrams p.o. t.i.d. times 10 days. 11. Nadolol 20 milligrams p.o. q. day. 12. Potassium chloride 20 milliequivalents p.o. q. day. 13. Magnesium oxide 800 milligrams p.o. q. day. 14. Lactulose 30 cc p.o. t.i.d. p.rn. 15. Ambien 5 milligrams p.o. q. H.S p.r.n. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 24503**], M.D. [**MD Number(1) 24504**] Dictated By:[**Name8 (MD) 8330**] MEDQUIST36 D: [**2152-10-3**] 15:20 T: [**2152-10-4**] 13:37 JOB#: [**Job Number 106522**]

[ "427.31", "038.11", "780.39", "V43.3", "287.5", "070.54", "998.12", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "99.62", "88.72", "03.31", "54.91", "38.93" ]

icd9pcs

[ [ [] ] ]

2292, 2310

13463, 13708

13734, 14697

2555, 2778

2801, 3858

162, 1650

3873, 13442

1672, 2275

2327, 2529

7,554

188,531

5718+5719

Discharge summary

report+report

Admission Date: [**2191-4-4**] Discharge Date: [**2191-4-15**] Date of Birth: [**2114-4-7**] Sex: M Service: [**Doctor Last Name 1181**] HISTORY OF PRESENT ILLNESS: This is a 76 year old white male with a history of coronary artery disease, diabetes mellitus, and venous stasis disease, peripheral vascular disease, status post history of left below the knee amputation, who developed increased pain and swelling and redness of both legs for an unknown length of time. The legs were painful and blood sugar also had been elevated per the patient. His primary care physician arranged for the patient to be directly admitted to the Vascular Surgery service. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Diabetes mellitus with neuropathy and retinopathy. 3. Venous stasis disease. 4. Arthritis of the left knee. 5. Peripheral vascular disease. 6. History of Methicillin resistant Staphylococcus aureus and VRE. PAST SURGICAL HISTORY: 1. Left thyroid lobectomy for nodule. 2. Amputation of the right first toe in [**2182-4-23**]. 3. Amputation of the right second toe [**2184-8-22**]. 4. Right below the knee popliteal to dorsalis pedis with an arm vein [**2184-8-22**]. 5. Left below the knee popliteal angioplasty [**2185-7-24**]. 6. Left below the knee amputation in [**2185-11-23**]. 7. Question fracture of the left upper arm. MEDICATIONS ON ADMISSION: 1. Nitro-Dur 0.6 mg patch on in morning and remove at night. 2. Imdur 120 mg p.o. q.d. 3. Lasix 80 mg p.o. q.a.m. 4. Tenormin 100 mg p.o. q.d. 5. Plavix 75 mg p.o. q.d. 6. Aspirin 81 mg p.o. q.d. 7. Zocor 40 mg p.o. q.h.s. 8. Multivitamin one q.d. 9. Insulin NPH 38 units in the morning and sliding scale insulin b.i.d. 10. Maxitrol one drop O.S. b.i.d. 11. Alphagan 0.2% one drop O.S. b.i.d. SOCIAL HISTORY: The patient lives in Senior Housing with close following by his daughter. PHYSICAL EXAMINATION: On presentation to the Vascular Surgery service, temperature was 98.0, pulse 62, respiratory rate 18, blood pressure 140/70, oxygen saturation 98% in room air. In general, the patient is an alert and cooperative white male in no apparent distress. Skin is warm and dry. Eyes - Sclera anicteric. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Pulses - 2+ radial bilateral pulses, 1+ right femoral pulse, left femoral pulse weakly dopplerable. Chest is clear to auscultation bilaterally with diffuse wheezes. Abdomen is soft, nontender, nondistended. Left stump site was erythematous with no drainage and nontender. Right venous stasis changes with no ulcerations. LABORATORY DATA: On admission, white blood cell count 6.8, hematocrit 30.0, platelets 212,000. Sodium 142, potassium 5.1, chloride 102, bicarbonate 30, blood urea nitrogen 69, creatinine 2.1, glucose 124. INR was 1.0. Chest x-ray revealed left ventricle decompensation without overt signs of congestive heart failure. Ultrasound of the left lower extremity revealed cellulitis of the left below the knee amputation stump with no drainable fluid collection. HOSPITAL COURSE: The patient was admitted to the Vascular Surgery service for management of presumed stump infection. He was treated with Levofloxacin and Flagyl. He had an ultrasound to rule out fluid collection as described above. This was determined not to be surgically debridable. During the course of the patient's admission on the Vascular Surgery service, routine laboratories revealed that the patient was suffering from acute on chronic renal failure. Additionally, a routine electrocardiogram revealed new onset left bundle branch block. The patient was ruled out for myocardial infarction by serial CKs and the patient did complain of primarily exertional chest pain. On [**2191-4-6**], the patient was transferred to the Medical service for further evaluation of chest pain and renal failure. Additional data prior to transfer to the Medical service, electrocardiogram revealed 70 beats per minute, wide complex regular sinus, left bundle branch block which was new from baseline electrocardiogram in [**2186**]. The PR interval was within normal limits. MEDICAL SERVICE HOSPITAL COURSE: 1. Infectious disease - For the patient's cellulitis, he was continued on Levaquin and Flagyl. These were renally dosed. He will complete a total fourteen day course of this antibiotic. The cellulitis did resolve over the course of his time on the Medical service and the patient remained afebrile. 2. Cardiovascular - On [**2191-4-7**], the patient was taken to cardiac catheterization to evaluate for his rest anginal pain. He was maintained on a Heparin drip prior to this and was given Mucomyst to prophylax against renal damage. Cardiac catheterization revealed three vessel disease and he received no intervention. 3. The patient was seen in consultation by the cardiac surgery service who felt that the patient was not a surgical candidate. In light of this information, the patient underwent repeat cardiac catheterization with the intention of high risk intervention. This cardiac catheterization revealed left main and three vessel coronary disease as determined on the prior catheterization with severe systolic ventricular dysfunction and successful left main coronary artery stenting and OM1 stenting with rescue percutaneous transluminal coronary angioplasty of the AV groove circumflex artery. Given the high risk nature of the patient's intervention, he was maintained on an intra-aortic balloon pump and was admitted to the Coronary Care Unit for overnight observation. He then returned to the Medical service following this catheterization and CCU stay, he has since had no further episodes of chest pain. Cardiac medications included a beta blocker. The patient's Lasix was held because of renal function described below. 4. Renal - For the patient's acute on chronic renal failure, he was seen in consultation by the renal service and was felt to have acute on chronic renal failure likely secondary to worsening diabetic nephropathy and likely renal artery vascular disease. In order to treat this renal artery vascular disease, the patient underwent left renal angioplasty during the cardiac catheterization on [**2191-4-7**]. The left renal artery was stented as well. Following this procedure, the patient's creatinine remained stable. However, over the course of [**2191-4-10**], to [**2191-4-11**], the patient's creatinine began to rise and it was felt that the patient likely had acute tubular necrosis secondary to the two dye loads he had received during the two cardiac catheterizations. The patient became anuric and was followed by the renal service. The renal service recommended that the patient be started on hemodialysis and that the prognosis for recovery of renal function is borderline to unlikely. On [**2191-4-12**], a permacath was placed using a tunneled fashion. The patient started on hemodialysis on [**2191-4-12**], and [**2191-4-13**]. His electrolytes remained stable with hemodialysis. 5. Hematologic - The patient's hematocrit was generally stable throughout the admission, however, on [**2191-4-10**], the patient's hematocrit dropped approximately ten points to a low of 20.0. The patient was hemodynamically stable during this and asymptomatic. CT scan of the abdomen and pelvis were negative for bleeding. No source was identified, however, the patient's hematocrit rose appropriately after two units of packed red blood cells and remained stable thereafter. Once started on hemodialysis, the patient received Epogen during dialysis. 6. Musculoskeletal - A right knee effusion was appreciated and confirmed by ultrasound. The patient underwent arthrocentesis on [**2191-4-11**]. Results of fluid analysis were consistent with osteoarthritis with no crystals and less than 300 white blood cells. Gram stain was negative. Culture was negative. The patient had relief of some of his knee pain following this but the effusion was felt to have reaccumulated at the time of this dictation. 7. Endocrine - The patient was managed with regular insulin sliding scale and NPH insulin. He had stable blood glucoses during the admission. 8. Additional laboratory studies during this admission - CT abdomen with contrast and CT pelvis without contrast [**2191-4-10**], looking for signs of bleeding revealed no evidence for retroperitoneal hematoma, bulky inguinal lymphadenopathy of uncertain clinical significance, small bilateral fat containing inguinal hernia, bilateral small effusions, greater on the left than the right, and atrophic appearing kidneys which demonstrated patchy areas of delayed enhancement felt to be possibly consistent with multifocal renal infarction. Renal ultrasound performed on [**2191-4-11**], revealed no hydronephrosis. Femoral ultrasound performed on [**2191-4-10**], looking for femoral pseudoaneurysm, status post cardiac catheterization, revealed no pseudoaneurysm. The patient's creatinine peaked at 7.7 on [**2191-4-12**], prior to institution of hemodialysis. The patient's lowest hematocrit was 20.7 on [**2191-4-10**]. A list of discharge diagnoses, follow-up instructions, discharge instructions and discharge medications will be dictated at a later date by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. [**Last Name (LF) **], [**Name8 (MD) **] M.D. [**MD Number(1) 9783**] Dictated By:[**Name8 (MD) 2665**] MEDQUIST36 D: [**2191-4-14**] 17:35 T: [**2191-4-14**] 18:00 JOB#: [**Job Number 22823**] Admission Date: [**2191-4-4**] Discharge Date: [**2191-4-18**] Date of Birth: [**2114-4-7**] Sex: M Service: This addendum details the events between [**4-15**] to [**4-18**]. 1. Infectious disease. The patient's cellulitis remained stable. He completed his course of Levaquin and Flagyl. He will have one further dose of Levaquin and Flagyl upon discharge. 2. Cardiovascular: The patient had his nitrates discontinued to observe if the patient would tolerate without angina without these medications. He had no further chest pain and these medication were permanently discontinued. 3. Renal: The patient received hemodialysis on [**2191-4-13**] and was planned for repeat dialysis on [**2191-4-15**]. However, patient's urine output began to increase markedly and his creatinine began to fall. No further episodes of dialysis were undertaken and the patient's renal failure was felt to be markedly improving. His Permacath was removed [**2191-4-13**]. 4. Hematologic: The patient's hematocrit remained stable throughout the remainder of the admission. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post cardiac catheterization. 2. Diabetes mellitus with neuropathy and retinopathy. 3. Venous stasis disease. 4. Osteoarthritis of the left knee. 5. Peripheral vascular disease. 6. Anemia requiring transfusion. 7. Congestive heart failure. 8. Renal failure secondary to contrast nephropathy. DISCHARGE INSTRUCTIONS: The patient should follow up with the rehabilitation physicians and should follow up with his primary care physician who may direct further renal follow up. He should have a creatinine checked along with electrolytes in approximately two to three days. Urine output should be monitored and net losses should be repleted with half normal saline. The patient should be kept somewhat negative 500c cc per day and it should be noted that the patient's Lasix has been held because of his elevated creatinine that it may become necessary in the near future to restart Lasix. He was receiving 80 mg p.o. q.d. before admission. Communication should be maintained with the patient's daughter who can be reached at area code [**Telephone/Fax (1) 22824**]. DISCHARGE MEDICATIONS: Levofloxacin 250 mg p.o. q.d. for one day, Flagyl 500 mg p.o. t.i.d. for one day, aspirin 325 mg p.o. q.d., Oxycodone/acetaminophen 1 to 2 tablets p.o. q.d. four to six hours p.r.n. and Neomycin, Polymyxin and Dexamethasone ointment drops o.s. b.i.d., Colace 100 mg p.o. b.i.d., Lopressor 25 mg p.o. b.i.d., heparin 5,000 units subcutaneously q. 12, Rimantadine tartrate 0.2% o.x. b.i.d., Lipitor 40 mg p.o. q.h.s., Plavix 75 mg p.o. q.d. times 30 days, multivitamin 1 p.o. q.d., NPH 32 units at breakfast and regular insulin sliding scale as written on page one. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**] Dictated By:[**Name8 (MD) 2665**] MEDQUIST36 D: [**2191-4-17**] 10:52 T: [**2191-4-17**] 11:30 JOB#: [**Job Number 22825**]

[ "411.1", "585", "E947.8", "997.5", "997.2", "440.1", "715.36", "682.6", "414.01" ]

icd9cm

[ [ [] ] ]

[ "88.56", "39.90", "37.61", "39.95", "39.50", "97.44", "81.91", "36.05", "36.06" ]

icd9pcs

[ [ [] ] ]

10740, 11116

11917, 12749

1402, 1805

4220, 10719

11141, 11893

971, 1376

1920, 3110

187, 681

703, 948

1822, 1897

71,146

116,826

51653

Discharge summary

report

Admission Date: [**2124-10-1**] Discharge Date: [**2124-10-6**] Date of Birth: [**2059-8-11**] Sex: F Service: CARDIOTHORACIC Allergies: Morphine Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest and jaw pain Major Surgical or Invasive Procedure: Ascending aorta replacement (26MM Gelweave graft) Resuspension of aortic valve History of Present Illness: this 62 year old caucasian female presented to the emergency room with the sudden onset o fchest pain readiating to her jaw at 1100 hours the day of admission. The pain resolved, however, she developed epigastric discomfort and general malaise. A CTA demonstrated mural thrombus with some contrast within the clot. This involved the ascending and descending aorta tothe renal arteries. She was seen by cardiac surgery and taken emergently to the operating room. Past Medical History: raynaud's disease ADHD s/p laminectomy for spinal stenosis s/p TAH brachial plexus injury-left Social History: 1.5 oz Vodka/D lactose intolerance nonsmoker retired psychiatrist Family History: Mother had [**Name (NI) 2481**] Father had [**Name2 (NI) 499**] cancer Physical Exam: Admission VS T HR70 BP93/42 RR16 02sat 99%RA Gen comfortable HEENT NCAT/EOMI, OP-wnl Pulm CTA CV RRR, nl S1-S2 Abdm soft, NT/ND Ext no C/C/E Neuro speach fluent sternum stable Pertinent Results: [**2124-10-1**] 09:47PM WBC-10.9 RBC-2.69*# HGB-8.2* HCT-23.8* MCV-88 MCH-30.6 MCHC-34.6 RDW-13.6 [**2124-10-1**] 09:47PM PLT COUNT-261 [**2124-10-1**] 09:47PM PT-15.3* PTT-49.4* INR(PT)-1.3* [**2124-10-1**] 12:30PM ALT(SGPT)-17 AST(SGOT)-25 CK(CPK)-123 ALK PHOS-62 TOT BILI-0.5 [**2124-10-1**] 12:30PM GLUCOSE-121* UREA N-28* CREAT-1.1 SODIUM-135 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-24 ANION GAP-14 [**2124-10-1**] 12:30PM cTropnT-<0.01 [**Known lastname 107018**],[**Known firstname 107019**] [**Medical Record Number 107020**] F 65 [**2059-8-11**] Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2124-10-1**] 1:39 PM [**Last Name (LF) 4758**],[**First Name3 (LF) 2353**] EU [**2124-10-1**] SCHED CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # [**Clip Number (Radiology) 107021**] Reason: Please evaluate for aortic dissection Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 65 year old woman with no sig PMH, present with acute onset of severe chest pain, radiating to the back, started with valsalva. REASON FOR THIS EXAMINATION: Please evaluate for aortic dissection CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: JXKc SUN [**2124-10-1**] 2:42 PM Acute intramural hematoma that begins at the aortic origin, involving the ascending and descending aortas. Emergent surgical eval recommended. d/w Dr. [**Last Name (STitle) **]. Final Report HISTORY: 65-year-old female with no significant past medical history who presents with acute onset of severe chest pain radiating to the back, started with Valsalva. Evaluate for aortic dissection. No prior studies available for comparison. TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the symphysis pubis with administration of IV contrast. Coronal and sagittal reformations were obtained. CTA AORTA: There is an acute intramural hematoma, originating from the aortic root, and extending to involve the thoracic ascending aorta as well as the descending aorta to the level of the aortic bifurcation in the abdomen. There is a focal puddling of contrast within an intramural location (3:15) in the descending thoracic aorta, as well as at the level of the renal arteries (3:54) on the right. The celiac artery, SMA, and renal arteries originate from the true lumen. CT OF THE CHEST WITH IV CONTRAST: The heart and pericardium reveal no evidence of a hemopericardium or pericardial effusion. There are no pathologically enlarged mediastinal, hilar, or axillary lymph nodes. Within the lungs, there is a focus of ill-defined airspace opacity anteriorly within the right upper lobe (3:19), likely infectious or inflammatory in nature. In addition, there is a 4-mm nodule within the right upper lobe (3:27), as well as a tiny pleural-based nodule within the right middle lobe (3:38). Otherwise, the lungs are clear. CT OF THE ABDOMEN WITH IV CONTRAST: The liver, gallbladder, spleen, pancreas, adrenal glands, and left kidney are normal. Peripheral wedge shaped hypodensities in the right kidney are concerning for renal infarcts. The stomach, small bowel, and large bowel are within normal limits. There is no free air, free fluid or pathologic adenopathy. CT OF THE PELVIS WITH IV CONTRAST: Urinary bladder, rectum, and uterus are unremarkable. There is no pelvic free fluid or adenopathy. OSSEOUS STRUCTURES: There are severe multilevel degenerative changes of the lumbar spine, with scoliosis and a Grade 2 anterolisthesis of L4 on L5. IMPRESSION: 1. Acute intramural hematoma involving the ascending and descending aorta, originating from the aortic root. A focus of contrast is seen in an intramural location within the descending thoracic aorta as well as at the level of the renal arteries. Emergent surgical evaluation recommended. 2. Segmental right renal infarct. Findings were discussed immediately with Dr. [**Last Name (STitle) **] and immediately posted to the ED dashboard. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 107018**], [**Known firstname 107019**] [**Hospital1 18**] [**Numeric Identifier 107022**] (Complete) Done [**2124-10-1**] at 6:33:39 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2059-8-11**] Age (years): 65 F Hgt (in): 69 BP (mm Hg): / Wgt (lb): 123 HR (bpm): BSA (m2): 1.68 m2 Indication: Aortic dissection. Chest pain. ICD-9 Codes: 441.00, 786.51 Test Information Date/Time: [**2124-10-1**] at 18:33 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW5-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 40% to 50% >= 55% Aorta - Sinus Level: 3.6 cm <= 3.6 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Arch: 2.0 cm <= 3.0 cm Aortic Valve - Peak Velocity: *9.2 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 7 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 4 mm Hg Aortic Valve - Valve Area: *2.0 cm2 >= 3.0 cm2 Findings The is an ascending aortic intramural hematoma beginning at the origin of the coronary arteries and extending at least to the level of the takeoff of the subclavian arteries. Flow in the RCA and LMCA was verified by using color doppler. There was no dissection flap seen. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. Ascending aortic intimal flap/dissection.. Thickened aortic wall c/w intramural hematoma. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Moderate (2+) AR. MITRAL VALVE: Normal mitral valve leaflets. No MS. [**Name13 (STitle) **] MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE BYPASS 1. The left atrium is normal in size. 2. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. 5. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. 6. There is no pericardial effusion. POST BYPASS 1. There is mild to moderate aortic regurgitation. 2. The synthetic graft is seen with its origin at the sinotubular junction. There is no apparent leak. 3. Left ventricular function is unchanged. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2124-10-2**] 15:27 Brief Hospital Course: After evaluation and review of studies, the patient was taken emergently to the OR where circumferential clot was found in the ascending aorta, with out an obvious intimal tear. The ascending aorta was replaced with a 26mm Gelweave graft and the aortic valve was resuspended. Circulatory arrest was utilized for a 20 minute period. See operative note for details. She weaned from CPB easily and Propofol alone. She was coagulopathic and was corrected with slowing of bleeding. She remained hemodynamically stable after surgery. On the morning after surgey she self-extubated. Her chest tubes and epicardial wires were removed. She was transferred to the surgical step-down floor. Her beta-blockade was titrated up as tolerated. She was ready for discharge to home on post-operative day 5. Medications on Admission: Estratest, Adderall, ibuprofen Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Amphetamine-Dextroamphetamine 5 mg Tablet Sig: Four (4) Tablet PO daily (). 7. Estratest 1.25-2.5 mg Tablet Sig: One (1) Tablet PO once a day. 8. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Type A Thoracic aortic dissection s/p Asc Ao replacement Raynaud's disease brachial plexus injury attention deficit hyperactivity disorder s/p hysterectomy s/p spinal stensosis surgery Discharge Condition: good Discharge Instructions: no lifting more than 10 pounds for 10 weeks no driving for 4 weeks and off all narcotics shower daily, no baths or swimming no lotions, creams or powders to incisions report any temperature greater than 100.5. report anyredness or drainage from incisions take all medications as directed Followup Instructions: [**Hospital 409**] clinic in 2 weeks Dr [**First Name (STitle) **] [**Name (STitle) 107023**] (PCP) ([**Telephone/Fax (1) 107024**] in [**2-6**] weeks Dr. [**Last Name (STitle) 914**] in 3 months with a CT scan with MMS protocol and en echocardiogram ([**Telephone/Fax (1) 170**]) Completed by:[**2124-10-6**]

[ "443.0", "511.9", "353.0", "458.29", "593.81", "441.01", "314.01" ]

icd9cm

[ [ [] ] ]

[ "38.45", "39.61", "88.72", "35.11" ]

icd9pcs

[ [ [] ] ]

11425, 11483

9523, 10322

293, 374

11712, 11719

1373, 2317

12055, 12367

1084, 1156

10403, 11402

2357, 2488

11504, 11691

10348, 10380

11743, 12032

8426, 9500

1171, 1354

235, 255

2520, 8377

402, 867

889, 985

1001, 1068

19,029

156,275

13408

Discharge summary

report

Admission Date: [**2110-4-8**] Discharge Date: [**2110-4-24**] Date of Birth: [**2066-10-31**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Ceftazidime / Carbamazepine / Cephalosporins / cefepime Attending:[**First Name3 (LF) 9152**] Chief Complaint: Lethargy, UTI, increased tracheostomy secretions Major Surgical or Invasive Procedure: G-tube revision (w/ interventional radiology) History of Present Illness: Ms. [**Known lastname **] is a 43 y/o woman with a h/o [**Doctor Last Name 73**] encephalitis s/p L partial hemispherectomy in [**2085**], refractory seizures, R hemiplegia, minimally verbal who presents from an OSH with continued lethargy and supratherapeutic dilantin level in the setting of UTI and increased secretions from her tracheostomy. At baseline, pt has a language deficit, refractory epilepsy, right spastic hemiplegia, and tracheobronchomalacia; she is trach and G-tube dependent and lives in a group home. Ms. [**Known lastname **] was admitted to [**Hospital **] Hospital on [**2110-4-3**] with increased lethargy and hypoxia (84% RA) in the setting of increased secretions from her trach. Sputum cx from the OSH were positive for E. Coli and Pseudomonas, UCx grew E. Coli, and blood cx are neg to date. Pt was started on meropenem and gentamycin on [**4-3**] at the OSH but developed pancytopenia, so her abx were changed to levofloxacin on [**4-6**] for the E. Coli UTI (Pseudomonas was felt to be a colonizer). She was also transfused with 2 units PRBCs. On admission to the OSH, pt's dilantin level was also elevated to 55, and trended down to 38 yesterday ([**2110-4-7**]). She is followed at [**Hospital1 18**] by Dr. [**First Name (STitle) 437**] from neurology and was transferred here for further care. On arrival here, T 96.5, BP 109/71, 98% on TC. She opened eyes to voice, but was lethargic and non-verbal, though her reported baseline is A&O x 3. There was no evidence of focal pain. Past Medical History: 1. [**Doctor Last Name **] encephalitis 2. Epilepsy 3. Partial left hemispherectomy at age 19 complicated by right hemiparesis and partial aphasia 4. Mental retardation 5. Left thoracolumbar scoliosis 6. Vagal nerve stimulator implanted [**12-7**], needs battery change 7. h/o Aspiration pneumonias, now on scopolamine patch 8. S/p PEG placement using T tube 9. S/p tracheostomy 10. MRSA line infection in the past 11. Hx multiple UTIs, Urosepsis (enterococcus, VRE, other) 12. Difficult venous access requiring femoral sticks 13. Constipation 14. Mood disorder, on SSRI; also Zyprexa - dense global aphasia w/ right hemiparesis - right spastic hemiplegia - tracheal stenosis and tracheobroncomalacia (trach dependent) - recent h/o Pseudomonas aspiration PNA requiring hospitalization - major depression Social History: No history of tobacco, alcohol, illicit drug use. Lives in a group home. Family History: Unremarkable. No h/o seizures or [**Doctor Last Name **]. Physical Exam: VS: 96.5F, HR 76, BP 109/71, RR 22, 98% RA (Baseline SBP 100s) Gen: Morbidly obese, chronically ill-appearing with trach in place HEENT: Sclera anicteric, MMM, oropharynx clear, copious oral secretions. Neck: supple, JVP difficult to assess, no LAD Lungs: Diffuse bilateral crackles, no wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obsese, non-tender, bowel sounds present. Well-healed G-tube site with some scabbing on L side. No rebound tenderness or guarding, no organomegaly. Ext: Warm, well perfused, +2 edema LE bilaterally. Legs in waffle boots. Neuro: Opens eyes to voice, non-verbal, pupils 4mm bilaterally and minimally reactive. RUE contracted at elbow and wrist. Is able to move left fingers on command but not legs. Pertinent Results: Admission Labs: [**2110-4-9**] 01:27AM BLOOD WBC-2.8* RBC-3.47* Hgb-10.6* Hct-31.9* MCV-92 MCH-30.6 MCHC-33.3 RDW-17.4* Plt Ct-61*# [**2110-4-9**] 01:27AM BLOOD Neuts-34* Bands-0 Lymphs-60* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2110-4-9**] 01:27AM BLOOD Hypochr-2+ Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL [**2110-4-9**] 01:27AM BLOOD PT-17.1* PTT-37.4* INR(PT)-1.5* [**2110-4-9**] 06:21AM BLOOD [**2110-4-9**] 01:27AM BLOOD Glucose-89 UreaN-14 Creat-0.7 Na-143 K-3.7 Cl-110* HCO3-28 AnGap-9 [**2110-4-9**] 01:27AM BLOOD ALT-42* AST-27 AlkPhos-169* TotBili-0.3 [**2110-4-9**] 06:21AM BLOOD proBNP-154 [**2110-4-9**] 01:27AM BLOOD Albumin-3.0* Calcium-7.6* Phos-3.0 Mg-1.8 [**2110-4-10**] 04:37AM BLOOD TSH-8.0* [**2110-4-11**] 03:47AM BLOOD T4-4.0* [**2110-4-13**] 04:59AM BLOOD Cortsol-12.3 [**2110-4-9**] 01:27AM BLOOD Phenyto-30.9* [**2110-4-12**] 08:54AM BLOOD Type-ART pO2-67* pCO2-54* pH-7.34* calTCO2-30 Base XS-1 [**2110-4-9**] 01:57AM BLOOD Lactate-1.0 EEG: [**2110-4-10**] This is an abnormal modified telemetry, due to the presence of continuously higher amplitude delta slowing seen over the left frontocentral region, with frequent high-amplitude sharp discharges seen over the [**Hospital1 **]-frontocentral regions, with a left sided predominance. This pattern is suggestive of a breach defect, with an underlying structural defect with high epileptogenic potential. In addition, the presence of occasional sharp discharges over the right posterior frontal region, phase reversing at F8, is suggestive of an independent region with epileptogenic potential. Finally, the presence of a disorganized, mixed [**4-11**] Hz theta and [**1-9**] Hz delta frequency, seen throughout the tracing is consistent with a moderate diffuse encephalopathy, most commonly caused by medication effect, metabolic disturbance, or infection. Brief Hospital Course: 43F with Rassmusen's encephalitis s/p L hemispherectomy, refractory epilepsy, and trach and G-tube dependency at baseline, who was admitted from an OSH with increased lethargy, an E. Coli UTI, and Pseudomonas pneumonia. BRIEF HOSPITAL COURSE BY ACTIVE PROBLEM: # PNEUMONIA: OSH sputum cultures contained E. coli and Pseudomonas. Patient was started on cefepime on arrival on [**2110-4-8**]. Infection disease was consulted. On the morning of [**2110-4-10**] she was noticed to have a rash so cefepime was stopped (patient has a history of pencillin allergy) and was put back on meropenem per ID recommendations (at that time her blood counts had recovered). Due to hypotension necessitating MICU transfer, CT chest was performed which was consistent with pneumonia. Ultrasound was used to assess for pleural fluid to rule out empyema, but there was no significant effusion that was felt safe to tap. Repeat sputum cultures here grew Pseudomonas and MRSA. Meropenem was eventually stopped due to the patient having increased seizures and the propensity of this drug to lower the seizures threshold. She was placed on tobramycin and vancomycin for a 10 day course. Levels were monitored and were therapeutic. She completed the course of antibiotics. # URINARY TRACT INFECTION: OSH urine culture was growing E. coli. Antibiotics were managed as above. # HYPOTENSION: Pt had labile blood pressures early on during her hospital stay. On admission, pt was hemodynamically stable with systolic BPs in the 90s-100s. On the evening of [**2110-4-10**], pt became hypotensive to the 70s and returned to baseline systolic BPs in the 90s after 2L of normal saline. She continued to have labile pressures over the course of the next few days, which responded to NS boluses. Blood, urine and sputum cultures were sent with no growth. The pt was continued on Meropenem for her E.Coli UTI and Pseudomonas PNA, and broadened to daptomycin on hospital day 3 for empiric coverage of VRE (h/o VRE) in the setting of continued BP lability. She was transferred to the MICU on hospital day 6 due to hypotension and requirement for Q1H suctioning from her trach collar. Her BP normalized and she was transfered back to the medical floor the following day and her BPs remained stable. Tryptase level was sent to rule out anaphylaxis. There was no evidence of sepsis or worsening infection. BPs readings eventually seemed more consistent by using a right leg BP cuff. She may have also had some degree of autonomic instability in the setting of infection and her neurologic disorder. # REFRACTORY EPILEPSY: Patient is on a four drug antiepilpetic regimen at baseline. Her dilantin and phenobarbital levels were supratherapeutic on admission and these drugs were initially held with daily levels sent. Neurology was consulted. She had an EEG which was at her baseline. On [**2110-4-13**], the patient began to have clusters of multiple seizures on [**2110-4-13**], up to [**4-11**] within 40 minute periods. She received ativan 2 mg IV with resolution of seizures. Her dilantin and phenobarbital were eventually restarted. She was transferred to the neurology service for further management of her epilepsy. Seizures improved when her infections resolved. # HYPOTHERMIA: Per her nurses at the group home, the patient's temperatures are chronically low, and she becomes more hypothermic when infected. While hospitalized, she was intermittently hypothermic requiring Bair hugger. # EDEMA: Patient developed significant lower extremity edema in the setting of holding her home lasix and fluid boluses for hypotension. When her blood pressures improved, she was given lasix 10 mg IV twice and then placed back on her standing home dose of lasix with significant improvement in her edema. # HYPOTHYROIDISM: Patient was found to have an elevated TSH and her free T4 was low, so she was started on a low-dose of levothyroxine. She will need her TSH rechecked in 6 weeks. # MENTAL STATUS: Her baseline mental status is alert and somewhat interactive with eyes open, tracking. She is able to sequeeze her left hand to command. During this hospitalization, she has intermittently been lethargic and unresponsive. # ANEMIA: Pt is chronically anemic with Hct 27-32. She was transfused 2 units of packed red blood cells at the outside hospital for pancytopenia thought secondary to meropenem and gentamycin. # DEPRESSION: Pt was continued on her home regimen of olanzipine and fluoxetine. # NUTRITION: Pt received home tube feeds. Nutrition was consulted. Medications on Admission: MEDICATION on TRANSFER from OSH: Fluoxetine 20 mg daily Zyprexa 5 mg QHS Phenobarbital 30 mg PO QHS, 60 mg PO Q12 Hrs Duonebs q4H while awake Keppra 1500 mg [**Hospital1 **] and 1000 mg Qnoon Levofloxacin 500 mg IV for 4 more days Singulair 10 mg daily Protonix 40 mg IV BID Senokot 10 mL daily Zonegran 400 mg daily Dilantin - on hold . ABX given at OSH: Vancomycin 1gm IV x 2 ([**Date range (1) 33169**]) Gentamycin 300mg IV QD ([**Date range (1) 40692**]) Meropenem 500mg IV Q6H ([**Date range (1) 40693**]) Levofloxacin 500mg IV QD ([**4-6**]- ) Discharge Medications: 1. phenobarbital 30 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO BID (2 times a day). 2. phenobarbital 30 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO QHS (once a day (at bedtime)). 3. levetiracetam 100 mg/mL Solution [**Month/Day (4) **]: Fifteen (15) ml PO BID (2 times a day). 4. levetiracetam 100 mg/mL Solution [**Month/Day (4) **]: Ten (10) ml PO DAILY (Daily). 5. zonisamide 100 mg Capsule [**Month/Day (4) **]: Four (4) Capsule PO DAILY (Daily). 6. Dilantin Infatabs 50 mg Tablet, Chewable [**Month/Day (4) **]: 1.5 Tablet, Chewables PO three times a day. 7. fluoxetine 20 mg/5 mL Solution [**Month/Day (4) **]: Five (5) ml PO DAILY (Daily). 8. olanzapine 5 mg Tablet, Rapid Dissolve [**Month/Day (4) **]: One (1) Tablet, Rapid Dissolve PO HS (at bedtime). 9. montelukast 10 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily). 10. levothyroxine 25 mcg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily). 11. furosemide 40 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily). 12. ipratropium bromide 0.02 % Solution [**Month/Day (4) **]: One (1) neb Inhalation Q4H (every 4 hours). 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Day (4) **]: One (1) neb Inhalation Q4H (every 4 hours). 14. senna 8.6 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily). 15. docusate sodium 50 mg/5 mL Liquid [**Month/Day (4) **]: Ten (10) ml PO BID (2 times a day). 16. nystatin 100,000 unit/g Powder [**Month/Day (4) **]: One (1) application Topical three times a day. 17. camphor-menthol 0.5-0.5 % Lotion [**Month/Day (4) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for dry skin. Discharge Disposition: Extended Care Facility: Group Home Discharge Diagnosis: Pneumonia Urinary Tract Infection Increased Seizure frequency Discharge Condition: Non-verbal, attentive and alert, bedbound, right hemiparesis Discharge Instructions: You were admitted to the hospital with increased seizure frequency and found to have both pulmonary and urinary tract infections. Infectious disease was involved and you were treated with meropenem, vancomycin and tobramycin for 10 day courses. You had a malfunction of your g-tube and had a revision done by interventional radiology. You were continued on your current AEDs with scheduled ativan during the period in which you were being treated for seizures. You were tapered off this medications. Dilantin was decreased from 75/75/100 to 75 mg TID (initial levels were supratherpeutic to 30.9) Discharge levels were 21.9. Followup Instructions: Patient should follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 856**] in 1 month, and with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] in [**1-9**] months. ([**Telephone/Fax (1) 40694**] Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 857**] Date/Time:[**2110-5-19**] 11:30 Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**] Date/Time:[**2110-6-16**] 10:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9153**] Completed by:[**2110-4-24**]

[ "780.65", "V55.0", "284.1", "536.42", "V49.84", "041.4", "458.9", "278.01", "E879.8", "296.90", "428.32", "428.0", "796.0", "244.9", "E936.1", "342.10", "348.30", "326", "319", "599.0", "693.0", "345.11", "519.19", "523.8", "482.1", "E930.5", "V85.30" ]

icd9cm

[ [ [] ] ]

[ "97.02", "96.6" ]

icd9pcs

[ [ [] ] ]

12556, 12593

5698, 9662

381, 429

12699, 12762

3785, 3785

13435, 14106

2911, 2970

10844, 12533

12614, 12678

10270, 10821

12786, 13412

2985, 3766

292, 343

457, 1976

3801, 5675

9677, 10244

1998, 2804

2820, 2895

23,197

139,620

3669

Discharge summary

report

Admission Date: [**2158-1-17**] Discharge Date: [**2158-1-21**] Date of Birth: [**2090-5-16**] Sex: F Service: SURGERY Allergies: Codeine Attending:[**First Name3 (LF) 2597**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: Intubation/extubation, mechanical ventilation Central venous line placement History of Present Illness: 67 y/o F DM1, CKD, hyperlipidemia who presents with acute onset seizure. Patient presented to ED to be evaluated for nausea, vomiting, diarrhea felt to be secondary gastroenteritis. During her ED course patient became less responsive (oriented to name only) and started seizing (fingerstick 297). Per report her gaze was deviated and left arm shaking. Patient recieved 4 mg ativan total and eventaully seizure broke. However during this time she was intubated to protect her airway. Prior to seizure patient was recieving ciprofloxacin for ? pyelonephritis, however per report only received several minutes worth. [**First Name3 (LF) 878**] evalauted who recommended MRI, EEG and felt this could be secondary to infection versus PRES. Initial VS were: T 95.6 P 45 BP 243/88 R 18 O2 sat 99 RA. Patient's blood pressure ranged from 136/49-231/88). Past Medical History: 1. Sciatica with h/o laminectomy. 2. DM1 for 36 years, on insulin pump, with gastroparesis, CKD, peripheral neuropathy 3. Hypercholesterolemia 4. h/o CP in [**2137**], cardiac cath clean - sx's felt to be ?spasms, recent [**Year (4 digits) 1608**] [**9-9**] wnl 5. HTN 6. Hiatal hernia 7. s/p hysterectomy 8. Hypothyroidism 9. Autonomic Dysfunction 10.CKD II, baseline creat 1.3-1.5 11.PAD s/p recent fem-tib bypass RLE [**9-9**] 12. Depression 13. DVT 14. [**Doctor Last Name 15532**] Esophagus EGD [**2-6**] 15. Orthostatic hypotension secondary to autonomic dysfunction 16. PVD Social History: Per OMR as patient intubated on arrival Home: lives with husband Occupation: retired secretary Tobacco: quit smoking in [**8-10**], previously with 60-80 PPY history (1.5-2PPD x 40 years) EtOH: Denies Drugs: Denies Family History: Mother - coronary artery disease with MI in her 50s, died at age 84 Father - coronary artery disease with MI in her 60s, died at age 82 Physical Exam: General: Sedated, moves limbs spontaneously, withdraws to pain, intermittently squeezes hand to voice. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Pupils 2mm b/l and reactive to light. Moves all limbs spontanenously. DTR patella [**1-4**]+. [**Name2 (NI) 167**] toes downgoing, left toes neither direction. Pertinent Results: CT HEAD W/O CONTRAST Study Date of [**2158-1-17**]: No acute intracranial hemorrhage or large infarct. If there is suspicion for other acute intracranial processes, MR can be ordered. . CT Abdomen/Pelvis [**2158-1-17**]: Bilateral perinephric stranding without renal perfusion abnormality. Markedly distended urinary bladder. Correlation with UA is recommended.. . CXR [**2158-1-17**]: No acute intrathoracic process. . EKG: Normal axis. HR 76. Lateral changes most likely secondary to LVH. . Trop-T: <0.01, CK 60 . 135 95 24 372 AGap=23 4.2 21 1.1 . PT: 12.8 INR: 1.1 . 88 8.5 > 13.6 < 198 41.0 N:93.2 L:3.2 M:2.9 E:0.5 Bas:0.2 . Serum tox negative, urine pos for benzos otherwise neg . EEG: pending . MRI head: pending final read. Prelim read - no acute intracranial processes Brief Hospital Course: 67 y/o F DM1, CKD, hyperlipidemia who presents with diarrhea, vomiting and developed witnessed seizure in ED. . # Peripheral [**Month/Day/Year **] Disease - Pt was a known patient of Dr. [**Last Name (STitle) **] and was seen by the [**Last Name (STitle) 1106**] team after admission. She was noted to have resting pain in her lower extremities and was worked up for this issue. Noninvasive [**Last Name (STitle) 1106**] studies were c/w peripheral [**Last Name (STitle) 1106**] disease and the patient was taken to the angio suite where she underwent angiography and balloon angioplasty of her previously existing graft. She tolerated the procedure and recovered from anesthesia without complication. She was observed postoperatively and was discharged to home with a creatinine of 1.0 . # Seizure: No prior history per OMR or family. Unlikely to be secondary to electrolyte abnormalities (Na normal on admission) and hypoglycemia (glucose normal). Less likely to be Alcohol withdrawal or illicit medications as no prior history and serum/urine toxicology essential normal. Patient recently suffering from gastroenteritis, certain viral etiologies can infect CSF and result in menigitis. Other etiologies on the differential include structural mass or CVA but CT head and MRI head were within normal limits. EEG (24 hour) was performed, per [**Last Name (STitle) **] recs, which showed preliminarily no seizure activity, positive encephalopathy. Lumbar puncture was performed which was negative for meningitis. Patient's citalopram, gabapentin, lorazepam, reglan and chantix were initially held for possibility of lowering seizure threshold. They were slowly added back, starting with gabapentin and reglan as patient clinically improved. . # Diarrhea, vomiting: Most likely gastroenteritis. However based on CAD/DM history patient was ruled out for inferior MI and EKGs within normal limits. . # Hypertension: Seizure could be result of PRES (posterior reversible encephalopathy syndrome). HTN as outpatient significantly lower, SBP100-154. Patient's BP dropped from 230 to 130 in ED following propofol. Once extubated, patient's blood pressures climbed to SBP180s which, per patient, is her baseline. She was resumed on her home lisinopril 10mg daily and given hydralazine 10mg IV as needed while in the MICU for management of her blood pressures. . # Chronic pain: Gave IV morphine during MICU stay. Of note, has PCP in [**Name9 (PRE) 191**], who Rx's 40 mg [**Name9 (PRE) 16604**] QAM, 10 mg QPM & oxyocodone 5-10 mg daily PRN. Restarted patient on [**Name9 (PRE) 16604**] 10 mg [**Hospital1 **] with good effect . # DM1: Continued on long acting glargine and insulin sliding scale, [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs. . # Hypercholesterolemia: Simvastatin 40 mg qpm . # Hypothyroid: Continued levothyroxine. . # CKD: Creatinine around baseline 1.2-1.5. . # Depression: Hold meds that decrease seizure threshold. . # Autonomic orthostatic hypotension: NaCl 2 gram [**Hospital1 **] was discontinued in setting of hypertension. . # Code: Full . Medications on Admission: Calcitriol [Rocaltrol] 0.5 mcg Capsule(s) by mouth once a day Citalopram 40 mg Tablet 1 (One) Tablet(s) by mouth once a day Clopidogrel [Plavix] 75 mg Tablet 1 Tablet(s) by mouth once a day Cyclosporine 0.05 % Dropperette 2 drops to both eyes twice a day Erythromycin 5 mg/gram Ointment apply [**Hospital1 **] to both eyes Gabapentin 800 mg Tablet 1 Tablet(s) by mouth qam Insulin Glargine [Lantus] 100 unit/mL Solution 12 units at bedtime Insulin Lispro [Humalog] 100 unit/mL Cartridge on insulin pump basal rate; 12am-4am 0.25 units hr 4a 0.15 units hr 5a 0.60 unit hr 8am 0.70 unit hr 8pm 0.50 unit hr 10pm 0.40 unit hr Levothyroxine [Levoxyl] 75 mcg Tablet 1 Tablet(s) by mouth daily Lorazepam 0.5 mg Tablet 1 Tablet(s) by mouth qpm Metoclopramide 10 mg Tablet 1 (One) Tablet(s) by mouth 30 minutes before meals Oxycodone 5 mg Tablet [**12-3**] Tablet(s) by mouth daily as needed for pain Oxycodone 10 mg Tablet Sustained Release 12 hr 4 Tablet(s) by mouth in the morning and 1 tab by mouth in the evening Pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by mouth once a day Simvastatin [Zocor] 40 mg Tablet 1 Tablet(s) by mouth qpm Chantix [**Month/Day (2) **] 81mg Calcium Carbonate 1500 mg qd Vitamin B12, folate MVI Fish Oil NaCl 2 gram [**Hospital1 **] . Allergies: Codeine Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 6. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*qs Capsule(s)* Refills:*2* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*qs Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO DAILY (Daily). Disp:*qs Tablet, Chewable(s)* Refills:*2* 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*qs Tablet(s)* Refills:*2* 11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*qs Capsule(s)* Refills:*2* 12. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 13. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO QHS (once a day (at bedtime)). Disp:*qs Tablet Sustained Release 12 hr(s)* Refills:*2* 14. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Two (2) Tablet Sustained Release 12 hr PO QAM (once a day (in the morning)). Disp:*qs Tablet Sustained Release 12 hr(s)* Refills:*2* 15. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). Disp:*qs Capsule(s)* Refills:*2* 16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 18. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*qs * Refills:*2* 19. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*qs Capsule(s)* Refills:*2* 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*qs Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Peripheral [**Hospital1 **] Disease Claudication Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Division of [**Hospital1 **] 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 [**1-4**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2158-2-15**] 9:50 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2158-2-20**] 2:30 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2158-2-20**] 3:30 Please also make an appointment with your primary care provider to follow your blood pressure in the next 1-2 weeks.

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icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "00.40", "39.50", "96.71", "88.48" ]

icd9pcs

[ [ [] ] ]

10726, 10732

3768, 6844

275, 352

10825, 10825

2947, 3745

13797, 14359

2082, 2219

8192, 10703

10753, 10804

6870, 8169

10970, 13364

13390, 13774

2234, 2928

228, 237

380, 1228

10839, 10946

1250, 1833

1849, 2066

81,111

179,864

53948

Discharge summary

report

Admission Date: [**2117-4-3**] Discharge Date: [**2117-4-6**] Date of Birth: [**2082-1-15**] Sex: M Service: MEDICINE Allergies: Compazine / morphine Attending:[**Doctor First Name 3298**] Chief Complaint: abdominal pain, vomiting blood Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: History of Present Illness: 35 y/o M with hx idiopathic pancreatitis and prior [**Doctor First Name 329**]-[**Doctor Last Name **] tear, who came to ED this morning for two days of epigastric pain radiating to his back and intermittent vomiting since late Thursday night. He vomited throughout the day yesterday, and then noticed small amounts of bright red blood in his emesis last night. He has chronically loose stools and takes pancreatic enzymes daily. His abdominal pain feels similar to his typical pancreatitis symptoms. Denies fevers, chills, exotic foods, sick contacts, urinary symptoms, lightheadedness, dizziness, dyspnea or chest pain. He does not drink any etoh. He does not take any NSAIDs, per prior doctor's recommendations. He is visiting the [**Location (un) 86**] area from New Jersey, for his uncle's funeral. In the ED inital vitals were, 98.3 122 106/69 16 100%. Exam notable for soft abdomen with TTP over epigastric area, no rebound tenderness or guarding. Labs revealed leukocytosis to 12K with mild left shift, hct 337, INR 1.0. Lipase was 69 and ALT/AST 62/47. CXR showed no thoracic process or subdiaphragmatic free air. ECG showed sinus tachycardia. He was given ondansetron 4 mg IV and hydromorphone 1 mg IV, as well as 2-3 liters IVF. GI was consulted and did not recommend immediate intervention. IV access was difficult to obtain, though ED team able to place right 18g EJ. Pt was typed/crossed 2 units RBCs. At 0630 he vomited ~200 cc of gastric contents mixed with blood, without further bleeding. GI was notified via page, but did not offer further recommendations prior to transfer to ICU. VS prior to transfer: 98.1, 122 (sinus), 142/70, 16, 100% on RA. On arrival to the ICU, the pt reports his pain is improved and he is not currently nauseous. He says he has been to [**Hospital1 18**] ED last year (around [**Month (only) **]) for similar complaints, as well as several visits when he was younger; although he has no prior records in OMR. He has had thorough workups of his pancreatitis in NY and NJ, including upper and lower endoscopies, endoscopic ultrasound, and ERCP. He believes he has a pseudocyst; he has had upper GI biopsies, but does not know of any findings other than gastritis. His amylase and lipase levels are rarely increased when he has symptoms attributable to pancreatitis. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain, headache, sinus tenderness, rhinorrhea, cough, palpitations, weakness, constipation, dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - chronic pancreatitis with multiple flares - multiple endoscopic procedures at [**Hospital3 110637**] in [**Location (un) 7349**] and [**First Name8 (NamePattern2) **] [**Hospital 11042**] Hospital in [**Location (un) 12365**] NJ - gastritis - hx [**Doctor First Name **]-[**Doctor Last Name **] tear - past episodes of symptomatic hypoglycemia - hx sinus surgeries as teenager for sinusitis; no residual problems - episode of bacteremia several years ago at OSH, s/p normal TEE Social History: Originally from [**Location (un) 86**] area but went to school in [**Location (un) 7349**] and now lives by himself in [**Location (un) 12365**] NJ. Visiting [**Location (un) 86**] this weekend for uncle's funeral. Works as director of operations at finance corporation in NY. Denies any past or current ETOH. Former cigarette smoker, ~[**8-13**] pack-years, quit 5 yrs ago. Denies illicits. Family History: Strong family history of type 2 DM: both parents, all four grandparents and one brother. Physical Exam: ON ADMISSION: Vitals: T:98.1 BP:131/83 P:97 R:17 O2:99% RA General: Alert, oriented, appears tired but in NAD HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, +TTP over epigastrium and LUQ. Non-distended, +BS throughout, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ DP/PT/radial pulses bilaterally, no clubbing, cyanosis or edema Skin: Erythematous patches and papules over left upper back and left upper extremity On Discharge: Exam notable for all vital signs being stable and patient being afebrile (though Tmax of 101.3 on night prior to discharge). Induration and warmth over left dorsum of hand. Abdomen less tender than previously in epigastrum. Pertinent Results: ADMISSION LABS: [**2117-4-3**] 05:45AM BLOOD WBC-12.1* RBC-4.20* Hgb-12.2* Hct-37.1* MCV-88 MCH-29.0 MCHC-32.8 RDW-14.4 Plt Ct-248 [**2117-4-3**] 05:45AM BLOOD Neuts-81.2* Lymphs-15.5* Monos-2.4 Eos-0.4 Baso-0.6 [**2117-4-3**] 05:45AM BLOOD Glucose-80 UreaN-18 Creat-1.1 Na-140 K-4.0 Cl-101 HCO3-25 AnGap-18 [**2117-4-3**] 05:45AM BLOOD ALT-62* AST-47* AlkPhos-80 TotBili-0.6 [**2117-4-3**] 05:45AM BLOOD Lipase-69* [**2117-4-3**] 05:45AM BLOOD Albumin-4.5 Calcium-9.9 Phos-3.1 Mg-1.7 Discharge Labs: [**2117-4-5**] 07:00PM BLOOD WBC-9.5 RBC-4.19* Hgb-12.5* Hct-36.7* MCV-88 MCH-29.8 MCHC-34.1 RDW-14.1 Plt Ct-156 IMAGING: CXR [**2117-4-3**] FINDINGS: The lungs are clear with no evidence of a consolidation, effusions, or pneumothorax. Cardiomediastinal silhouette is normal. No free air is noted underneath the hemidiaphragms. No acute fractures are identified. IMPRESSION: No acute cardiopulmonary process. [**2117-4-3**] abdominal u/s FINDINGS: The liver is normal in echotexture without focal lesion, intra- or extra-hepatic biliary ductal dilatation. The common bile duct is not dilated measuring 3 mm. The gallbladder is distended but without stones, sludge, mural thickening or pericholecystic fluid to suggest acute cholecystitis. Son[**Name (NI) 493**] [**Name2 (NI) 515**] sign was negative. Sub-3-mm polyp is seen. The pancreatic distal body and tail is not well seen due to overlying bowel gas; however, the portion of the head and proximal body that is seen is slightly echogenic but otherwise unremarkable. The kidneys are normal bilaterally without hydronephrosis, stone, or mass. The right kidney measures 11.1 cm. The left kidney measures 10.4 cm. The spleen is normal measuring 11.3 cm. The imaged IVC is unremarkable. The imaged aorta is normal in caliber; however, the distal portions are not well seen due to overlying bowel gas. No free intra-abdominal fluid is seen. The main portal vein is patent with hepatopetal flow. IMPRESSION: 1. Gallbladder distention without evidence of cholecystitis or cholelithiasis. This is likely because the patient has not eaten since [**2117-4-1**] 2. Sub-3-mm gallbladder wall polyp is likely of little clinical significance. EKG [**2117-4-3**]: 0330: Sinus tachycardia @ 110 bpm. NA. QTc 453 ms. [**Last Name (Titles) **]' morphology V1-V2; QRS 118 ms. [**Name13 (STitle) **] ischemic changes. 0656: ST @ 100 bpm. [**Name13 (STitle) **]' resolved. QTc 414 ms. Chest Radiograph [**2117-4-5**]: FINDINGS: As compared to the previous radiograph, there is no relevant change. Normal appearance of the lung parenchyma, no evidence of pneumonia. Normal size of the cardiac silhouette. No pleural effusions, no pulmonary edema. EGD [**2117-4-6**]: Impression: Gastric ectopic mucosa (inlet patch) Friability and erythema in the antrum compatible with gastritis (biopsy) Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 35 y/o M with hx chronic pancreatitis, admitted to ICU for hematemesis in setting of possible pancreatitis. 1) Hematemesis, likely due to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear: Patient presented with hematemesis and reporting fresh blood in emesis though this was never witnessed in the hospital and in fact he only was noted to have small amounts of clotted blood. Given history of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear and hemodynamic and overall stability most likely etiology was felt to be recurrent tear due to vomiting in context of possible exacerbation of pancreatitis. Thus endoscopy was not immediately pursued and serial hematocrits were followed with patient on PPI. His hematocrit was stable and no further significant upper or lower bleeding was noted. Eventually, he did have EGD for persistent abdominal pain, which showed only gastritis. He was discharged on omeprazole for treatment of gastritis. H pylori serologies are pending and he will be contact[**Name (NI) **] if these are positive. 2) Nausea/vomiting/likely acute on chronic pancreatitis: The patient presented with hematemesis in the context of vomiting and epigastric pain consistent with flare of pancreatitis. Lipase was minimally elevated but this would be unsurprising in context of chronic pnacreatitis. He was initially kept NPO, hydrated, and given IV hydromorphone and pain improved. Leukocytosis at presentation improved with this supportive therapy. His pain steadily improved though did not fully resolve (as he has chronic abdominal pain). He was switched to his home dose of PO hydromorphone and tolerated a regular, low fat diet without increased pain at eating. He will follow up with his regular providers regarding further management of pancreatitis. He was continued on pancreatic enzymes. 3) Fever: Pt had ultrasound of abdomen and two chest radiographs without signs of infection and he had no localizing signs of infection except for possible infiltration of left dorsal hand IV. He received no antibiotic therapy and had defervesced by time of discharge. Extremely low suspicion of acute bacterial infection. TRANSITIONAL ISSUES -Less than 3-mm gallbladder wall polyp was noted on abdominal Ultrasound. This should be reassessed on repeat U/S in [**3-9**] months. -GI biopsies including sampling for H pylori are pending at time of discharge. GI team will follow these and contact the patient with results. Medications on Admission: - creon daily - hydromorphone 4 mg 1-2x/day Discharge Medications: 1. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO every four (4) hours as needed for pain: do not drive or operate heavy machinery while using this medication as it can make you sleepy. Disp:*16 Tablet(s)* Refills:*0* 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Hematemesis due to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear Gastritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with abdominal pain and bleeding with vomiting. This bleeding is felt likely due to what is called a [**Doctor First Name **]-[**Doctor Last Name **] tear, which is a small rip in your esophagus due to vomiting. This will heal on its own. We did do an upper endoscopy to rule out more concerning causes of abdominal pain and bleeding, and this did not show any ulcer or concerning findings. You do have mild gastrititis (inflammation of the stomach) which will be treated with an acid blocking medicine (omeprazole). Your medications have been changed. You were started on omeprazole (PRILOSEC) 20 mg twice a day to help heal the inflammation in your stomach. YOu have been given a very small supply of additional hydromorphone (dilaudid) as your pain fades back to your baseline level. Followup Instructions: You should contact your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow up in approximately 1-2 weeks to monitor you and confirm you are improving.

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icd9cm

[ [ [] ] ]

[ "45.16" ]

icd9pcs

[ [ [] ] ]

11049, 11055

7899, 10397

311, 340

11218, 11218

4958, 4958

12204, 12389

3950, 4041

10492, 11026

11076, 11197

10423, 10469

11369, 12181

5460, 7876

4056, 4056

4712, 4939

2752, 3014

241, 273

397, 2733

4974, 5444

4070, 4698

11233, 11345

3036, 3519

3535, 3934

24,065

121,777

29686

Discharge summary

report

Admission Date: [**2130-2-7**] Discharge Date: [**2130-2-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: s/p fall, cerebral SDH & SAH Major Surgical or Invasive Procedure: none History of Present Illness: 85 yo man w/ PMH of CAD, CHF, DMII, CLL, and recent TIA who fell resulting in extensive SAH and SDH. Patient was walking when he bent forward to pick up dropped mail, lost his balance, and fell backwards hitting the posterior of his head on the ground. His son who witnessed the event states that the patient had no LOC. EMT was called and on arrival to OSH, he was nauseous, vomiting, and had blood draining from his L ear. Head CT showed extensive SAH and SDH and a L temporal bone fracture, and the patient was transfered to [**Hospital1 18**] for further management. Patient had no prodrome or preceeding palpitations, chest pain, dizziness, headaches, no recent fever or chills, and no visual changes. No seizure or fall history. Patient had a TIA 2 weeks ago characterized by slurred speech. He had been on ASA and plavix, but discontinued after the TIA and was switched to aggrenox. . The patient was admitted to neurosurgery, but due to the extensive bleed, there were no surgical options, so he was medically managed with seizure prophylaxis. The NeuroICU course was c/b NSTEMI ([**2130-2-8**] CK=1338), CHF exacerbation, and desats into the 80's. Patient was on lasix gtt for volume overload. ECHO on [**2-7**] showed EF>55%, moderate diastolic dysfunction. EKG showed periods of SVT. Per cardiology consult, treatment options were limited as the pt cannot be on anti-platelet agents or anticoagulants due to SAH and SDH. The patient was medically managed w/ beta blocker, ACE I, statin, and lasix IV for CHF. The patient has a history of CLL and his WBC trended up from 66K on admission to 88K. Past Medical History: -Chronic lymphocytic leukemia, diagnosed one year ago -Transient Ischemic Attack 2 weeks ago causing slurred speech, resolved without intervention -CAD s/p stenting 10 years ago -DMII -Congestive Heart Failure -Hypertension -obstructive sleep apnea Social History: Lives at home with his wife in [**Name (NI) 47**]. Community ambulator with a cane. Has 7 children, 2 live nearby. Denies current alcohol use, not since [**53**] yrs ago. Quit smoking 40 yrs ago, smoked 2ppd. Family History: father died of MI, mother had diabetes Physical Exam: Vitals: Tm 100.2 Tc 98.0 BP 116/55;116-150/55-72 HR 76; 70-110's RR 20-24 94% O2 on 5L FSG 281 Gen: somnelent but arousable, awake, alert, AOx1 (only to person, at home in [**Location (un) 47**], [**2130-3-8**]) HEENT: PEERL 2mm bilaterally, EOMI, full visual fields, no nystagmus, dry oral mucous membranes. CVS: irregular rate and rhythm, [**2-14**] holosystolic murmur, JVP not visualized Lungs: diffuse scattered rhonci Abd: protuberant, soft, NT Ext: no LE edema, warm, well perfused Neuro: MS: intact repetition, can recall [**2-11**] words on prompting, can spell WORLD forwards, one incorrect letter in spelling WORLD backwards, can repeat "no ifs ands or buts." +Babinski bilaterally, unable to elicit patellar and biceps reflex. [**5-13**] strength throughout. Gait not tested. Pertinent Results: Admission Labs: [**2130-2-7**] 06:55PM WBC-66.4* RBC-3.89* HGB-10.8* HCT-32.1* MCV-83 MCH-27.8 MCHC-33.7 RDW-15.7* [**2130-2-7**] 06:55PM CK(CPK)-74 [**2130-2-7**] 06:55PM CK-MB-NotDone cTropnT-<0.01 [**2130-2-7**]: Non-contrast head CT: IMPRESSION: 1. Extensive subarachnoid hemorrhage seen within the frontal lobes bilaterally, right frontal lobe, left parietal lobe. Layering blood also seen within the lateral ventricles. 2. Intraparenchymal contusion/hemorrhage seen within the anterior frontal lobes bilaterally. 3. Subdural hematoma seen in the frontal regions bilaterally, and tracking along the falx. 4. Nondisplaced fractures of the left temporal bone, with associated hemotympanum. [**2130-2-9**] Cardiac ECHO: Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: #Cerebral SAH/SDH: Initial head CT on [**2-7**] showed extensive SDH and SAH with blood in the lateral ventricles, no mid-line shift, left temporal bone fracture, and hemotympanum. Patient was admitted to neurosurgical ICU. Neurosurgery was consulted and no surgical intervention was indicated because of extensive nature of SDH and SAH and poor prognosis. Repeat head CT on [**2-8**] showed no significant interval change. He was started on phenytoin 100mg po tid for seizure prophylaxis. . #NSTEMI: Patient had NSTEMI on [**2-7**]. EKG showed diffuse ST depressions. Per cardiology, patient was not a good candidate for catherization because of his extensive SAH and SDH such that he could not be placed on anti-platlet therapy afterwards. Patient medically managed with B blocker, nitroglycerin, ACEI, and atorvastatin 80mg po daily. No anti-coagulation or anti-platlet therapy added. Family discussion confirmed DNR/DNI status and patient preference for non-invasive care. On [**2-8**], CK-MB elevated to 88 and troponin elevated to 2.78. He was monitored on telemetry and had episodes of paroxysmal SVT to 120's, otherwise HR well controlled to 60's. Metoprolol dose was increased to 50mg po bid. . #SOB: Patient with desats to 70-80's on [**2130-2-10**] at night thought to be due to flash pulmonary edma secondary to diastolic heart failure and NSTEMI on [**2-7**]. Patient improved with 40mg IV lasix and lopressor 5mg IV. The patient's urine output was monitored and was good. On [**2130-2-11**] in the AM, patient had a desat to mid-80's, HR's 60-80's, BP 148/62. He improved with 10L O2 by facemask, nitropaste topically, and nebulizer. CXR did not show worsening compared to prior. EKG showed ST depression in anterolateral leads. Due to concern for aspiration and mucous plugging, tube feeds were held and chest PT and deep suctioning were performed with improved respiratory status. Later that day, the patient had increased SOB, somnelence, tachycardia, and was febrile. Medical team met with the family to discuss care options of MICU with intubation or CMO given that patient was DNI. During family discussion, patient began agonal breathing and passed away. . #Pneumonia: On [**2130-2-10**], there was concern for aspiration PNA due to persistent R lower lobe hazy opacity since admission, low grade fever to 100.8, and increased cough. The patient had persistent leukocytosis due to CLL. Sputum gram stain and culture were ordered. Patient was started on vancomycin 1000mg IV q48 hrs and Zosyn 2.25 gm IV q6. . Diastolic Dysfunction/CHF: Patient had an ECHO on [**2130-2-9**] showing LVEF>55%. Regional left ventricular wall motion is normal. Grade II (moderate) LV diastolic dysfunction. Moderate (2+) mitral regurgitation, moderate [2+] tricuspid regurgitation, and moderate pulmonary artery systolic hypertension is seen. His lisinopril 5mg was held because of creatinine trending up to 2.5. . #HTN: Patient was on atenolol 25mg qam on admission, this was changed to metoprolol and was titrated to metoprolol 50mg [**Hospital1 **] for improved HTN control. He was on lisinopril 5mg daily on admission which was discontinued due to rising creatinine. . #CLL: WBC trended up from 66k to 88k on [**2130-2-10**] and decreased to 76.7K on [**2130-2-11**]. Patient was on leukoram 2mg daily on admission, this was held during admission due to acute medical issues and was to be restarted on discharge. . #Chronic renal disease: Patient has Cr has ranged from 1.4-2.5 during hospital course. Baseline per PCP office is 1.5 in [**10-14**]. Fractional excretion Urea: 18% based on urine electrolytes indicated creatinine rise likely due to pre-renal disease. . #Anemia: Patient has chronic anemia per prior PCP notes due to CLL and iron deficiency. On admission, the patient's Hct was 32.1 and it trended down to 28. Stool guaiac was ordered. . #DMII: Patient had hyperglycemia during hospital course, transiently on insulin gtt. He was on glargine 10u daily and RISS with QID FSBG. Glargine was decreased to 5u when patient's tube feeds were held on [**2130-2-11**] due to concern for aspiration. . #Obstructive sleep apnea: patient was given a trial of CPAP on [**2130-2-10**] in the evening. . #Diet: SLP evaluated patient and determined he may be aspirating PO's and given altered MS, so patient continued on NG tube feeds. Tube feeds were held on [**2130-2-10**] due to concern for aspiration. . #PPX: Patient was on pneumoboots for DVT prophylaxis. Bowel regimen with colace and senna. . #Code status: DNR/DNI per health care proxy discussion, confirmed on [**2130-2-10**] with discussion with health care proxy. Medications on Admission: metformin 1g qam 500mg qpm glipizide 10mg [**Hospital1 **] atenolol 25mg qam lasix 20mg qam aggrenox 200mg [**Hospital1 **] lisinopril 5mg leukeram 2mg qpm after food Discharge Medications: n/a Discharge Disposition: Extended Care Discharge Diagnosis: Primary: 1. Traumatic Subarachnoid Hemmorhage. 2. Intraparenchymal contusion/hemorrhage. 3. Subdural hematoma. 4. Left temporal bone fracture and hemotympanum 5. NSTEMI. 6. Acute Renal Failure. 7. Dysphagia. 8. Aspiration Pneumonia. 9. Severe Cervical Spinal Stenosis. 10. Diastolic Heart Failure. 11. Mild Aortic Stenosis([**Location (un) 109**] 1.2-1.9cm2). 12. 2+ Mitral and Tricuspid Regurgitation. Secondary: 1. Coronary Artery Disease s/p PCI-Stent. 2. Chronic Lymphocytic Leukemia. 3. Diabetes Mellitus Type II. 4. Transient Ischemic Attack. 5. Hypertension. 6. Diastolic Heart Failure. Discharge Condition: Expired Completed by:[**2130-2-14**]

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Discharge summary

report

Admission Date: [**2187-3-17**] Discharge Date: [**2187-3-23**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8747**] Chief Complaint: left sided weakness Major Surgical or Invasive Procedure: intubation History of Present Illness: This is a 81 yo woman with a large suprasellar mass/meningioma (patient refused surgical removal in recent past) causing panhypopituitaryism, who was admitted yesterday from the ED with sepsis to the [**Hospital Unit Name 153**]. I am now being called for left sided weakness since about 4:30am (it is now 10AM). She was found unresponsive in bed at [**Location (un) 15383**] Home where she lives, incontinent, fever to 104. No seizure activity noted. +N/V for several days beforehand. In our ED she was 104.8 degrees F and hypotensive to the 80's. Her BP picked up with IVF, she was given CTX/Vanco/Flagyl in the ED (now on CTX/Vanco in [**Hospital Unit Name 153**]), and steroids were increased to stress dose (from 20mg hydrocort a day to 50 IV q6). She had an LP yesterday that was unremarkable. No OP withdrawn, 4 cc obtained in the ED. In the [**Hospital Unit Name 153**] she was noted to have left sided weakness at around 4:30am, team was notified at 7:30am, and neurology was called around 9:45am. Patient seen immediately. Please see my exam below. She is confused, slumps to the right (left neglect), left hemiparesis (arm is plegic) but sensation intact. ROS: no arrhythmias overnight. She was hypotensive to 91/30 and given fluid bolus overnight. Patient currently has no complaints but is confused. Past Medical History: 1. Tuberculum sellae meningioma with suprasellar extension and superior and posterior displacement of the optic chiasm, 4.1 x 3.4 x 2.1 cm in transverse x anterior posterior x superior inferior dimensions. dx'd ~5yrs ago per pt at BU. Patient was admitted in [**10-21**] and underwent extensive evaluation of this mass by onc/neurosurg/xrt. She was admitted for an unresponsive episode that was thought to be secondary to adrenal insufficiency. Patient refused surgery on her mass. She is on replacement thyroid, steroids. 2. Seizure disorder: Details unclear--pt first reported being on dilantin for ~1 year, then reported being on it only 6 weeks. She is unable to provide details of the seizures. 3. Hypertension 4. COPD 5. Hypothyroidism 6. Cataracts and ?glaucoma left eye. Pt unsure if has had surgery on it. 7. Severely decreased vision L eye, etiology uncertain but likely due to mass 8. Likely has dementia per Dr. [**Last Name (STitle) 4253**]. ALL: NKDA Social History: lives at [**Location (un) **] Home for past 5 years or so. +Tobacco for at least 20 yrs, reports [**12-18**] ppd for 5yrs. Previously drank ~1pint/day, none for [**4-25**] yrs. Used to work as maid at Colonnade Hotel until ~5 yrs ago. Family History: Unknown Physical Exam: PHYSICAL EXAM: VITALS: T 100.2 current, 89, 109/34, 21, 98% RA. FS 129 GEN: elderly woman slumping to the right in bed, not intubated, in [**Hospital Unit Name 62876**]: no rash HEENT: NC/AT, anicteric sclera, mmm NECK: supple, no carotid bruits CHEST: normal respiratory pattern, CTA bilat CV: regular rate and rhythm without murmurs ABD: soft, nontender, nondistended, +BS EXTREM: no edema NEURO: Mental status: Patient is alert, awake but falls asleep in middle of exam. She is confused, unable to tell me why she's here or any story. She is oriented to self, "06", but not location, "I'm here." She names her right thumb and her nose, but when asked to name her left thumb she gives nonsense answer. Language is fluent with fair comprehension (follows simple commands), no dysarthria. Unable to perform further testing as she falls asleep. Cranial Nerves: I: deferred II: Visual acuity: not tested today. Visual fields: no blink to threat on the left. Fundoscopic exam: unable, small pupils. Pupils: 1 mm and fixed. III, IV, VI: Looks to the right well, does not cross the midline, but does dolls laterally appropriately (when sleepy). No nystagmus or ptosis. V: + corneals. VII: left lower facial weakness VIII: unable IX, X: gag reflex present bilaterally. [**Doctor First Name 81**]: unable XII: unable Sensory: withdrawls vigorously on the right, winces and cries on the left to painful stim with minimal withdrawl of the left leg proximally. Left arm plegic. Motor: Normal tone. Left hemiparesis with left arm plegia. Reflexes: [**Hospital1 **] BR Tri Pat Ach Toes RT: 2 2 2 tr 0 down LEFT: 2 2 2 tr 0 mute Coordination: unable Gait: unable Pertinent Results: [**2187-3-17**] 08:45PM GLUCOSE-86 UREA N-20 CREAT-1.0 SODIUM-143 POTASSIUM-4.6 CHLORIDE-118* TOTAL CO2-14* ANION GAP-16 [**2187-3-17**] 08:45PM CK(CPK)-141* [**2187-3-17**] 08:45PM CK-MB-3 cTropnT-<0.01 [**2187-3-17**] 08:45PM CALCIUM-6.1* PHOSPHATE-3.1 MAGNESIUM-1.5* [**2187-3-17**] 08:45PM WBC-7.7 RBC-4.51 HGB-13.2 HCT-41.6 MCV-92 MCH-29.3 MCHC-31.7 RDW-15.5 [**2187-3-17**] 08:45PM NEUTS-89.1* BANDS-0 LYMPHS-7.0* MONOS-3.1 EOS-0.6 BASOS-0.2 [**2187-3-17**] 08:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2187-3-17**] 08:45PM PLT SMR-NORMAL PLT COUNT-190 [**2187-3-17**] 08:45PM PT-13.4* PTT-29.5 INR(PT)-1.2* [**2187-3-17**] 06:26PM GLUCOSE-93 UREA N-20 CREAT-1.0 SODIUM-142 POTASSIUM-4.6 CHLORIDE-117* TOTAL CO2-12* ANION GAP-18 [**2187-3-17**] 06:26PM CK(CPK)-138 [**2187-3-17**] 06:26PM CALCIUM-6.5* PHOSPHATE-2.8 MAGNESIUM-1.6 [**2187-3-17**] 06:26PM WBC-8.8# RBC-4.74 HGB-13.8 HCT-43.9 MCV-93 MCH-29.0 MCHC-31.3 RDW-15.5 [**2187-3-17**] 06:26PM NEUTS-70 BANDS-22* LYMPHS-5* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2187-3-17**] 06:26PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2187-3-17**] 06:26PM PLT SMR-NORMAL PLT COUNT-209 [**2187-3-17**] 06:26PM PT-26.5* INR(PT)-2.7* [**2187-3-17**] 05:02PM TYPE-ART PO2-71* PCO2-34* PH-7.30* TOTAL CO2-17* BASE XS--8 INTUBATED-NOT INTUBA [**2187-3-17**] 05:02PM LACTATE-0.9 [**2187-3-17**] 01:50PM CEREBROSPINAL FLUID (CSF) PROTEIN-110* GLUCOSE-73 [**2187-3-17**] 01:50PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-1* POLYS-0 LYMPHS-92 MONOS-8 [**2187-3-17**] 12:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2187-3-17**] 12:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2187-3-17**] 11:19AM LACTATE-2.0 [**2187-3-17**] 11:10AM GLUCOSE-106* UREA N-25* CREAT-1.6* SODIUM-144 POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-21* ANION GAP-15 [**2187-3-17**] 11:10AM ALT(SGPT)-24 AST(SGOT)-27 CK(CPK)-64 ALK PHOS-102 AMYLASE-149* TOT BILI-0.2 [**2187-3-17**] 11:10AM cTropnT-<0.01 [**2187-3-17**] 11:10AM CK-MB-NotDone [**2187-3-17**] 11:10AM TOT PROT-6.6 ALBUMIN-4.1 GLOBULIN-2.5 CALCIUM-8.6 MAGNESIUM-1.8 [**2187-3-17**] 11:10AM TSH-0.18* [**2187-3-17**] 11:10AM CORTISOL-9.3 [**2187-3-17**] 11:10AM PHENYTOIN-19.4 [**2187-3-17**] 11:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2187-3-17**] 11:10AM WBC-5.2 RBC-4.50 HGB-13.4 HCT-40.9 MCV-91 MCH-29.7 MCHC-32.7 RDW-15.2 [**2187-3-17**] 11:10AM NEUTS-78* BANDS-11* LYMPHS-10* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2187-3-17**] 11:10AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2187-3-17**] 11:10AM PLT SMR-NORMAL PLT COUNT-247 [**2187-3-17**] 11:10AM PT-13.1 PTT-22.6 INR(PT)-1.1 TRANSTHORACIC ECHO: Cardiology Report ECHO Study Date of [**2187-3-19**] PATIENT/TEST INFORMATION: Indication: Cerebrovascular event/TIA. Left ventricular function. Height: (in) 62 Weight (lb): 162 BSA (m2): 1.75 m2 BP (mm Hg): 156/59 HR (bpm): 75 Status: Inpatient Date/Time: [**2187-3-19**] at 12:52 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006E006-0:36 Test Location: East MICU Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.9 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 4.6 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.3 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.6 cm Left Ventricle - Fractional Shortening: 0.37 (nl >= 0.29) Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%) Aorta - Valve Level: 2.6 cm (nl <= 3.6 cm) Aorta - Ascending: 2.9 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 1.1 m/sec Mitral Valve - E/A Ratio: 0.73 Mitral Valve - E Wave Deceleration Time: 263 msec TR Gradient (+ RA = PASP): *38 to 48 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV systolic function. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Mild [1+] TR. Moderate PA systolic hypertension. PERICARDIUM: No pericardial effusion. 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. Conclusions: 1.The left atrium is mildly dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 6.There is moderate pulmonary artery systolic hypertension. 7.There is no pericardial effusion. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. Compared with the findings of the prior study (images reviewed) of [**2186-10-20**], no change. IMPRESSION: No cardiac source of embolism seen. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2187-3-19**] 17:29. HEAD CT AT PRESENTATION [**3-17**]: NON-CONTRAST HEAD CT: Comparison with [**2186-10-20**] CT scan and [**2186-10-21**] MRI. The suprasellar mass exerting mild mass effect on the left inferior frontal lobe is again identified, measuring 34 x 32 mm, not significantly changed in size or appearance. There is no hydrocephalus. There is no shift of normally midline structures, intra- or extra-axial hemorrhage, or acute major vascular territorial infarct. The [**Doctor Last Name 352**]-white differentiation appears preserved. There is scattered opacification of mastoid air cells, but the remainder of the imaged sinuses appear clear. IMPRESSION: Stable appearance of large suprasellar meningioma. No other acute intracranial hemorrhage or mass effect. MRI: This study is compared with similar examination performed on [**2186-10-21**]. FINDINGS: MRI of the brain without contrast was performed. There is no MR evidence of hemorrhage, edema, midline shift or hydrocephalus. Diffusion-weighted images demonstrate a focal area of restricted diffusion in the right frontal and parietal regions and also on the left side in the similar region and appears to be along the watershed zone between the anterior and middle cerebral artery distributions. MR angiography is severely limited by motion. Faint flow is noted in the middle cerebral arteries bilaterally, right greater than the left. Again noted is a sellar meningioma, which appears to be unchanged in size and extension since the prior examination. IMPRESSION: Acute infarct noted in the watershed zone within the anterior and middle cerebral artery distribution on the right and also on the left. MR [**First Name (Titles) 4058**] [**Last Name (Titles) 4059**] absent flow in the right internal carotid artery, suggesting right internal carotid artery occlusion. Faint flow is noted in the right middle cerebral artery and appears to be via the anterior communicating artery from the left side. These findings were immediately discussed with Dr. [**Last Name (STitle) 7673**] from neurology at the time of interpretation. [**3-19**] head CT: COMPARISON: [**2187-3-17**]. TECHNIQUE: Noncontrast head CT scan. FINDINGS: Compared to yesterday's study, multiple new cortical hypodensities are seen within the right frontal and frontoparietal regions. There is no evidence of acute intracranial hemorrhage. There is no shift of normally midline structures. The ventricles appear unchanged compared to prior study. Again seen is a large suprasellar mass in the left inferior frontal region, not significantly changed in size or appearance compared to yesterday's study. Mild mucosal thickening is seen within the ethmoid air spaces. There is evidence of a left-sided mucous retention cyst in the left maxillary sinus. Scattered opacification of the mastoid air cells appears unchanged. IMPRESSION: 1. Multiple new cortical hypodensities seen within the right frontal and frontoparietal regions, consistent with MCA infarct. 2. No acute intracranial hemorrhage or shift of normally midline structures. 3. Unchanged appearance of large suprasellar mass seen in the left inferior frontal region. Findings discussed with Dr. [**Last Name (STitle) 7673**] at 10:30 a.m. on [**2187-3-18**]. [**3-19**] CTA: TECHNIQUE: Non-contrast head CT was first performed and then, a CTA was performed with IV contrast. FINDINGS: There are no prior comparison examinations. Correlation is obtained with the prior MRI of [**2187-3-18**]. The non-contrast head CT [**Year (4 digits) 4059**] multiple hypodensities within the territory of the right middle cerebral artery territory brain cortex, consistent with early subacute infarcts. There is no evidence of intracranial hemorrhage or shift of the normally midline structures. A large suprasellar mass slightly eccentric to the left is again identified, reportedly characteristic of a meningioma from prior MRIs. CTA [**Year (4 digits) 4059**] the left common carotid artery has mild areas of narrowing from its origin at the arch due to atherosclerotic plaques. At the bifurcations of both internal carotid arteries, there is a large amount of atherosclerotic plaque. On the left, the internal carotid artery is severely narrowed at its origin. On the right, only a few mm of the proximal internal carotid artery are identified. There is no flow just distal to this point. The right internal carotid artery then reconstitutes at its petrous segment and flow is present in its cavernous and supraclinoid portions, although with atherosclerotic plaque some of which is calcified. The left internal carotid artery just distal to its internal carotid artery origin has flow with calcified atherosclerotic plaque at its cavernous segment. The supraclinoid left internal carotid artery then is encased by the presumed meningioma with significant narrowing of its normal caliber. Once the vessel leaves the suprasellar mass, the normal caliber is restored and there is flow within the middle cerebral artery and minimal flow within a hypoplastic segment of the left A1 anterior cerebral artery. Flow is seen within the right middle cerebral artery as well as within both anterior cerebral arteries. The right vertebral artery is noted to be very thin and irregular from its origin on the aortic arch. The left vertebral artery appears to be dominant. The basilar artery appears normal. There may be a small segment of stenosis at the proximal right posterior cerebral artery. The remainder of the posterior cerebral arteries enhance normally. IMPRESSION: Non-visualization of the right internal carotid artery from its origin to the petrous segment. At the petrous segment, the right internal carotid artery is reconstituted and courses normally to its bifurcation into the anterior and middle cerebral arteries. The left internal carotid artery has stenosis at its origin due to atherosclerotic plaque. It then courses superiorly and is encased by the suprasellar mass at its supraclinoid portion. In this region, the lumen of the left internal carotid artery appears significantly narrowed. Once the left internal carotid artery exits the mass, a more normal caliber is restored and there is opacification of the anterior and middle cerebral arteries. The right vertebral artery appears small throughout its entire course and slightly irregular, likely due to atherosclerotic disease. EKG AT PRESENTATION" Sinus tachycardia. Low limb lead voltage. Compared to the previous tracing of [**2186-10-25**] the rate has increased. Otherwise, no diagnostic interim change. Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 111 112 74 322/387.71 65 77 64 Brief Hospital Course: 81 yo RH woman with hx HTN, COPD, sz d/o and a large suprasellar mass/meningioma for which she had apparently refused surgical removal and w/u currently considering xrt, mass causing panhypopituitarism, on outpatient hydrocortisone, initially admitted to the [**Hospital Unit Name 153**] on [**2187-3-18**] with fever and hypotension after being found unresponsive in bed at [**Location (un) 45045**] NH. She had apparently been found unresponsive in bed at [**Location (un) 15383**] Home where she lives, incontinent of urine, with fever to 104. No seizure activity had been noted by staff; of note, according to hx obtained by her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], she had had viral illness with nausea and vomiting for days before she came in, and many other NH residents were also sick with an apparent viral illness. She was taken to [**Hospital1 18**] ED where temp was 104.8 and SBP was in the 80s - it transiently increased with IVF then required many boluses IVF; patient was treated with vanco and flagyl, 4L IVF, LP was negative with neg cx (though no OP recorded, and only 4cc fluid sent) and she was transferred to the [**Hospital Unit Name 153**]/[**Hospital Ward Name 516**] for further workup of what was thought at the time to be sepsis. Initial head ct had been negative for new changes or infarcts but showed stable size of meningioma. The following morning, she was noted to have L-sided weakness and the neurology team was called at 7:30 AM. She was felt to be confused, slumping to the right, neglecting the left, and with left sided hemiplegia; sensation reported as intact. Further workup of septic source for fever/hypotension was negative, including negative blood cultures, negative TTE, and negative chest xray/UA. She was intubated for airway protection with change in MS, later extubated without event on [**3-21**]. CT of the brain had suggested bilateral watershed infarcts; MRI was consistent with this finding, though images reviewed by the stroke consult team suggested right watershed infarcts and tight RCA, with ?L embolic infarct. Blood pressure has been stable for 24 hours, and she is ready for transfer to the neurology service. The patient has no complaints except not being able to move her left side. Visual loss is also a complaint, but this is chronic and related to the sellar mass according to her primary care doctor. He reports that her baseline is "oriented times one," with very poor memory, but able to ambulate independently without a cane. She apparently has a bed reserved at [**Last Name (un) **] NH when she has stabilized. Sepsis workup was negative, including cx and TTE, and imaging was found to have R>L infarcts on head ct thought watershed from low bp, versus embolic on one side. She had imaging with L ICA occlusion/severe stenosis that was not present on MRI in [**2185**]. She was initially started on Aggrenox and switched to Plavix; she is now on plavix, aspirin, a statin, and on an ACE-I as her BP is more stable with stress-dose steroids. One possible mechanism for her stroke (also suggested by PCP) was viral illness with poor endogenous steroid response related to panhypopit and resulting functional adrenal crisis. On hydrocortisone she has done much better and endocrine is following her. She was continued on continue current meds from [**Hospital Unit Name 153**]; lytes and dilantin level were monitored and were within goal range (dilantin level 16.4 on [**3-23**]), stroke workup was completed including Hba1c of 5.9, FLP pending. With dementia and comorbidities, she was felt to be a poor candidate for surgical correction of carotid stenosis; stent is one possibility, but as the other carotid is completely occluded, it might be a risky procedure. She was also felt to be a he will be a poor coumadin candidate secondary to poor vision and now a fall risk due to hemiplegia. She was continued on aspirin and plavix. PT and OT felt that she might benefit from rehab stay; she was transferred to rehab at [**Hospital3 537**], where her NP and HCP [**Name (NI) 11320**] [**Name (NI) 16528**] could continue to follow her. Medications on Admission: MEDICATIONS IN HOUSE Magnesium Sulfate 3 gm / 250 ml D5W IV ONCE Duration: 1 Doses Phenytoin 100 mg IV Q12H [**3-17**] @ 2054 View Calcium Gluconate 2 gm / 100 ml D5W IV ONCE Duration: 1 Doses Insulin SC (per Insulin Flowsheet) Sliding Scale 04/01 @ 1826 View Levothyroxine Sodium 37.5 mcg IV DAILY [**3-17**] @ 1826 View Ipratropium Bromide Neb 1 NEB IH Q6H [**3-17**] @ 1826 View Albuterol 0.083% Neb Soln 1 NEB IH Q6H [**3-17**] @ 1826 View Hydrocortisone Na Succ. 50 mg IV Q6H [**3-17**] @ 1826 View Ceftriaxone 1 gm IV Q24H Start: In am [**3-17**] @ 1826 View Vancomycin HCl 1000 mg IV Q48H Start: In am Heparin 5000 UNIT SC TID [**3-17**] @ 1826 View Pantoprazole 40 mg IV Q24H [**3-17**] @ 1826 View Aspirin 81 mg PO DAILY [**3-17**] @ 1826 View Discharge Medications: 1. Hydrocortisone 10 mg Tablet Sig: see below Tablet PO see below: Taper Hydrocortisone as follows: -Take 25 mg po q6h (5 tabs) x 2 days, then -Take 25 mg po q8h (5 tabs) x 2 days, then -Take 25 mg po bid (5 tabs) x 2 days, then -Home dose of 20 mg (4 tabs) qAM and 10 mg (2 tabs) qPM thereafter. Call Endocrinologist if any questions. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 11. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Phenytoin 50 mg Tablet, Chewable Sig: see below Tablet, Chewable PO twice a day: take 2 tablets (100 mg) qam and 1 tablet (50 mg) qpm for total of 150 mg daily. 13. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous once a day for 1 days: please give dose on [**3-24**] then D/C peripheral IV. 14. Rocephin in Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 1 days: please give one dose 4/8 then d/c peripheral IV. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Watershed cerebral infarctions Hypotension Fever Adrenal insufficiency related to panhypopituitarism Discharge Condition: Left-sided hemiplegia, right-sided weakness, visual acuity poor with likely visual field cuts, left-sided hemineglect and hemisensory changes (diminished pinprick and light touch). Memory poor (baseline dementia). Stable blood pressure. Discharge Instructions: Please [**Name8 (MD) 138**] MD or return to ED if new changes in mental status, worsened weakness, or any other signs of stroke. If she becomes hypotensive or sick, consider also calling her endocrinologist Dr. [**Last Name (STitle) 10759**], as this might indicate an episode of adrenal insufficiency. Followup Instructions: Primary care: Dr. [**Last Name (STitle) **] - please call for appointment once rehab stay completed. Neurology: please call office of Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 7394**] for appointment in 4 weeks. Endocrinology: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12647**] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2187-4-24**] 4:00 Completed by:[**2187-3-23**]

[ "729.89", "518.81", "244.8", "401.9", "780.39", "584.9", "255.4", "458.9", "781.8", "294.8", "276.52", "253.2", "433.11", "225.2", "342.92", "496" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

24438, 24509

17787, 21938

284, 296

24654, 24894

4677, 7725

25246, 25677

2916, 2926

22758, 24415

24530, 24633

21964, 22735

24918, 25223

7751, 11057

2956, 3349

224, 246

324, 1652

3815, 4658

13117, 17764

3364, 3799

1674, 2647

2663, 2900

7,016

163,629

26305

Discharge summary

report

Admission Date: [**2182-1-28**] Discharge Date: [**2182-2-11**] Date of Birth: [**2117-3-22**] Sex: M Service: CARDIOTHORACIC Allergies: Blue Dye Attending:[**First Name3 (LF) 1283**] Chief Complaint: Fatigue/Dyspnea on exertion Major Surgical or Invasive Procedure: Redo Aortic Valve Replacement (21mm CE perimount) [**2182-1-28**] Exploratory Laparotomy w/ lysis of adhesions [**2182-2-2**] History of Present Illness: Very pleasant 64 y/o male s/p CABGx1/AVR(tissue)/MV Repair in [**Country 4194**] in [**2172**] now with increased fatigue, DOE, and CP. Admitted to [**Hospital1 **] where he was found to have severe aortic insufficiency. Given the severity of his disease, he was referred for surgical management. Past Medical History: Coronary Artery Disease s/p CABG x 1/AVR(tissue)/MV Repair [**2172**] Hypertension Hypercholesterolemia Gastroesophageal Reflux Disease Depression s/p Bowel Resection secondary to obstruction s/p Appendectomy s/p Lipoma removal on back Social History: Quit smoking [**12-21**] after 1ppd x 40yrs Denies ETOH Family History: Non-contributory Physical Exam: VS: 56 16 131/57 123/40 64" 131# General: WD, very thin caucasian male in NAD. Appears older than stated age. Skin: Warm, dry with well-healed sternotomy incision. Multiple Nevi. HEENT: NCAT, PERRL, Anicteric sclera. OP benign. Neck: Supple, FROM, -JVD, delayed upstrokes, ?bruit vs. murmur radiation Chest: CTAB -w/r/r Heart: RRR, 4/6 systolic murmur and [**2-18**] diastolic murmur Abd: Soft, NT/ND, +BS w/ well-healed RLQ scar Ext: Warm, well-perfused, -edema, GSV harvested from L thigh. Superficial varicosities. 2+ pulses throughout Neuro: Grossly intact, A&O x 3, Gait slow/steady, mild hand tremor, strength 5/5 bilaterally Pertinent Results: [**2182-1-29**] 03:57AM BLOOD WBC-12.8* RBC-3.25*# Hgb-10.5*# Hct-29.2* MCV-90 MCH-32.2* MCHC-35.9* RDW-15.0 Plt Ct-89* [**2182-2-5**] 06:20AM BLOOD WBC-8.5 RBC-2.54* Hgb-8.4* Hct-23.6* MCV-93 MCH-32.9* MCHC-35.6* RDW-15.0 Plt Ct-184 [**2182-2-11**] 05:10AM BLOOD WBC-7.5 RBC-3.29* Hgb-10.2* Hct-29.6* MCV-90 MCH-30.8 MCHC-34.3 RDW-15.9* Plt Ct-308 [**2182-1-28**] 04:50PM BLOOD PT-16.6* PTT-44.3* INR(PT)-1.5* [**2182-2-5**] 05:11AM BLOOD PT-15.7* PTT-31.3 INR(PT)-1.4* [**2182-1-28**] 04:50PM BLOOD UreaN-17 Creat-0.8 Cl-110* HCO3-25 [**2182-2-11**] 05:10AM BLOOD Glucose-111* UreaN-4* Creat-0.5 Na-140 K-4.0 Cl-103 HCO3-31 AnGap-10 [**2182-2-7**] 05:08AM BLOOD Mg-1.7 [**2182-2-1**] 02:26AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-6.5 Leuks-NEG AbdXR [**1-31**]: Findings most consistent with an ileus, especially given the postoperative status of the patient. Early/partial obstruction cannot be entirely excluded, especially given disproportionate dilation of the small bowel compared to the large. ABD CT [**2-2**]: 1. Small bowel obstruction with a transition point seen in the mid lower abdomen. 2. Right basilar pneumothorax. CXR [**2-8**]: Stable bilateral pleural effusions. Brief Hospital Course: Patient was a same day admit and on [**2182-1-28**] he was brought directly to the operating room where he underwent a Redo Aortic Valve Replacement. Please see op note for surgical details. Patient tolerated the procedure well and was transferred to CSRU. He remained on mechanical ventilation until post op day one when he was weaned from sedation, awoke neurologically intact, and was extubated. He remained on minimal inotropic support until post op day two. Chest tubes were removed on this day and patient was transferred to the cardiac surgery step down unit. B blockers and diuretics were initiated and he was gently diuresed towards his pre-op weight during his post-op course. On post-op day three patient began to c/o n/v along with abdominal pain and distension. Initial abdominal x-ray revealed either a ileus vs. small bowel obstruction (dilated small bowel loops). NG tube was inserted and surgery was consulted. He had another x-ray on post-op day four which showed similar results and then underwent an abdominal CT on [**2-2**]. CT revealed a small bowel obstruction with a transition point in his mid lower abdomen. TXP surgery then brought patient to the operating room where he underwent a exploratory laparotomy and lysis of adhesions. He was transferred to [**Hospital Ward Name 121**] 10 overnight and then transferred back to the cardiac step-down unit on [**2-4**] (post op day 7). On post op day 8 he began to tolerate clear liquids. He was transfused one unit of PRBC's on this day d/t anemia. On post op day 9 (4 days since ex-lap) he began having flatus along with bowel movements. KUB done on this day revealed dilated small-bowel with air-fluid levels and interval increase in small bowel diameter. Despite this his diet was slowly advanced and he was tolerating regular diet by time of discharge. Physical therapy worked with patient during his post-op period for strength and mobility. Over the next several days patient continued to improve. His sternal staples were removed on post-op day 14. He cleared level 5, labs and physical exam were stable, and he was discharged home with VNA services with the appropriate follow-up appointments. Medications on Admission: 1. Aspirin 325mg qd 2. Lisinopril 10mg qd 3. Lopressor 12.5mg [**Hospital1 **] 4. Lipitor 40mg qd 5. Nitro 0.4mg prn 5. Omeprazole 40mg qd 6. Wellbutrin 150mg [**Hospital1 **] 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 DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 4. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*0* 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:*30 Capsule(s)* Refills:*0* 9. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Disp:*30 Tablet Sustained Release(s)* Refills:*0* 10. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Aortic Insufficiency s/p Redo-Aortic Valve Replacement Small Bowel Obstruction s/p Exploratory Laparotomy w/ Lysis of Adhesions Coronary Artery Disease s/p CABG x 1 [**2172**] Hypertension Hypercholesterolemia Gastroesophageal Reflux Disease Depression Discharge Condition: Good Discharge Instructions: Can take shower. Wash incisions with water and gentle soap. Gently pat dry. Do not take bath. Do not apply lotions, creams, ointments or powders to incisions. Do not drive for 1 month. Do not lift more than 10 pounds for 2 months. If you notice any sternal/chest drainage or experience a fever greater than 101.5, please contact office immediately. Please make follow-up appointments. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] in 4 weeks Dr. [**First Name (STitle) 1075**] in [**1-18**] weeks Dr. [**Last Name (STitle) 65121**] in [**12-17**] weeks Completed by:[**2182-2-11**]

[ "997.4", "997.1", "560.1", "530.81", "272.0", "414.00", "V45.81", "424.1", "427.31", "401.9", "285.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "99.04", "39.61", "35.21", "54.59" ]

icd9pcs

[ [ [] ] ]

6768, 6827

3048, 5224

303, 430

7123, 7129

1789, 3025

1104, 1122

5450, 6745

6848, 7102

5250, 5427

7153, 7539

7590, 7774

1137, 1770

236, 265

458, 756

778, 1015

1031, 1088

17,384

184,053

9771

Discharge summary

report

Admission Date: [**2134-2-8**] Discharge Date: [**2134-2-27**] Date of Birth: [**2099-9-10**] Sex: F Service: SURGERY Allergies: Penicillins / Tetracyclines / Succinylcholine / Clozaril Attending:[**First Name3 (LF) 668**] Chief Complaint: ESRD Major Surgical or Invasive Procedure: [**2134-2-9**] R groin dialysis catheter placement [**2134-2-12**] RLE venogram, IVC filter placement, TPA thrombolysis x 24hrs [**2134-2-13**] RLE venogram, balloon angioplasty of R ext-common iliac vv, suction thrombectomy [**2134-2-15**] RLE venogram, suction thrombectomy, removal of IVC filter, stent of R femoral v -> lower IVC, R groin dialysis catheter placement [**2134-2-16**] RUE brachial v. dialysis access [**2134-2-21**] RUE brachial v. dialysis access removed [**2134-2-24**] attempted insertion of PD catheter [**2134-2-26**] R tunneled groin catheter placed History of Present Illness: 34F with ESRD due to IgA nephropathy who has had problems with access for HD. In [**10-10**], she has had RUE AV graft placed, but this became infected and the AV graft was removed on [**2133-12-25**]. She was discharged with a tunneled catheter for HD access. She was getting HD as scheduled, and the dialysis ctr reported R permacath "clotted" on [**2134-2-7**]. Then, the catheter "fell out." Pt presented to OR on [**2134-2-8**] for HD access. Past Medical History: 1. ESRD due to IgA nephropathy 5. GERD 2. Schizoaffective disorder 6. Cardiomyopathy 3. Depression 7. Hypothyroidism 4. Anemia 8. GI bleed PSH: s/p L upper & lower AV fistula - failed s/p R AV fisula basilic v transposition - failed s/p R forearm AV graft - failed s/p PD catheter '[**27**] - failed central venous stenosis - R brachiocephalic v. occlusion of inominate v. s/p R arm brachial->axilla AV graft ([**2133-10-9**]) s/p thrombectomy & angioplasty of outflow stenosis ([**2133-10-11**]) s/p thrombectomy ([**2133-10-23**]) s/p thrombectomy and revision of R arm AV graft ([**2133-11-12**]) s/p thrombectomy of R arm AV graft ([**2133-11-16**], [**2133-12-15**]) s/p excision of infected R arm AV graft ([**2133-12-25**]) Social History: Lives at [**Location (un) **] Health and Rehab center, unemployed, no tobacco, alcohol, or recreational drug use. Family History: Non-contributory. Physical Exam: T96.5 P100 100/60 R22 AAOx3, sleepy PERRLA, EOMI supple neck no carotid bruit RR S1 S2 no MRG decreased bibasilar breath sounds soft NT ND, well healed PD cath site, no puss R groin old permacath site - no erythema, no purulence Pertinent Results: [**2134-2-8**] 03:15PM WBC-5.1# HGB-13.1# HCT-41.0# MCV-103* PLT COUNT-414 [**2134-2-8**] 03:15PM PT-18.7* PTT-29.6 INR(PT)-2.2 [**2134-2-8**] 03:15PM GLUCOSE-76 UREA N-84* CREAT-12.5*# SODIUM-132* POTASSIUM-6.3* CHLORIDE-92* TOTAL CO2-23 ANION GAP-23* [**2134-2-8**] 03:15PM ALT(SGPT)-41* AST(SGOT)-34 ALK PHOS-161* TOT BILI-0.4 Brief Hospital Course: Pt went to the OR [**2134-2-9**] and had R femoral dialysis catheter placed. Due to the known R groin venous stenosis, dialysis catheter flow was variable. [**2134-2-12**] RLE venogram showed THROMBOSIS of R EXT ILIAC V and COMMON ILIAC V with free thrombus extending into IVC. IVC filter was placed, and TPA thrombolysis x 24hrs initiated. [**2134-2-13**] Repeat RLE venogram showed continued thrombosis as above despite TPA. Balloon angioplasty of R ext-common iliac vv and suction thrombectomy were done. [**2134-2-15**] RLE venogram showed persisting thrombus load. Suction thrombectomy was performed, and IVC filter was removed. Venous stents were placed from R femoral v -> lower IVC, and R groin dialysis catheter placement [**2134-2-16**] RUE brachial v. was accessed for dialysis since the R groin dialysis catheter flow was sluggy. [**2134-2-21**] RUE brachial v. dialysis access removed with improved flow of R groin dialysis catheter. [**2134-2-17**] Pt spiked fever to 102.3. Pt was cultured, and was empirically started on Levaquin & Vancomycin. BCx from [**2-17**] and [**2-20**] eventually grew out Staph Coag Neg. Because the pt was still febrile despite being on Vancomycin, pt was switched to Linezolid. [**2134-2-24**] Pt went to the OR for attempted insertion of PD catheter. During the surgery, pt became bradycardic and very hypotensive, and the case was aborted. Pt was placed on pressor support and transferred to the SICU. Cardiology consult was obtained. Echocardiogram showed some depressed LV function, but no focal abnormality was found. No solid evidence for the cause of cardiovascular collapse was established; however, pt remained stable and was weaned off the pressor. [**2134-2-26**] Pt was stable enough to go to Interventional Radiology for placement of groin catheter. She was dialyzed on [**2-26**] and on [**2-27**] as well. Medications on Admission: Diltiazem 30mg po TID Cogentin 0.5mg po BID Epogen 10,000 units SC x3/wk Synthroid 75mcg po DAILY Klonopin 0.75mg po BID Prolixin 20mg po BID Thorazine 25mg po BID Remeron 45mg po HS Plavix 75mg po DAILY EC-ASA 81mg po DAILY Coumadin 1.5mg alternating with 2mg Lipitor 10mg po HS Reglan 10mg po TID Protonix 40mg po DAILY Nephrocap 1 cap po DAILY Renagel Discharge Medications: 1. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days. 2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluphenazine HCl 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 8. Clonazepam 0.5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 9. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO PRN (as needed) as needed. 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4-6H (every 4 to 6 hours) as needed. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 12. Coumadin 3 mg Tablet Sig: 0.5 Tablet PO at bedtime: please adjust for INR 2.0. 13. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 15. Outpatient Lab Work CBC, Chem7, PT, PTT, INR to be checked Monday & Thurs - fax results to [**Telephone/Fax (1) 697**] 16. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 17. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day. 18. Epogen 10,000 unit/mL Solution Sig: One (1) mL Injection x3 / wk. 19. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) **] Health & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: ESRD secondary to IgA nephropathy Placement of R groin permcath [**2134-2-9**] RLE DVT (R ext iliac -> IVC) s/p TPA thrombolysis [**2-12**], thrombectomy, angioplasty & stent attempted PD catheter placement Schizoaffective Hypothyroid HTN GERD Discharge Condition: stable Discharge Instructions: check R groin catheter site Q shift. If with fever, chills, nausea, vomiting, feeling unwell, please call the Transplant Office ASAP. [**Month (only) 116**] restart COUMADIN. Goal INR 2.0 Followup Instructions: Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Where: LM [**Hospital Unit Name 5628**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2134-3-1**] 10:40 Completed by:[**2134-2-27**]

[ "244.9", "276.2", "V56.1", "276.7", "295.70", "614.6", "403.91", "998.12", "426.6", "311", "038.10", "425.4", "427.81", "997.1", "453.8", "E879.8", "285.1", "459.2", "995.91" ]

icd9cm

[ [ [] ] ]

[ "39.50", "00.14", "38.09", "38.95", "38.94", "99.29", "88.66", "38.07", "99.10", "38.91", "88.51", "99.04", "54.0", "39.99", "39.95", "38.7", "39.90" ]

icd9pcs

[ [ [] ] ]

6825, 6926

2956, 4827

319, 898

7215, 7223

2593, 2933

7459, 7690

2308, 2327

5232, 6802

6947, 7194

4853, 5209

7247, 7436

2342, 2574

275, 281

926, 1376

1398, 2161

2177, 2292

20,402

168,324

27221

Discharge summary

report

Admission Date: [**2137-12-29**] Discharge Date: [**2138-1-10**] Date of Birth: [**2079-1-25**] Sex: F Service: MEDICINE Allergies: Indocin / Tigan Attending:[**First Name3 (LF) 348**] Chief Complaint: Malfunctioning AV Graft Major Surgical or Invasive Procedure: Thrombectomy History of Present Illness: Ms. [**Known lastname 25922**] is a 58yo woman with multiple medical problems including DM, ESRD on HD, CHF with EF 25%, afib on amiodarone and coumadin, obesity and T11-12 vertebral fractures who initially presented to the hospital on [**2137-12-29**] with CC of clotted R AVG and increasing DOE and orthopnea c/w fluid overload. ROS otherwise non-contributory. Of note, pt. wears 2LNC at baseline for unclear reasons as she has no diagnosis of COPD or other lung disease. Past Medical History: CHF home O2, AF, RA, DM 20yrs on HD since [**1-11**], gastroparesis, GERD PSH: AICD (VFIB), cholecystectomy, cataracts, ovarian cysts drainage Social History: Recently at [**Hospital1 1501**] since [**Month (only) 359**] s/p compression fx c/b osteomyelitis. Married, normally lives at home with her husband. [**Name (NI) **] tobacco/EtOH/illicits. Family History: NC Physical Exam: 9 BP 105/52 HR 92 O2 sat 100% on bipap RR 18 General: obese, sleepy female, agitated after receiving narcan HEENT: anicteric sclera, dry MM Neck: supple, difficult to assess JVP Chest: rhonchorous BS b/l CV: RRR, nl S1 S2, no m/r/g Abd: soft, obese, NT, +BS Ext: [**1-7**]+ peripheral edema, L>R Neuro: alert,awake conversing after narcan Pertinent Results: [**2137-12-29**] 03:45PM PLT COUNT-242 [**2137-12-29**] 03:45PM WBC-9.9 RBC-4.61 HGB-12.1 HCT-41.8 MCV-91# MCH-26.3* MCHC-29.0* RDW-18.5* [**2137-12-29**] 03:45PM DIGOXIN-0.5* [**2137-12-29**] 03:45PM calTIBC-195* FERRITIN-950* TRF-150* [**2137-12-29**] 03:45PM ALBUMIN-3.7 CALCIUM-9.5 PHOSPHATE-7.2*# MAGNESIUM-2.6 IRON-24* [**2137-12-29**] 03:45PM CK-MB-NotDone cTropnT-0.06* [**2137-12-29**] 03:45PM CK(CPK)-16* [**2137-12-29**] 03:45PM estGFR-Using this [**2137-12-29**] 03:45PM GLUCOSE-63* UREA N-58* CREAT-7.1*# SODIUM-142 POTASSIUM-7.2* CHLORIDE-104 TOTAL CO2-20* ANION GAP-25* [**2137-12-29**] 05:50PM PT-21.0* PTT-32.4 INR(PT)-2.0* [**2137-12-29**] 05:58PM PTH-105* [**2137-12-29**] 10:05PM CK-MB-NotDone cTropnT-0.05* [**2137-12-29**] 10:05PM CK(CPK)-15* [**2137-12-29**] 10:05PM POTASSIUM-5.4* . CTA 1. No evidence of central pulmonary embolism. 2. Mediastinal lipomatosis. 3. Multinodular and heterogeneous thyroid gland with calcifications. Correlate clinically, with physical exam and biochemical profile, and if necessary, thyroid ultrasound. 4. No definite evidence of interstitial lung disease. Dedicated high- resolution CT of the chest would be more suitable for assessing for subtle interstitial changes. 5. Cardiomegaly, with leftward mediastinal deviation. Brief Hospital Course: Ms. [**Known lastname 25922**] is a 58 yo woman with ESRD on HD, CHF, Afib, DM, obesity, and vertebral fractures, who presented with clotted AVG and DOE, was transferred to the MICU for further respiratory distress in the setting of narcotics, successfully reversed and diuresed and called out to the floor at her baseline O2 requirement. The following issues were investigated during this admission: . 1. Dyspnea/Respiratory Acidosis: While on the floor,the patient received narcotics for pain control and subsequently went into respiratory distress which largely responded to Narcan in the ICU. She was treated with Zosyn/vanc for 5 days for possible aspiration along with hypotension on original presentation to the ICU (requiring levophed for less than 24 hours). Her respiratory distress however, did not completely resolve and subsequent ABGs performed in the ICU suggested that her baseline is likely acidemia with pH of 7.2. CXRs were negative for evidence of parenchymal lung disease (an initial concern given her amiodarone use) and w/u for PE was negative. It was concluded that her respiratory acidosis likely represented a combination of restrictive picture secondary to her obesity, CHF and possible COPD. Additionally, her respiratory decline began approximately 2 weeks prior to admission when her Digoxin was stopped, so this was restarted. The patient was transferred back to the general medicine floor at her baseline oxygen requirement with no complications. She continued to have oxygen saturations in the high 90s on 2L with no complaints of dyspnea. . 2. AVG Thrombus: Because the patient went into respiratory distress, she was not able to have the thrombectomy performed initially. She continued HD through a groin catheter. She eventually had a tunneled R IJ [**Last Name (un) **] placed where she continued to have HD done. After arriving to the floor, an attempt was made to perform a thrombectomy, but this failed and the patient continued HD daily with the tunneled catheter. . 3. T11-12 vertebral fractures: Case was discussed with orthopedics and pt. was determined to not be a surgical candidate. She was maintained on calcium, vitamin D and calcitonin, with Tylenol for pain. . 4. CHF: Patient was maintained on Spironolactone and Ace-inhibitor and Carvedilol. Digoxin was restarted as stated above. . 5. Afib: Pt. was maintained on Amiodarone for rhythm control and Coumadin for anticoagulation, held only briefly in the perioperative period for the thrombectomy. . 6. RA: Pt. was treated with a Prednisone taper and Leflunomide. . 7. Skin breakdown: Pt. had various areas of skin breakdown around pannus and coccyx. For which wound care and plastic surgery were consulted. Wound care recommendations as have been provided in the discharge paperwork, were followed. . 8. NIDDM - Pt. was maintained on an insulin sliding scale and NPH with good control. . 9 GERD - Pt. was maintained on a PPI Medications on Admission: Coumadin 1 mg qd Metamucil powder 5 ml Prednisone 10 mg qd Nephrocaps 1 Tricor 154 mg qd Areva 10 mg qd Aldactone 25 mg qd Lactulose 30 mg qd Coreg 25 mg qd Colace 100 mg [**Hospital1 **] Renagel 800 mg TID Captopril 25 mg TID Reglan 10 mg qid Pravachol 80 mg qd Licocaine patch Amiodarone 200 mg qd Ativan 1 mg q 24 hrs prn dilaudid 4 mg q 3 hours prn protonix 40 mg [**Hospital1 **] Zofran 4 mg q 6 hours prn Humulin 1000 (20 units SC BID) Sliding scale Zinc Vitamin C Multivitamin Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 5. Sevelamer 400 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. Leflunomide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO QSUN,TUES,THURS,SAT (). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed. 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed. 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 doses. 16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. 17. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) Nasal DAILY (Daily). 18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 19. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 21. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 22. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 23. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 24. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 25. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment Sig: One (1) Appl Topical DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 **] senior healthcare of [**Location (un) 7168**] Discharge Diagnosis: Primary CHF Clotted AV Graft . Secondary AFib on amio and coumadin RA on chronic prednisone 20mg po qday NIDDM x 20yrs ESRD on HD since [**1-11**] Gastroparesis GERD s/p AICD for vfib s/p CCY s/p cataract surgery s/p ovarian cyst drainage s/p occluded right brachiocephalic PTFF graft [**9-11**]; failed thrombectomy, changed [**2137-10-3**]. On coumadin Discharge Condition: Stable, afebrile, at baseline O2 requirement. Discharge Instructions: You were seen and evaluated for a malfunctioning AV graft as well as shortness of breath, which was thought to be due to fluid-overload from congestive heart failure. You had to briefly go to the intensive care unit for management of your breathing and heart failure, after which you were evaluated for the malfunctioning AV graft. The graft could not be repaired but, you can continue hemodialysis through another catheter you had placed in your neck. You are being discharged to your previous rehabilitation center so that you can continue your therapy. * Please take all of your medications as directed. * Please keep all of your follow-up appointments * Call your doctor or go to the ER for any of the following: fevers/chills, nausea/vomiting, shortness of breath, chest pain or any other concerning symptoms. Followup Instructions: Please call your primary care doctor to make an appointment as soon as possible.

[ "428.0", "V58.61", "V58.65", "E937.9", "278.00", "707.03", "530.81", "V45.02", "276.2", "453.9", "286.9", "E932.0", "996.73", "250.40", "733.09", "518.84", "707.8", "585.6", "714.0", "241.1", "733.13" ]

icd9cm

[ [ [] ] ]

[ "39.42", "99.07", "93.90", "38.93", "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

8542, 8631

2917, 5848

300, 314

9030, 9078

1585, 2894

9948, 10032

1206, 1210

6383, 8519

8652, 9009

5874, 6360

9102, 9925

1225, 1566

237, 262

342, 817

839, 983

999, 1190

21,181

148,391

2257

Discharge summary

report

Admission Date: [**2135-10-22**] Discharge Date: [**2135-10-27**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: Unclear speech Major Surgical or Invasive Procedure: None History of Present Illness: 83 yo woman with possible h/o monocular left eye melanoma and HTN presents with slurred speech. Her nephew spoke with her this morning and found her speech to be clear. She apparently has been complaining of dizziness on/off for the past two weeks or so but had refused to see her PCP. [**Name10 (NameIs) **] friend called her at about 5PM and heard that her speech was slurred and called 911. She was brought to [**Hospital6 **] where she was noted to have coherent but slurred speech and right sided weakness of the face and arm. She denied headache. A NC CT of the head was performed which revealed a left-sided capsular hemorrhage. She was transferred to [**Hospital1 18**] for neurosurgical evaluation and further management. Past Medical History: 1. Malignant melanoma isolated to left eye s/p enucleation 28 years ago 2. IBS 3. GERD 4. Hyperparathyroidism, w/ slightly elevated Ca 5. h/o Zoster 6. Stable R adnexal mass 7. L breast nodule Social History: Lives alone. Widowed 5 years ago. Independent, handles own ADLs. HCP is nephew [**Name (NI) **] [**Name (NI) **]. Family History: Brother died from brain aneurysm. Extensive family h/o heart disease at young age. Physical Exam: Admission Physical Exam: T 98.8 HR 67 BP 209/79 RR 21 Sat 98% PE: Gen NAD, supine in bed HEENT AT/NC, MMM no lesions, no bruits Neck Supple, no thyromegaly, no [**Doctor First Name **], no bruits, no Lhermitte's sign Chest CTA B CVS RRR w/o MGR ABD soft, NTND, + BS EXT no C/C/E. no rashes or petechiae, no asterixis Neuro MS: Alert, eyes open to voice. Knows that she is in the hospital. Does not know the date. Follows 1 and 2 step commands. Somewhat sleepy but arousable. Speech is dysarthric and hypophonic but fluent and cohesive. There is agraphesthesia of the right hand. There is no obvious neglect of the right side. CN: I--not tested; II,III-right pupil [**12-21**] reactive, VFF by confrontation in OD, optic discs sharp with normal vasculature on right, the left eye is prosthetic; III,IV,VI-EOMI w/o nystagmus, no ptosis; V--sensation intact to LT/PP, masseters strong symmetrically; VII-there is a RIGHT facial sparing the forehead; VIII-hears finger rub bilaterally; IX,X--voice normal, palate elevates symmetrically, uvula midline, gag intact; [**Doctor First Name 81**]-- SCM/trapezii [**3-24**]; XII--tongue protrudes midline, no atrophy or fasciculation. Motor: Normal bulk and tone. No rigidity, no tremor, no bradykinesia Strength: Delt [**Hospital1 **] Tri WE WF FF FE IO R 5 5 5 5 5 5 5 5 L 4 5 3 4 5 5 4 5 IP Abd Add Quad Ham TA [**First Name9 (NamePattern2) **] [**Last Name (un) 938**] R 5 - - 5 5 5 5 5 L 4 - - 5 4 4 4+ 4 Coord: There is dyscoordination of the right hand in proportion to weakness. [**Doctor First Name **] in left hand appropriate. Refl: [**Hospital1 **] Tri Brachio Pat [**Doctor First Name **] Toe R 2 2 2 2 2 down L 1 1 1 1 0 down [**Last Name (un) **]: LT intact without extinction to DSS. Gait: deferred. Pertinent Results: [**2135-10-27**] 05:00AM BLOOD Plt Ct-295 [**2135-10-27**] 05:00AM BLOOD Glucose-109* UreaN-14 Creat-0.6 Na-147* K-3.1* Cl-113* HCO3-27 AnGap-10 [**2135-10-26**] 06:00AM BLOOD WBC-12.2* RBC-3.99* Hgb-12.9 Hct-36.4 MCV-91 MCH-32.3* MCHC-35.4* RDW-13.5 Plt Ct-312 [**2135-10-25**] 01:27AM BLOOD WBC-15.7* RBC-3.96* Hgb-12.9 Hct-36.2 MCV-92 MCH-32.5* MCHC-35.6* RDW-13.4 Plt Ct-325 [**2135-10-24**] 01:26AM BLOOD WBC-16.4* RBC-4.01* Hgb-12.7 Hct-38.0 MCV-95 MCH-31.6 MCHC-33.3 RDW-13.5 Plt Ct-302 [**2135-10-23**] 01:26AM BLOOD WBC-12.9* RBC-4.29 Hgb-13.9 Hct-38.6 MCV-90 MCH-32.3* MCHC-35.9* RDW-13.0 Plt Ct-308 [**2135-10-23**] 12:30AM BLOOD WBC-10.8 RBC-4.30 Hgb-13.8 Hct-40.1 MCV-93 MCH-32.2* MCHC-34.5 RDW-13.1 Plt Ct-302 [**2135-10-23**] 12:30AM BLOOD Neuts-88.4* Bands-0 Lymphs-8.8* Monos-2.1 Eos-0.5 Baso-0.3 [**2135-10-26**] 06:00AM BLOOD Plt Ct-312 [**2135-10-26**] 06:00AM BLOOD PT-12.5 PTT-24.6 INR(PT)-1.0 [**2135-10-26**] 06:00AM BLOOD Glucose-113* UreaN-20 Creat-0.6 Na-148* K-3.3 Cl-115* HCO3-23 AnGap-13 [**2135-10-25**] 01:27AM BLOOD Glucose-132* UreaN-17 Creat-0.6 Na-148* K-3.5 Cl-114* HCO3-24 AnGap-14 [**2135-10-24**] 01:26AM BLOOD Glucose-113* UreaN-15 Creat-0.6 Na-145 K-3.4 Cl-112* HCO3-25 AnGap-11 [**2135-10-24**] 01:26AM BLOOD CK(CPK)-55 [**2135-10-22**] 10:15PM BLOOD AST-23 LD(LDH)-254* AlkPhos-85 TotBili-0.4 [**2135-10-24**] 01:26AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2135-10-23**] 06:15PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2135-10-23**] 09:51AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2135-10-26**] 06:00AM BLOOD Calcium-10.9* Phos-2.1* Mg-1.9 [**2135-10-25**] 01:27AM BLOOD Calcium-11.5* Phos-2.1* Mg-2.0 [**2135-10-24**] 01:26AM BLOOD Calcium-9.8 Phos-2.4* Mg-2.1 Cholest-157 [**2135-10-24**] 01:26AM BLOOD %HbA1c-5.5 [Hgb]-DONE [A1c]-DONE [**2135-10-24**] 01:26AM BLOOD Triglyc-56 HDL-81 CHOL/HD-1.9 LDLcalc-65 [**2135-10-22**] 10:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Head CT: Intraparenchymal hemorrhage in the region of the left basal ganglia with mild mass effect on the left lateral ventricle. While this is most probably secondary to hypertension, other etiologies cannot be excluded. Please correlate clinically. No herniation present at this time. A small amount of hyperdensity consistent with blood in the temporal [**Doctor Last Name 534**] of the left lateral ventricle. Tiny lacunar infarct is noted in the genu of the interncal capsule on the right. CXR [**10-24**] - no PNA Speech/Swallow: 1. Advance diet to regular solids and thin liquids 2. Try pills whole w/water 3. If there are any signs of aspiration, we would be happy to perform a videoswallow 4. OT consult in [**11-21**] days, when arteiral line is d/c'd for help with self feeding TTE: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to high cardiac output. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: Mrs. [**Known lastname 11906**] is an 83 yo F w/distant h/o left monocular melanoma who was admitted with a left-sided frontal lobe hemorrhage near the external capsule, right facial and arm weakness, and dysarthria. The patient was transferred to the Neuro Step-Down [**2135-10-25**] as she improved and stabilized in the ICU. NEUROLOGY Patient did well in the ICU. Her neurological exam has improved since admission especially with regard to mental status. She has had increased awareness and alertness. She still has right facial weakness and right UE weakness, distal more than proximal. Her repeat head CT showed the bleed to be stable in size. Her work-up included a stroke work-up. Her Stroke risk factors: HbA1C 5.5, LDL 65. The intraparenchymal hemorrhage was in a fairly typical location for a hypertensive bleed. Discussion with her PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] at [**Hospital3 **] revealed that she had in fact had a history of somewhat labile blood pressures with pressures as high as 160/90s. She had previously been on atenolol but this was discontinued many years ago. Because of her previous melanoma (28 yrs previously), the thought that her hemorrhage was secondary to underlying brain metastases was entertained. An MRI to look for small lesions and/or bleeds was not performed because the patient's prosthetic eye is a contraindication. In support of the hypothesis that the bleed was hypertensive in nature, the patient has been consistenly hypertensive despite double drug therapy. We recommend that she have a repeat scan in several weeks, preferably with contrast to further address the issue of possible underlying metastases. CARDIOVASCULAR Of note, in the ICU she was noted to have HTN that was difficult to control as well as runs of atrial fibrillation responsive to beta blockers. She was started on metoprolol. Her BPs have remained elevated despite upward titration of both Metoprolol and Lisinopril. Her pressures seem to be most elevated in the morning. We recommend trying to switch her Lisinopril to HS dosing or alternatively, perhaps captopril with TID dosing or perhaps adding a diuretic. The patient was noted to have a heart murmur that was not originally picked up on exam. A TTE was performed which revealed no vegetations and EF~70%. FEN/GI The patient has been started on low-salt diet. And while she requires some supervision, is able to eat without difficulty. She was cleared by speech/swallow. She has been started on a bowel regimen. ID The patient was diagnosed with possible aspiration PNA and was started on Levaquin. Her WBC have normalized and her lungs are clear. SHe will complete another 4 days of Levaquin. DISPO She will be transferred to [**Hospital3 7**] for acute rehabilitation. Discharge Summary Gen: NAD Lungs: CTA B Heart: RRR, II/VI systolic murmur NEURO: Patient is alert with eyes open. Oriented to self, date, and to "rehab". Unsure of medical condition. Says she "had a shock" to her right side. Language is fluent and comprehension intact. Repetition and naming are intact. There is no visual field deficit in the right eye. There is a right UMN facial. Right deltoid and wrist extensors are [**2-22**]. The lower extremities are full. Sensation is intact to DSS. Gait is unsteady and wide-based. Discharge Condition: Stable Medications on Admission: Fosamax ASA Eye drops Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 2. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:*225 Tablet(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO HS. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: LEFT INTRAPARENCHYMAL FRONTAL HEMORRHAGE Hypertension Discharge Condition: Stable Discharge Instructions: Please take your medications If you develop any new weakness, numbness, SOB, chest pain, please call a doctor immediately Please have follow-up CT of the brain in about 3-4 weeks (order in [**Hospital1 18**] system already) Followup Instructions: STROKE - [**Telephone/Fax (1) 3767**] - Dr. [**Last Name (STitle) **], [**Hospital Ward Name 23**] [**Location (un) **] [**11-29**] @ 4:30PM F/U w/PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] ([**Hospital3 2568**]) [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "V10.84", "431", "366.9", "401.9", "277.3", "507.0", "V10.82" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10954, 11033

6805, 10128

280, 287

11130, 11139

3290, 5236

11411, 11806

1413, 1497

10231, 10931

11054, 11109

10184, 10208

11163, 11388

1538, 3271

226, 242

315, 1048

5245, 6782

1070, 1265

1281, 1397

31,695

182,883

5550

Discharge summary

report

Admission Date: [**2199-7-19**] Discharge Date: [**2199-8-2**] Date of Birth: [**2140-9-14**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: 1. Subtotal colectomy. 2. End ileostomy. 3. Gastrostomy tube. 4. Flexible bronchoscopy and therapeutic aspiration History of Present Illness: Mr. [**Known lastname 2418**] is a 58 Male with cerebral palsy and mental retardation with a chief complaint of abdominal pain of 1 week's duration. He was last well 1 week ago, when nurses at his care facility noticed he was complaining of abdominal pain. The pain seemed to be diffuse in nature, constant, sharp, and not alleviated or exacerbated by anything. He has a decade-long history of chronic constipation, for which he requires daily laxatives, and had not had a bowel movement for 5 days prior to admission. He did not have any fever, vomiting, rectal bleeding, or decreased appetite. The pain persisted until the day of admission, when his nurse noticed that he was "not himself," his abdomen was more distended and tense, and he was found to be hypotensive to 74/52 and tachycardic to the 110s. At this time he was brought to the [**Hospital1 18**] ED. Past Medical History: mental retardation, cerebral palsy, inappropriate/obsessive behaviors tried on multiple psych meds, constipation since mid [**2182**] tx w/ fleet phosphosoda then milk of magnesia, anemia, sz d/o since [**2175**], B/L cataracts, multiple falls/fractures. S/P right inguinal hernia repair. Social History: Mr. [**Known lastname 2418**] has been in and out of institutions for the past 30 years, and is currently living in a group home. Family History: Sister with diabetes, s/p MI x3. Physical Exam: VS: T: 98.6 HR: 100 BP: 60/38 RR:16 PO2: 94% on 4L PE: Awake, alert, answers simple questions, diaphoretic, in mild distress, HEENT: Sclerae anicteric, oropharynx pink and moist CV: tachycardic, regular rhythm, no M/G/R Chest: Coarse breath sounds B/L Abd: Firm, greatly distended, tympanitic, diffusely tender, with rebound tenderness and involuntary guarding diffusely as well. BS were high pitched. Rectal: no stool, guiaic negative Pertinent Results: [**2199-7-19**] 05:40PM WBC-39.9*# RBC-4.38* HGB-14.1 HCT-38.5* MCV-88 MCH-32.3* MCHC-36.6* RDW-13.9 [**2199-7-19**] 05:40PM GLUCOSE-156* UREA N-36* CREAT-1.5* SODIUM-133 POTASSIUM-6.3* CHLORIDE-96 TOTAL CO2-22 ANION GAP-21* [**2199-7-19**] 05:57PM LACTATE-6.9* [**7-19**] CXR:FINDINGS: Cardiomediastinal contours are unremarkable, and unchanged. Pulmonary vasculature is not enlarged, and there is no evidence of CHF. Lung volumes are low, but there is no focal consolidation, pleural effusion, or pneumothorax. Massive colonic distention, particularly in the right upper abdomen, is increased, even from baseline distention on multiple studies dating back to [**2198-8-14**]. Resulting elevation of the right hemidiaphragm is unchanged. There is no definite evidence of free intraperitoneal air, although CT would be more sensitive for evaluation. IMPRESSION: 1. No definite evidence of free intraperitoneal air, although CT would be more sensitive for evaluation. 2. Massive colonic distention, increased even from baseline distention of multiple prior studies. [**7-19**] CT:FINDINGS: Cardiomediastinal contours are unremarkable, and unchanged. Pulmonary vasculature is not enlarged, and there is no evidence of CHF. Lung volumes are low, but there is no focal consolidation, pleural effusion, or pneumothorax. Massive colonic distention, particularly in the right upper abdomen, is increased, even from baseline distention on multiple studies dating back to [**2198-8-14**]. Resulting elevation of the right hemidiaphragm is unchanged. There is no definite evidence of free intraperitoneal air, although CT would be more sensitive for evaluation. IMPRESSION: 1. No definite evidence of free intraperitoneal air, although CT would be more sensitive for evaluation. 2. Massive colonic distention, increased even from baseline distention of multiple prior studies. Brief Hospital Course: On presentation Mr. [**Known lastname 2418**] was tachycardic and hypotensive to SBP in the 60s, so was resuscitated in the ED with fluids and 2 units of blood. His chest Xray and CT scan were consistent with a diagnosis of colonic volvulus, and as he had peritoneal signs, his lactate was 6.9, and WBCs were 40, the decision was made to take him to the OR emergently. Total abdominal colectomy with end ileostomy and gastric tube insertion was performed by Dr. [**Last Name (STitle) **]. See operative report dictated [**7-19**] for details of the procedure. Postoperatively Mr. [**Known lastname 2418**] was re-intubated for respiratory distress and admitted to the ICU on fentanyl and propofol drips for sedation, as well as neosynephrine for pressure control. The sedatives and neosynephrine were weaned off by POD 3, and he was started on tube feeds. On POD4, he underwent an extubation trial, but had respiratory distress once again on POD5. Chest Xray demonstrated bilateral effusions; a CT angiogram was performed and was negative for PE. At this time a flexible bronchoscopy was performed and a large amount of thick mucus was evacuated from his airways. Sputum was sent for culture and grew MRSA and Proteus. He was started on Zosyn and Vancomycin IV. On POD 6 he once again had respiratory distress, and a repeat chest Xray showed collapse of the left lung. He also had a brief episode of atrial fibrillation, which converted on an amiodarone drip. Bronchoscopy was repeated, and a large mucus plug was removed from his left main bronchus. On POD 7 a cosyntropin stimulation test was performed, and he was found to have low baseline cortisol levels, so was started on stress steroids. On POD 8, he was extubated once again and this time remained extubated. On POD 10, Mr. [**Known lastname 22359**] central line was DC'd, peripheral IV access attained, and he was transferred to the floor. Speech and swallow study was performed and he was started on his usual soft diet with thin liquids on POD11. Also on POD11, a PICC line was placed in anticipation of his discharge with IV antibiotics. By POD 13, his PO intake had improved and he was breathing fine on room air. He was seen by physical therapy, which recommended rehab services prior to returning to his group home. The decision was made to discharge him to an extended care facility for rehab on [**2199-8-2**] Medications on Admission: 1. Risperdal 3mg QHS 2. tegretol 400 [**Hospital1 **], 3. Luvox (OCD) 4. Cogentin 0.5''' 5. Colace, 6. MOM, 7. Prilosec 40' 8. Iron, 9. Fiberlax, 10. MVI, 11. K-Dur, 12. Oscal Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. Disp:*250 mL* Refills:*2* 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q 12H (Every 12 Hours) for 5 days. Disp:*10 g* Refills:*0* 4. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 5 days. Disp:*15 Recon Soln(s)* Refills:*0* 5. PICC line care per facility protocol 6. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) mL Injection QTUTHSA (Every Tue-[**Last Name (un) **]-Sat). Disp:*15 mL* Refills:*2* 7. Benztropine 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 9. Carbamazepine 100 mg/5 mL Suspension Sig: Ten (10) mL PO QID (4 times a day). 10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 13. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO DAILY (Daily). 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 17. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-15**] Sprays Nasal QID (4 times a day) as needed. 18. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO BID (2 times a day). 19. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two (2) Packet PO BID (2 times a day). 20. Abdominal binder on at all times Discharge Disposition: Extended Care Facility: [**Hospital 1263**] Hospital Inpt Discharge Diagnosis: Sigmoid volvulus. Discharge Condition: Stable. Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: Rehab therapy for transfer, gait training, and strengthening. PLEASE continue limb x2 restraints and keep abdominal binder at all times over gastric tube and ostomy site to prevent pulling them out. Medications: Resume your home medications. You will be continuing some new medications as well: 1. Roxicet - pain medication which may make you drowsy. 2. Vancomycin and Zosyn - antibiotics which you will continue until [**8-6**]. 3. Amiodarone - to prevent arrhythmias. 4. Epogen - to increase red blood cell production You may resume your normal diet (soft food with thin liquids) with 1:1 observation during feeding. Followup Instructions: Call Dr.[**Name (NI) **] office ([**Telephone/Fax (1) 3201**]) to schedule your follow-up appointment for about 2 weeks if you do not already have one. Completed by:[**2199-8-2**]

[ "482.41", "345.90", "997.1", "343.9", "933.1", "560.2", "458.9", "997.3", "250.00", "300.3", "518.0", "318.0", "427.31", "V09.0", "V18.0", "518.5", "564.00" ]

icd9cm

[ [ [] ] ]

[ "46.21", "43.19", "96.6", "33.23", "99.04", "45.79", "33.22", "96.71", "96.56", "38.93", "96.04", "96.05" ]

icd9pcs

[ [ [] ] ]

8623, 8683

4232, 6626

328, 444

8745, 8755

2326, 4209

9964, 10146

1821, 1855

6852, 8600

8704, 8724

6652, 6829

8779, 9941

1870, 2307

274, 290

472, 1345

1367, 1658

1674, 1805

16,856

184,720

51474

Discharge summary

report

Admission Date: [**2177-4-7**] Discharge Date: [**2177-4-26**] Date of Birth: [**2111-6-10**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 1283**] Chief Complaint: DOE/Edema Major Surgical or Invasive Procedure: [**2177-4-8**] Redo coronary artery bypass graft x2 (Saphenous vein graft > right coronary artery, Saphenous vein graft > interposition to Saphenous vein graft> obtuse marginal graft) Mitral Valve replacement (31mm [**Company 1543**] Mosaic Porcine valve) History of Present Illness: 65 year old with pmhx of CABGx4 in [**2154**] and severe biventricular decompensated heart failure s/p AICD/PPM with known tricuspid and mitral valve regurgitation followed by serial echocardiogram. He was admitted earlier this month for CHF where an echo showed 3+ MR and 3+ TR. Massive diuresis was initiated and he was referred for surgical revascularization. Past Medical History: -CAD s/p MI [**2153**] s/p CABG [**2154**] -h/o VT s/p ICD [**2164**] -CHF w/ EF<20% by echo [**5-27**] -DM on insulin -HTN -Hypercholesterol -CRF w/ baseline Cr (1.5-1.8) -Hypercalcemia -Osteopenia -Erectile Dysfunction -Hypothyroid -Obesity -LFT abnormalities attributed to NASH, possibly amio Social History: Lives with his wife and two adopted sons in [**Name (NI) 28318**], MA. Remote hx THC. Rare EtOH; denies tobacco, IVDA. Retired attorney. Family History: Father d. MI at 60; DM in mother's side. Physical Exam: PE: Postop 97.8 130/66 61 95-98% ra gen well appearing, non-diaphoretic, nad cv distant heart sound lungs crackles in bases bilaterally abd active bs, soft ntnd, no organomegaly appreciated ext bilateral lower ext pitting edema; right lower ext bandage c/d/i; right upper extremity with edema > left Pertinent Results: [**2177-4-26**] 06:16AM BLOOD WBC-8.7 RBC-3.37* Hgb-10.0* Hct-31.3* MCV-93 MCH-29.6 MCHC-31.9 RDW-17.1* Plt Ct-267 [**2177-4-7**] 05:24PM BLOOD WBC-10.8 RBC-4.74 Hgb-14.5 Hct-41.8 MCV-88 MCH-30.6 MCHC-34.7 RDW-17.1* Plt Ct-129* [**2177-4-26**] 06:16AM BLOOD Plt Ct-267 [**2177-4-26**] 06:16AM BLOOD PT-31.5* PTT-37.9* INR(PT)-3.4* [**2177-4-7**] 05:24PM BLOOD Plt Ct-129* [**2177-4-7**] 05:24PM BLOOD PT-11.6 PTT-26.6 INR(PT)-1.0 [**2177-4-26**] 06:16AM BLOOD Glucose-120* UreaN-64* Creat-2.8* Na-142 K-4.0 Cl-97 HCO3-37* AnGap-12 [**2177-4-7**] 05:24PM BLOOD Glucose-224* UreaN-100* Creat-2.9* Na-136 K-4.7 Cl-97 HCO3-27 AnGap-17 CHEST (PA & LAT) [**2177-4-24**] 11:33 AM CHEST (PA & LAT) Reason: evaluate pleural effusions [**Hospital 93**] MEDICAL CONDITION: 65 year old man s/p MVR REASON FOR THIS EXAMINATION: evaluate pleural effusions REASON FOR EXAMINATION: Follow up of patient after mitral valve replacement. PA and lateral upright chest radiograph compared to [**2177-4-19**]. The right internal jugular line tip terminates at the cavoatrial junction. There is no pneumothorax or apical hematoma. The heart size is markedly enlarged but stable. There is no change in the mediastinal contours. The ICD-pacemaker terminating in the right atrium and right ventricle are again noted . Small amount of pleural effusion decreased compared to [**2177-4-18**]. The lungs are essentially clear. IMPRESSION: 1) Cardiomegaly, no evidence of failure. 2) Decreased pleural effusion, small. 3) Standard position of right internal jugular line. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]Approved: FRI [**2177-4-25**] 1:25 PM PATIENT/TEST INFORMATION: Indication: Left ventricular function. Valvular heart disease. Height: (in) 66 Weight (lb): 252 BSA (m2): 2.21 m2 BP (mm Hg): 113/60 HR (bpm): 64 Status: Inpatient Date/Time: [**2177-4-18**] at 10:13 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W031-0:00 Test Location: West Echo Lab Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.1 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *6.0 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: *7.6 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 7.2 cm Left Ventricle - Fractional Shortening: *0.05 (nl >= 0.29) Left Ventricle - Ejection Fraction: *<= 20% (nl >=55%) Aorta - Valve Level: *4.0 cm (nl <= 3.6 cm) Aorta - Arch: 2.8 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec) Mitral Valve - Mean Gradient: 5 mm Hg Mitral Valve - Pressure Half Time: 81 ms Mitral Valve - E Wave: 1.9 m/sec Mitral Valve - A Wave: 1.4 m/sec Mitral Valve - E/A Ratio: 1.36 Mitral Valve - E Wave Deceleration Time: 456 msec TR Gradient (+ RA = PASP): *33 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: This study was compared to the prior study of [**2177-2-22**]. LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV cavity. Severe regional LV systolic dysfunction. No LV mass/thrombus. No resting LVOT gradient. RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic function. AORTA: Moderately dilated aortic sinus. Normal aortic arch diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR well seated, with normal leaflet/disc motion and transvalvular gradients. No MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate to severe [3+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left and right atria are moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe regional left ventricular systolic dysfunction with thinning and akinesis of septum, anterior and lateral walls, and hypokinesis of the remaining segments. No masses or thrombi are seen in the left ventricle. The right ventricular cavity is mildly dilated, and right ventricular systolic function is borderline normal. The aortic root is moderately dilated athe sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present, with normal leaflet motion and transvalvular gradients. No mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Dilated left ventricle with severe systolic dysfunction. Borderline-mild right ventricular systolic dysfunction. Normally-functioning mitral valve bioprosthesis. Moderate-to-severe tricuspid regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [**2177-2-22**], regurgitant native mitral valve is no longer present, replaced by a bioprosthesis. The other findings are similar. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD on [**2177-4-18**] 11:37. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. RADIOLOGY Final Report UNILAT UP EXT VEINS US LEFT [**2177-4-13**] 12:04 PM UNILAT UP EXT VEINS US LEFT Reason: pt with swollen left hand. Pls eval for UE DVT. [**Hospital 93**] MEDICAL CONDITION: 65 year old man with REASON FOR THIS EXAMINATION: pt with swollen left hand. Pls eval for UE DVT. INDICATION: Fall on left hand, evaluate for upper extremity DVT. No prior examinations. LEFT UPPER EXTREMITY DEEP VENOUS ULTRASOUND: [**Doctor Last Name **]-scale and Doppler examination of the left internal jugular vein, subclavian, axillary, brachial, cephalic, and basilic veins was performed. These demonstrate intraluminal thrombus with the left cephalic vein with expansion of the vein suggestive of acute clot. This thrombus extends to the confluence of the subclavian vein, however, does not extend into the subclavian vein. The remainder of the veins demonstrates normal compressibility, augmentability, and respiratory variation and flow. IMPRESSION: Left cephalic vein thrombus extending to the confluence with the subclavian vein, presumably due to recent IV line. Findings were discussed with the ordering provider, [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 916**] at 1:10 p.m. on [**2177-4-13**]. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 18394**] [**Name (STitle) 18395**] DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: MON [**2177-4-14**] 9:34 AM Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 106730**],[**Known firstname **] [**2111-6-10**] 65 Male [**Numeric Identifier 106731**] [**Numeric Identifier 106732**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cofc SPECIMEN SUBMITTED: MITRAL VALVE LEAFLETS (1). Procedure date Tissue received Report Date Diagnosed by [**2177-4-8**] [**2177-4-8**] [**2177-4-10**] DR. [**Last Name (STitle) **]. LOMO/mrr?????? DIAGNOSIS: Mitral valve, valvuloplasty: Valve leaflet with myxoid degeneration. Clinical: Mitral valve disorder/mitral valve replacement; TVR; possible replacement via right thorax. Gross: The specimen is received in saline labeled with "[**Known firstname 5987**] [**Known lastname **]," the medical record number, and "mitral valve leaflets". It consists of a single piece of cardiac valve with attached chordae, measuring 2.3 x 1.1 x 0.4 cm. No significant calcifications are grossly noted. It is represented in A. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2177-4-7**] for surgical management of his valvular heart and coronary artery disease. On [**4-8**], Dr. [**Last Name (STitle) 1290**] performed a redo-sternotomy with coronary artery bypass grafting and a mitral valve replacement with a 31 mm [**Company 1543**] mosaic porcine valve. Postoperatively he was taken to the cardiac surgical intensive care unit for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics as he gradually weaned from pressor support. Low dose beta blockade was resumed. Due to persistent blood glucose levels, the [**Last Name (un) **] service was consulted to assist in the postop management of his type II diabetes mellitus. His CSRU course was otherwise uneventful and he transferred to the CSRU on postoperative day four. He was noted to have swelling in his left upper extremity. He was also thrombocytopenic at that time. Postoperative platelet count dropped as low as 69K. Ultrasound revealed a left cephalic vein thrombus extending to the confluence with the subclavian vein. HIT assay returned positive for HEPARIN PF4 antibodies. Argatroban anticoagulation was subsequently started with slow transition to Warfarin. Further evaluation included a lower extremity ultrasound which found no evidence of deep vein thrombosis. Postop course was also complicated by significant fluid overload and heart failure which temporarily required intravenous Lasix drip. The cardiology service was consulted to assist in the management on his congestive heart failure and diuretic regimen. Diuretics were titrated daily with gradual improvement in fluid status. He was slowly transitioned to PO/oral diuretics. His renal function remained relatively stable throughout his hospital stay. He also experienced sternal drainage with a leukocytosis. He remained afebrile. White count peaked to 17K, and he was empirically treated with Vancomycin. By discharge, his white count normalized and his sternal drainage improved. He eventually became therapeutic on Warfarin with appropriate Argatroban overlap. Warfarin should be dosed for a goal INR between 2.0 - 3.0. Given thrombus in setting of positive HIT assay, he will need Warfarin for at least six months. Plan for follow up with coumadin dosing by [**Company 191**] anti coagulation clinic. Medications on Admission: Aspirin 81 qd, Fosamax, Ambien 10 qhs, Imdur 30 qd, Lipitor 20 qd, Folate, Coreg 50 [**Hospital1 **], Amiodarone 200 qd, Lisinopril 2.5 qd, Levoxyl, Senispan 30 qod, Humalog, Humulin, Allopurinol, Torsemide 100qd, Digoxin 0.125 qd, Zoloft 50 qd, Spirinolactone 25 qd Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO QOD (). Disp:*30 Tablet(s)* Refills:*0* 9. 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* 10. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every Thursday). Disp:*30 Tablet(s)* Refills:*0* 11. Coreg 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 12. Coumadin 1 mg Tablet Sig: 1-2 Tablets PO once a day: hold coumadin tonite. restart sun. Disp:*60 Tablet(s)* Refills:*2* 13. Torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company **] Discharge Diagnosis: Mitral Regurgitation s/p MVR Coronary Artery Disease s/p CABG Heparin Indued Thromboctyopenia c/b Upper Extremity Thrombosis Postop Leukocytosis with Sternal Drainage Ischemic Cardiomyopathy Systolic Heart Failure Chronic Renal Insufficiency Ventricular tachycardia w/ AICD Hyperparathyroid Elevated cholesterol Diabetes mellitus type 2 Obesity Sleep Apnea Hypothyroidism Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet with 100ml fluid Restriction. [**Month (only) 116**] shower, no baths or swimming. Monitor wounds for infection - redness, drainage, or increased pain. Report any fever greater than 101. No creams, lotions, powders, or ointments to incisions. No driving for approximately one month. No lifting more than 10 pounds for 10 weeks. Take Warfarin as directed. Goal INR 2.0 - 3.0. INR shouled be checked within 48-72 hours of discharge. Dr. [**First Name4 (NamePattern1) 1169**] [**Last Name (NamePattern1) **] will manage Warfarin as an outpatient. Fax [**Telephone/Fax (1) 106733**] Office [**Telephone/Fax (1) 250**] Followup Instructions: 1)Dr [**Last Name (STitle) 1290**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment 2)Dr [**Last Name (STitle) **] in [**12-24**] weeks ([**Telephone/Fax (1) 250**]) please call for appointment 3)Dr [**First Name (STitle) 437**] in [**12-24**] week - please call for appointment 4)Dr [**Last Name (STitle) **] in [**1-26**] weeks - please call for appointment 5)Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3633**]) Coumadin dosing by [**Hospital 191**] [**Hospital3 **] Completed by:[**2177-4-28**]

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icd9cm

[ [ [] ] ]

[ "99.07", "36.12", "93.90", "35.23", "39.61", "89.60", "99.04" ]

icd9pcs

[ [ [] ] ]

14907, 14952

10727, 13150

304, 562

15368, 15375

1827, 2557

16139, 16716

1445, 1488

13467, 14884

8246, 8267

14973, 15347

13176, 13444

15399, 16116

3663, 7930

1503, 1808

255, 266

8296, 10704

590, 954

7962, 8209

976, 1274

1290, 1429

66,649

157,838

35046

Discharge summary

report

Admission Date: [**2158-4-16**] Discharge Date: [**2158-4-18**] Date of Birth: [**2073-12-25**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7333**] Chief Complaint: complete heart block Major Surgical or Invasive Procedure: St. [**Male First Name (un) 923**] Dual Chamber Pacemaker Placement History of Present Illness: Mr. [**Known firstname **] [**Known lastname **] is a 84 year old Chinese-speaking male with a PMH of HTN, CAD, DM2 transferred from NEBH for further evaluation and management of complete heart block. History obtained from the patient and his son who assisted in translating. . Briefly, he presented to NEBH earlier today after noting increased fatigue, bilateral leg swelling, and dizziness for the past week. He has noticed a slight increased work of breathing. He denies any chest pain or pressure or palpitations. At NEBH initial VS were HR 36, BP 227/64, RR 18, O2 sat 100% RA. EKG demonstrated complete heart block. He received 2-inches nitro paste and also Vasotec 1.25 mg IV. BP came down to 180/55 and heart rate remained between 30-40 bpm. . On review of systems, he has a history of prior stroke in the [**2137**] from which he has completely recovered. He has some occasional nausea relieved by his PPI. He has chronic myalgias and lower extremity pain from peripheral neuropathy as well as chronic constipation (last BM yesterday). He denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. All of the other review of systems were negative. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: Stent to LCX [**2139**], stent LAD [**2142**]. Cath in [**2142**] showed total occlusion of the RCA with L->R collaterals, primarily from the left circumflex. 3. OTHER PAST MEDICAL HISTORY: - CAD - Hypertension. - High cholesterol. - Status/post CVA [**2137**]. Full recovery per son. - DM2, on oral agents only. - Gastroesophageal reflux disease. - Hx GI bleed with question of gastric polyp. - Chronic renal insufficiency - Traumatic subarachnoid hemorrhage [**2155**] Social History: Originally from [**Country 651**]. Lives with his wife. Quit smoking over 20 years ago. Rare drinks alcohol. Patient planning to go to a traditional Chinese wedding on Friday that requires air travel. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission: VS: T=99.2 BP=202/50 HR=32 RR=14 O2 sat=100% RA GENERAL: WDWN elderly male in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no LAD. JVP not elevated. CARDIAC: Bradycardic, regular rhythm, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: 1+ edema at ankles bilaterally. No clubbing or cyanosis. No femoral bruits. SKIN: Bilateral petechiae of the lower legs. No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Radial 2+ DP 1+ Left: Carotid 2+ Femoral 2+ Radial 2+ DP 1+ Pertinent Results: [**2158-4-18**] 04:30AM BLOOD CK-MB-4 cTropnT-0.06* [**2158-4-18**] 04:30AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0 [**2158-4-18**] 04:30AM BLOOD Glucose-247* UreaN-17 Creat-1.3* Na-138 K-3.8 Cl-104 HCO3-24 AnGap-14 [**2158-4-18**] 04:30AM BLOOD PT-12.8 PTT-49.3* INR(PT)-1.1 [**2158-4-18**] 04:30AM BLOOD WBC-8.3 RBC-3.91* Hgb-13.1* Hct-37.3* MCV-95 MCH-33.6* MCHC-35.2* RDW-13.2 Plt Ct-172 Brief Hospital Course: Mr. [**Known lastname **] is a 84 year old male with a PMH of HTN, CAD, DM2 transferred from NEBH for further evaluation and management of complete heart block treated with the placement of a dual chamber pacemaker. # RHYTHM: Patient was admitted with HR in the 30s, likely a slow junctional escape rhythm with compelete AV dissociation. As he also had hypertension, suggesting that the rhtyhm was not compensated. He had a dual chamber pacemaker placed on [**2158-4-17**]. Post-procedue, he had a heart rate in the 70s and patient felt well. He tolerated pacemaker placement well. He was discharged on metoprolol succinate 25mg daily and will follow-up in device clinic in one week. # CORONARIES: Patient has a history of CAD with a distant history of PCI. He denied any current symptoms of ischemia. He was continued on atorvastatin, aspirin and metoprolol. # PUMP: He has no known history of CHF. He had an elevated BNP and mild pulmonary edema likely secondary to his slow heart rate and hypertension, however his lack of a supplemental oxygen requirement was reassuring. Post pacemaker placement he was breathing comfortably and ambulating well. # Hypertension: His hypertension was long-standing and likely acutely elevated on admission in the setting of bradycardia and was allowed permissive hypertension to ensure adequate perfusion in the setting of bradycardia. He was continued on valsartan and was restarted on metoprolol. In addition, amlodipine 5mg daily was started for additional blood pressure control with appropriate response. This should be titrated as an outpatient. # Type 2 diabetes: Complicated by neuropathy and CRI. His glimiperide was held during his admission and put on humalog ISS with fingersticks QID/ACHS. He was restarted on glimiperide on discharge. # Hyperlipidemmia: He was continued on his home atorvastatin. # Neuropathic pain: He was continued on his home lidocaine patches and neurontin. Medications on Admission: Glimeperide 10 mg daily Valsartan 160 mg daily Folate 1 mg daily Lidoderm patches 4 patches (2 to each leg) daily Lipitor 40 mg daily Neurontin 300 mg TID Protonix 40 mg daily Toprol XL 25 mg daily Colace prn Discharge Medications: 1. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 1 days. Disp:*3 Capsule(s)* Refills:*0* 10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: CareTenders- VNA Discharge Diagnosis: Complete Heart Block Cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], You were admitted to the hospital for dizziness and fatigue. You were found to have an abnormal heart rhythm (complete heart block) which likely caused your symptoms. You were evaluated and treated by the cardiology service. You received a pacemaker to control your heart rhythm and you symptoms improved. You were also noted to have redness on your legs which was concerning for a skin infection (cellulitis) and you received antibiotics that improved the appearance of your skin. Please take your medications as prescribed and keep your outpatient appointments. The following changes have been made to your home medications. 1. You have been STARTED on Amlodipine 5mg daily 2. You have been STARTED on Cephalexin 500mg every 8 hours for 1 day, you will only take three doses of this medication No other changes have been made to your home medications. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2158-4-26**] at 10:00 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name3 (LF) **] A. Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**] Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 9749**] Phone: [**Telephone/Fax (1) 26860**] When: Tuesday, [**2158-5-2**]:15AM

[ "426.0", "250.60", "272.4", "585.9", "414.01", "357.2", "V45.82", "V12.54", "403.90" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.72" ]

icd9pcs

[ [ [] ] ]

7225, 7272

4084, 6027

326, 396

7348, 7348

3670, 4061

8409, 8972

2610, 2725

6286, 7202

7293, 7327

6053, 6263

7499, 8386

2740, 3651

1860, 2058

266, 288

424, 1728

7363, 7475

2089, 2372

1772, 1840

2388, 2594

10,274

130,694

2054

Discharge summary

report

Admission Date: [**2105-12-2**] Discharge Date: [**2105-12-10**] Date of Birth: [**2046-11-15**] Sex: M Service: OMED CHIEF COMPLAINT: Fatigue. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male with history of metastatic melanoma with brain metastases who presents with a complaint of fatigue for several days. The patient had a complete response to IL-2- temozolomide based bio-chemotherapy the forth cycle of which caused pancreatitis. He also had pancreatitis on IL-2 and IL-12 therapy. He recently developed brain metastases and has undergone whole brain XRT, Decadron and was also started on an six weeks course of temozolomide finished on [**2105-11-30**]. Mr. [**Known lastname 11193**] has been seen in the [**Hospital **] Clinic on [**2105-11-30**], where he complained of fatigue, dysuria and frequency. q.i.d. and patient was started on a five day course of ciprofloxacin for presumptive urinary tract infection. One day after having been seen in the Clinic the patient reported a dramatic increase in sense of fatigue and lack of energy. States he has been inactive since then with decreased p.o. intake. Denies any fever, chills, nausea, vomiting, abdominal pain, cough, sputum production, flank pain or skin rash but notes persistent dysuria and polyuria. Notes mild abdominal distention but denies any pain and has had regular bowel movements and flatus. Currently notes nausea times one hour prior to admission. In the Emergency Department blood pressure was found to be 81/48 with a heart rate of 78. Blood pressure remained in the high 80's systolic despite three liters of normal saline with no change in the urine output so dopamine was started via peripheral IV with blood pressure climbing to the 95-100 range systolic. PAST MEDICAL HISTORY: Significant for: 1. Malignant melanoma diagnosed in [**2097**] with metastases to lung and brain status post bio-chemotherapy treatment, status post resection of lung recurrence in the right lower lobe status post IL-2, IL-12, s/p Gleevec trial with observed progression of disease, status post whole brain XRT on Decadron, currently with week six of eight of temozolomide. 2. Hypertension. 3. History of pancreatitis. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Atenolol, Decadron, Protonix, ciprofloxacin, Ativan. SOCIAL HISTORY: No alcohol or tobacco use. Works in human resources. Married and lives in [**Location 912**]. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.5, heart rate 76, blood pressure 94/54, respiratory rate 20, oxygen saturation 96% on room air. In general, comfortable in no acute distress, chronically ill-appearing. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements full. Oropharynx erythematous with persistent whitish plaques. Neck: Multiple palpable supraclavicular nodules versus supraclavicular lymph nodes on the right. No nuchal rigidity. No jugular venous distention. Cardiovascular examination: Regular rate and rhythm. Normal S1, S2. Slightly tachycardic. No murmurs, rubs or gallops. Lungs clear to auscultation bilaterally. Abdomen mildly distended, soft, non-tympanitic, non-tender, positive bowel sounds, palpable, subcutaneous nodules. Extremities: 2+ pitting edema over the lower extremities bilaterally, 1+ pedal pulses. Skin: No rash. Neurological: Alert and oriented times three. Cranial nerves II through XII intact. Sensation and strength intact in all extremities. LABS ON ADMISSION: White blood cell count 14.9, hematocrit 30.0, platelets 206,000, neutrophils 94, 4 lymphocytes, 2 macrophages. Sodium 134, potassium 6.3 which was hemolyzed corrected to 5.1, chloride 99, bicarbonate 20, BUN 80, creatinine 2.4, glucose 189, amylase 59, lipase 43, albumin 2.5, phos 7.0, magnesium 2.0, T-bili 0.7. UA: Negative nitrites, negative leukocyte esterase, [**5-4**] white blood cells, [**1-27**] red blood cells, many bacteria. Blood and urine cultures pending at the time of admission. IMPRESSION: Patient is a 59-year-old male with history of malignant metastatic melanoma failed multiple regimens complicated by brain metastases status post XRT and Decadron who presents with complaints of fatigue and subsequently found to be hypotensive and minimally responsive to volume resuscitation. HOSPITAL COURSE: 1. Hypotension: Given the warm extremities and lack of response to volume resuscitation, the hypotension was felt to be a distributed etiology either due to sepsis or adrenal insufficiency. He was started on stress dose steroids as well as IV vancomycin and IV ceftriaxone and was continued on dopamine and transferred to the Medical Intensive Care Unit for further management. Intravenous fluids were continued as were the stress dose steroids and broad spectrum antibiotics and the dopamine was slowly weaned over the next several days with gradual improvement of urine output as well as pressures. 2. Infectious Disease: The patient was felt to have likely a urinary source for current presentation; however, abdominal examination was somewhat concerning for possible perforation. He underwent abdominal CT which showed no evidence of fluid collections or free air suggestive of perforation or abscess. He was continued on ceftriaxone and vancomycin for broad spectrum coverage. Antibiotics were continued for the next six days and were discontinued as the goals of care were now felt to be more of comfort care as opposed to active treatment after extensive discussion with the family who now feel that they would not like to pursue aggressive treatment at this point. 3. Hematology/Oncology: Patient with significant metastatic melanoma with increased tumor burden on abdominal CT underwent echocardiogram on [**2105-12-7**], which showed a mass in the left ventricle consistent with thrombus versus metastatic melanomatous lesion. 4. Pulmonary: Patient had significant oxygen requirement with subjective dyspnea without oxygen by face mask or by nasal cannula. This will be continued as comfort measures. 5. Code Status: After a lengthy discussion with the family, social worker and palliative care team, it was felt that goals of care would now be for comfort only and would not pursue any active resuscitation or intubation if the patient's condition were to significantly worsen and for this reason he will be listed as a DNR/DNI. DISCHARGE DIAGNOSES: 1. Metastatic melanoma. 2. Hypotension likely secondary to sepsis. 3. Adrenal insufficiency. DISCHARGE CONDITION: Fair. Patient is comfortable and currently without any focal complaints and may be discharged to a hospice facility for further management and end of life care. It is possible he will remain in the hospital for his remaining days. MEDICATIONS ON DISCHARGE: Morphine IV drip titrate to subjective comfort, Ativan 0.5 mg to 1 mg IV q. 2-4h. p.r.n. comfort, prednisone 50 mg p.o. q. day times one day, 30 mg p.o. q. day times one day, then 10 mg p.o. q. day times one day, then off. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1736**] Dictated By:[**First Name3 (LF) 11194**] MEDQUIST36 D: [**2105-12-9**] 16:23 T: [**2105-12-9**] 15:44 JOB#: [**Job Number 11195**]

[ "197.0", "038.9", "255.4", "599.0", "276.2", "584.9", "789.5", "785.59", "198.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6593, 6825

2482, 2521

6474, 6571

6852, 7344

2297, 2351

4398, 6453

156, 166

195, 1785

3572, 4381

1808, 2270

2368, 2465

14,131

136,336

10743

Discharge summary

report

Admission Date: [**2118-3-28**] Discharge Date: [**2118-4-4**] Date of Birth: [**2058-4-29**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1257**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Left Thoracentesis [**3-29**] History of Present Illness: 59 y/o F referred by [**Hospital 100**] Rehab for acute kidney injury and concern for CHF exacerbation. Patient was evaluated at [**Hospital 100**] Rehab by nephrology due to increasing creatinine ([**2118-3-25**] 2.6 now 3.9) and recommended general work-up for renal failure. Recently patient also developed low grade fevers and increased eryhtema of her right heel - ID was consulted and started on IV Abx (Cipro, Flagyl, Vanco) for concern of osteomyletis based on supportive x-ray (per report). She was scheduled for CT scan this Wednesday. Patient being aggressively diuresised, given 120 mg IV lasix prior to transfer. Weight stable 78 kg past week despite aggressive diuresis. [**Name (NI) **] husband concerned regarding increasing cough, laboured breathing and worsening edema. No chest pain. Per husband her mental status has been her baseline. She has not been sleeping for the past 72 hours. . In the ED, initial vs were: T 98.1 P 93 BP 178/82 R 22 O2 sat 100% NRB. During ED patient's oxygenation improved to high 90s-100% on 2 L. Patient was given 2 baby [**Name (NI) **]. During stay patient became progressively somnolent and is being admitted to the MICU for altered mental status. Of note, patient had recent admission [**2118-2-22**] to [**2118-3-11**] for delirium work-up. During hospital stay patient had mutiple episodes of hallucinations/agitation/anxiety with intermittent lucidity. Felt to be secondary to recent hosptialization, poor PO intake, and at least five psychiatric medications, all in the setting of a poor substrate (i.e. Hypoxic Brain Injury), however, pt's baseline is alert and oriented x3 and highly functioning. B12/folate/RPR wnl. TSH was high, but on synthroid, and unclear how to interpret while hospitalized. OSH records indicating ?thalamic stroke were obtained, and read by [**Hospital1 18**] radiologist who said that in the setting of a noncontrast study, not ideal study, but nothing to suggest acute thalamic stroke. Psychiatry, Neurology, and Geriatrics followed her case closely while she was hosptialized. Patient was tried on depakote (stopped because LFT's began to trend up after having previously normalized in the setting of stoping mexilitine), and a trial of low-dose seroquel (ultimately not effective enough). Patient was eventually tried on [**Hospital1 **] with close monitoring of the QTc. Review of systems: (+) Per HPI (-) Denies recent fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - CAD s/p anterior MI, multiple PCIs and history of left main thrombosis during last cath in [**3-/2112**]; with thrombotic event developed 10 minute asystolic arrest. Since then she has had positive stress test, not deemed to be intervened upon due to high risk. - Ischemic CHF with most recent known EF 20-25% in [**Month (only) 1096**] [**2117**]. - VT s/p ICD (hx torsades) - PVD s/p fem-[**Doctor Last Name **] bypass. - DM type I - CKD - baseline creatinine 2.5-3 - Legally blind due to diabetic retinopathy - Anoxic brain injury resulting from PEA arrest in cath as above. - Memory and word finding difficulties of unclear etiology; has been evaluated by neurology and cognitive neurology. - Diabetic neuropathy - Hypothyroidism - Anxiety - Depression - s/p carpal tunnel surgery - ?severe pulmonary hypertension Social History: She has one son. She finished a bachelor's degree in college, is married, and lives with her husband. She is a nonsmoker and does not drink any alcohol. At baseline uses a walker as a result of her diabetic neuropathy and can get around the house on her own. Thinking is clear, not as good as 10-15 years ago Family History: Her mother died at 50 of heart-related illness. Physical Exam: General: Pt sitting in bed, in NAD. Some intermittent chest pain from cough. HEENT: Sclera anicteric, subconjunctival hemorrage in L eye. PERRL 3->2 MMM, oropharynx clear. Neck: supple, JVP not elevated, no LAD. Lungs: No increased WOB, mild crackles in the LLL, diffuse rhonchi CV: Regular rate and rhythm, normal S1 + S2, no MRG appreciated, though difficult to appreciate due to scattered lung sounds L sided ICD with overlying ecchymosis, area somewhat firm, no erythema or warmth or fluctuance. Mild ecchymosis over left chest/breast. Abdomen: soft, appears non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: well perfused, 2+ DP pulses, no clubbing, cyanosis. Minimal LE edema bilaterally, mild edema on dorsum of hands BL . R heel with deep decubitus ulcer with eschar. No surrounding erythema or pus ntoed. Neuro: A&O x3 Pertinent Results: Admission labs: [**2118-3-28**] 06:45PM BLOOD WBC-6.7 RBC-2.78* Hgb-8.2* Hct-26.2* MCV-94 MCH-29.5 MCHC-31.3 RDW-16.5* Plt Ct-231 [**2118-3-28**] 06:45PM BLOOD Neuts-78.6* Lymphs-16.2* Monos-4.7 Eos-0.3 Baso-0.3 [**2118-3-28**] 06:45PM BLOOD PT-13.6* PTT-28.9 INR(PT)-1.2* [**2118-3-29**] 03:27AM BLOOD ESR-70* [**2118-3-28**] 06:45PM BLOOD Glucose-126* UreaN-89* Creat-4.1*# Na-138 K-4.3 Cl-104 HCO3-22 AnGap-16 [**2118-3-28**] 06:45PM BLOOD CK(CPK)-266* [**2118-3-28**] 06:45PM BLOOD CK-MB-3 cTropnT-0.07* proBNP-[**Numeric Identifier 35141**]* [**2118-3-29**] 03:27AM BLOOD Albumin-2.8* Calcium-8.0* Phos-6.2*# Mg-1.9 [**2118-3-28**] 06:45PM BLOOD VitB12-730 Folate-19.7 [**2118-3-28**] 06:45PM BLOOD TSH-5.2* [**2118-3-28**] 06:45PM BLOOD Free T4-1.4 [**2118-3-29**] 03:27AM BLOOD CRP-35.4* [**2118-3-28**] 06:45PM BLOOD Vanco-30.1* [**2118-3-28**] 06:48PM BLOOD Lactate-1.5 [**2118-3-28**] 08:48PM BLOOD pO2-98 pCO2-41 pH-7.38 calTCO2-25 Base XS-0 [**2118-3-28**] 10:00PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.016 [**2118-3-28**] 10:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2118-3-28**] 10:00PM URINE RBC-0 WBC-[**4-8**] Bacteri-FEW Yeast-NONE Epi-0 [**2118-3-28**] 10:00PM URINE CastHy-0-2 [**2118-3-28**] 10:00PM URINE Eos-NEGATIVE . Discharge Labs: . . . Pleural fluid [**2118-3-29**] 05:54PM PLEURAL WBC-75* RBC-1630* Polys-3* Lymphs-63* Monos-6* Meso-10* Macro-18* [**2118-3-29**] 05:54PM PLEURAL TotProt-1.3 Glucose-153 LD(LDH)-78 Albumin-<1.0 MICRO: Urine Legionella Ag neg Pleural Fluid NGTD (prelim result) **** STUDIES: CXR [**2118-3-28**]: Hazy right base opacity concerning for consolidation and acute infectious process. Prominence of the hilum may relate to vascular engorgement. . NCHCT [**2118-3-28**]: No acute intracranial process. . TTE [**2118-3-29**]: The left atrium is mildly dilated. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with focal hypokinesis of the mid to distal anterior wall, lateral wall, apex, and distal inferior wall. The remaining segments contract normally (LVEF = 35-40 %). 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 ([**2-5**]+) 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: Moderate regional left ventricular systolic dsyfunction consistent with coronary artery disease. Mild to moderate mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. . Renal U/S [**2118-3-29**]: 1. No hydronephrosis of the right kidney or left kidney. Probable tiny calculus at the lower pole of the right kidney. 2. Several small calculi are seen within the gallbladder. . Bilateral Foot XRAYs [**2118-3-29**]: No evidence osteomyelitis of the right heel and left big toe. Probable bony destruction of the PIP joint of the right second toe possibly representing osteomyelitic changes in correct clinical setting. Subluxation of IP joints of both first toes. Brief Hospital Course: 59F with CAD s/p multiple PCIs, ischemic CHF, Type I DM, Hx of Anoxic Brain Injury, chronic kidney disease, anxiety, and depression who presents with altered mental status. # Altered Mental Status: When patient arrived in the ICU after transfer from the ED she was oriented x 3 when woken, but very lethargic. Per husband, patient had not slept in 72 hours on admission and was likely hypersomnolent. After sleeping, patient was much more interactive and A&O x 3. A CT was performed that showed no acute change. MRI was not performed because of patient's ICD. Workup for causes of altered mental status including B12, folate, TSH, and LFTs were normal. RPR was recently was negative. When patient was transferred to the medicine floor from the ICU, she was sleepy but fully oriented. Patient had one episode of confusion and delusions overnight for which she was treated with Olanzapine. She was continued on Olanzapine nightly (5mg) due to history of confusion, particularly at night. QTc was monitored during the hospitalization, and remained in the 440-460 range. At discharge, QTc was 392. . # Acute kidney injury: On admission the patient's creatinine was increased from baseline of 1.8-2.0 to 4.1. Patient had been treated at outside rehab facility with diuresis for worsening kidney function due to the belief that it was being caused by an acute exacerbation of CHF. However, the patient was not responsive to diuresis and in fact her kidney function continued to worsen. On admission to the ICU, the patient was thought to be in prerenal failure (with questionable ATN) most likely due to volume depletion and overdiuresis. An ultrasound was performed and showed no signs of obstruction. The patient was treated with IV fluid rehydration, and her kidney function improved over the course of several days. At discharge patient's creatinine had improved to 2.6. Her diuretics and ACE inhibitor were held for the duration of her stay. Patient should continue to have electrolytes carefully monitored when she returns to her rehab facility. At rehab, [**Last Name (un) **] and diuretic can be restarted with her kidney function returns to baseline (Creatinine of 2.0). Once her creatinine reaches 2.0 she can be started on losartan at home dose of 100mg daily. When her creatinine reaches 2.0 the patient can also be restarted on furosemide, prior dose was 80mg, would favor starting more slowly that this when ready. Patient should not be diuresed too rapidly given history of acute renal failure in setting of volume depletion. We recommend keeping patient even to slightly positive until her creatinine improve and stabilizes. # CHF: (see discussion above). Diuretics were held during the time of patient's admission. Patient was continued on a B-blocker Metoprolol Tartrate 50 mg PO/NG [**Hospital1 **] and Isosorbide Dinitrate 10 mg PO/NG TID. Patient should continue these medications as an outpatient. Patient can re-start diuretics and ACE inhibitor, once her acute kidney injury has improved. (see above). #Pneumonia: When patient came in to the hospital she had a low grade fever, cough and SOB. A chest x-ray from [**3-29**] in the ICU showed opacity in the LLL, consistent with a pleural effusion. A left thoracentesis was performed and 1000 ml of fluid removed, with improvement in the patient's symptoms. The fluid was sent for culture, with no growth to date. It was also sent for cytologic evaluation and was negative for any malignant cells. After the drainage the patient was able to breathe much easier. The patient continued to have a low grade fever off and on for the next several days. The patient was started on Aztreonam for broad coverage (is allergice to pennicillins so could not receive a cephalosporin). Patient should continue receiving aztreonam until [**2118-4-11**]. She should continue to receive vancomycin that is dosed by level because of rapidly changing renal function. Vancomycin levels should be checked daily, with a goal vancomycin trough of 15-20. Her vancomycin course stops on [**2118-4-11**]. #Depression: Patient was evaluated by psychiatry during her inpatient stay on the medicine floor for suicidal ideation and depression. Per husband, patient has had trouble with depression and suicidal ideation in the past but has never had suicidal attempt. Patient was titrated up on her fluoxetine by 10mg q48h per psychiatry recommendations. She is on 40mg daily of fluoxetine at date of discharge to rehab. She should continue to be titrated up by 10mg every other day until she reaches her baseline home dose of 60mg daily. ** She should be increased to 50mg daily on Wednesday, [**4-6**] and titrated up to final home dose of 60mg on Friday, [**4-8**]. Patient was followed by psychiatry during her stay. She was also seen by social work. Patient should follow up closely with her PCP after discharge. ** It was recommended that patient have frequent check-ins on her to help assuage anxiety throughout the day, perhaps hourly during the hours of [**7-15**] pm daily. As discussed with the patient, Social Work is working on setting up outpatient follow up with a therapist. # Heel ulcer: Patient was evaluated by both podiatry and wound care during the duration of her stay. Patient had previously been started on antibiotics at her rehab facility due to concern for osteomyelitis infection. An x-ray performed on [**3-29**] showed no cortical destruction or subcutaneous gas to suggest osteomyelitis. Podiatry felt that this ulcer was likely chronic, not infected and secondary to PVD and diabetes. They recommended that the patient did not need to continue on antibiotic therapy so treatment was stopped. Wound care recommended protective boots and application of dry dressing applied daily. Patient should continue to have dressings changed and checked by podiatry once she is discharged to her rehab facility. # CAD: Patient reported mild chest pain during one of her nights on the inpatient medicine floor. This was likely due to musculoskeletal pain from coughing, but cardiac enzymes were sent to rule out MI given known CAD and multiple risk factors. CK-MB was found to be normal and Trop-T only very mildly elevated. Her EKGs continued to be unchanged from prior. She was continued on [**Month/Year (2) **], clopidogrel, and Atorvastatin. Patient should continue on these medications after discharge. # Borderline QTc: Patient was found to have mildly prolonged QTc on admission (450). Due to her history of Torsades, her QTc was monitored daily. She received [**Month/Year (2) **] almost daily at night. No worsening QTc prolongation was noted during the admission, but she should continued to undergo periodic ECGs to monitor QTc while taking [**Month/Year (2) **]. Upon discharge, QTc was 392 (within normal limits). # DM: Patient receieved a sliding scale of humolog while in house. She also received her home dose of glargine [**Hospital1 **] (16units, 8 units). Patient should continue on sliding scale per our recommendations and on glargine [**Hospital1 **] as an outpatient in rehab. # Hypothyroidism: Patient was continued levothyroxine. She should be maintained on her home dose of levothyroxine as an outpatient. # Anemia: Patient appeared to be at her baseline throughout her stay here. Iron studies prior to discharge were most consistent with anemia of chronic disease. She had been on epogen in the past and we encourage her to discuss re-initiation of this with her nephrologist/PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3271**]. #Access: PICC was replaced on [**3-29**] while in the ICU. Patient was Full Code during this hospitalization. Medications on Admission: - [**Month/Year (2) **] 81 mg - Atorvastatin 40 mg qhs - Cipro 500 mg once daily - [**Month/Year (2) **] 75 mg qd - Vitamin B12 qd - Iron 325 mg qd - Fluoxetine 20 mg qd - Lasix 80 mg IV BID - Gabapentin 200mg [**Hospital1 **] - Glargine plus sliding scale - Isosorbide Mononitrate 30 mg once daily - levothyroxine 88mcg - Lidocaine - Losartan 100 mg wd - Melatonin 1 mg bedtime - Metoprolol 100 mg qd - Flagyl 500 mg TID - MVI - Olanzapine - Pantoprazole - Spironolactone 25 mg qd - Thiamine 100 mg qd - Albuterol NEB - Benzonatate - Bisacodly - Guaifensisin - Ipratropium NEB - Zofran prn - Senna, Miralox Discharge Medications: 1. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) injection Injection TID (3 times a day): Please discontinue as appropriate when patient ambulatory. 3. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Cyanocobalamin 500 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 7. Levothyroxine 88 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 8. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 9. Benzonatate 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3 times a day). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 12. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q48H (every 48 hours). 13. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 14. Aztreonam in Dextrose(IsoOsm) 1 gram/50 mL Piggyback [**Hospital1 **]: One (1) 1000 mg Intravenous Q8H (every 8 hours): to end on [**2118-4-11**]. 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Date Range **]: One (1) 1000mg Intravenous Q48H (every 48 hours): To end on [**2118-4-11**]. Give every 48 hours as needed if vanco trough is <15. trough this am 20, please repeat am of [**4-5**]. 16. Sodium Chloride 0.9 % 0.9 % Piggyback [**Month/Day (2) **]: Three (3) ML Intravenous Q8H (every 8 hours) as needed for line flush. 17. Isosorbide Dinitrate 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3 times a day). 18. Metoprolol Tartrate 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day). 19. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid [**Month/Day (2) **]: [**6-13**] MLs PO Q4H (every 4 hours) as needed for cough. 20. Olanzapine 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at bedtime): can offer at bedtime if needed. 21. Humalog 100 unit/mL Cartridge [**Month/Year (2) **]: One (1) cartridge Subcutaneous sliding scale: Follow sliding scale protocol . 22. Lantus 100 unit/mL Cartridge [**Month/Year (2) **]: 16 unit am, 8 unit pm units Subcutaneous twice a day: Give 16 unit in am Give 8 inits in pm. 23. Fluoxetine 10 mg Capsule [**Month/Year (2) **]: Four (4) Capsule PO DAILY (Daily): continue to increase dose by 10 mg every other day until home dose of 60mg is reached. 24. Trazodone 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO qHS PRN as needed for insomnia: PRN for insomnia. 25. Fluticasone 50 mcg/Actuation Spray, Suspension [**Month/Year (2) **]: One (1) Spray Nasal DAILY (Daily). 26. 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. 27. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Year (2) **]: 1-2 puffs Inhalation every six (6) hours as needed for cough or SOB. 28. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Year (2) **]: 1-2 puffs Inhalation every six (6) hours as needed for cough, sob. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnoses: Acute on Chronic Kidney Disease Healthcare associated Pneumonia Pleural Effusion Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to the hospital from a rehab facility due to concern regarding your worsening kidney function. You were also thought to be confused and very lethargic when you were admitted. You were initially admitted to the ICU, where you were found to have pneumonia and you were started on antibiotics. In addition, fluid was drained from around your lung to help your breathing. After draining the fluid from your lungs you were transferred from the ICU to the inpatient medicine floor with improved breathing. Your kidney failure was thought to be secondary to dehydration, and you were rehydrated with IV fluids with good effect. Additionally, you were seen by psychiatry for depression, and your anti-depressants increased. . CHANGES IN MEDICATIONS: START: Aztreonam and Vancomycin; last day on [**2118-4-11**]. INCREASED: Fluoxetine 40mg Daily (continue to increase by 10 mg every other day until home dose of 60mg is reached) STOPPED: Flagyl, Ciprofloxacin, Lisinopril, Lasix Followup Instructions: Follow up with PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3271**] 2 weeks after discharge from rehab. Phone: [**Telephone/Fax (1) 35142**] Please discuss possibly re-starting epogen for your anemia with him at your next visit. Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**], please call for follow up appointment after rehab discharge: ([**Telephone/Fax (1) 2037**]

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Discharge summary

report

Admission Date: [**2118-1-13**] Discharge Date: [**2118-1-21**] Date of Birth: [**2038-3-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: fatigue/ dyspnia on exertion Major Surgical or Invasive Procedure: redo sternotomy/AVR(#23 CE pericardial) History of Present Illness: 79yoM who developed increasing SOB and dyspnea on exertion in late [**Month (only) **]. Patient had known AS an echo showed worsening AS and 3+ MR. [**Name13 (STitle) **] was referred to Dr [**Last Name (STitle) **] and surgery was scheduled. Past Medical History: HTN elev. lipids gout CAD s/p cabg x3 [**2103**]; PTCA /stent [**2115**] chronic renal insufficiency (baseline above 2.0) nephrolithiasis BPH-outflow obstruction glomerulosclerosis Social History: retired foreman lives alone with supervision quit smoking 40 years ago no ETOH use Family History: non-contrib. Physical Exam: Admission: VS 98 83 151/78 20 98%RA GEN: NAD HEENT: PERRL, anicteric, OP benign, Neck: supple, no JVD Pulm: CTA bilat CV RRR 2/6 SEM Abdm: soft, NT/ND/+BS Ext: warm, trace Bilat edema. Rt well healed SVG site. Left-small varicosity Discharge: Gen: NAD Neuro: non focal exam CV: RRR, sternum stable, incision CDI Pulm: CTA bilat Abdm: soft, NT/ND/+BS Ext: warm [**2-16**]+edema bilat Pertinent Results: [**2118-1-13**] 01:21PM GLUCOSE-124* NA+-137 K+-3.2* [**2118-1-13**] 01:08PM UREA N-38* CREAT-2.1* CHLORIDE-112* TOTAL CO2-18* [**2118-1-13**] 01:08PM ALT(SGPT)-14 AST(SGOT)-40 ALK PHOS-54 AMYLASE-34 TOT BILI-0.4 [**2118-1-13**] 01:08PM LIPASE-30 [**2118-1-13**] 01:08PM WBC-13.3* RBC-3.21* HGB-10.0* HCT-29.3* MCV-91 MCH-31.1 MCHC-34.2 RDW-15.6* [**2118-1-13**] 01:08PM PLT COUNT-148* [**2118-1-13**] 01:08PM PT-15.1* PTT-46.7* INR(PT)-1.3* [**2118-1-21**] 07:50AM BLOOD WBC-11.1* RBC-3.14* Hgb-9.7* Hct-30.0* MCV-95 MCH-30.7 MCHC-32.2 RDW-15.4 Plt Ct-260 [**2118-1-21**] 07:50AM BLOOD Plt Ct-260 [**2118-1-16**] 02:46AM BLOOD PT-13.8* PTT-35.8* INR(PT)-1.2* [**2118-1-21**] 07:50AM BLOOD Glucose-180* UreaN-51* Creat-2.1* Na-152* K-4.5 Cl-114* HCO3-25 AnGap-18 [**2118-1-14**] 12:58AM BLOOD ALT-16 AST-112* AlkPhos-57 Amylase-39 TotBili-0.5 RADIOLOGY Preliminary Report CHEST (PA & LAT) [**2118-1-21**] 11:07 AM CHEST (PA & LAT) Reason: eval for pleural effusion [**Hospital 93**] MEDICAL CONDITION: 79 year old s/p AVR REASON FOR THIS EXAMINATION: eval for pleural effusion PA & LATERAL VIEWS CHEST. REASON FOR EXAM: S/P AVR, assess pleural effusion. Comparison is made with prior studies including [**2118-1-7**]. ___of the cardiac silhouette is due to mild cardiomegaly and mediastinal fat. There is a tiny right pleural effusion. Blunting of the posterior left CP angle is longstanding due to mild elevation of the hemidiaphragm. There is no left pleural effusion. There are calcified pleural plaques posteriorly on the left. Patient is post median sternotomy and AVR. There is no pneumothorax or obvious CHF. DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**] RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2118-1-15**] 2:13 PM CT HEAD W/O CONTRAST Reason: r/o cva [**Hospital 93**] MEDICAL CONDITION: 79 year old man with not waking s/p AVR REASON FOR THIS EXAMINATION: r/o cva CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 79-year-old man, not waking status post AVR. COMPARISON: [**2117-12-13**]. TECHNIQUE: Non-contrast head CT. CT OF THE HEAD WITHOUT CONTRAST: There is no intracranial mass lesion, hydrocephalus, shift of normally midline structures, major vascular territorial infarct, or intra- or extra-axial hemorrhage. Confluent hypodensities within the periventricular white matter consistent with chronic microvascular ischemic changes. Again noted, cavum septum pellucidum/vergae. Prominence of the sulci and ventricles consistent with age-related cerebral atrophy. The visualized paranasal sinuses are unremarkable. The surrounding osseous and soft tissue structures are unremarkable. IMPRESSION: No acute intracranial process. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17726**] DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 39291**], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 39292**] (Complete) Done [**2118-1-13**] at 12:21:52 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2038-3-10**] Age (years): 79 M Hgt (in): 66 BP (mm Hg): 130/60 Wgt (lb): 180 HR (bpm): 72 BSA (m2): 1.91 m2 Indication: Post CABg with Severe AS and moderate MR [**Name13 (STitle) 15199**]9 Codes: 424.1, 424.0, V42.2 Test Information Date/Time: [**2118-1-13**] at 12:21 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW01-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 45% >= 55% Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aortic Valve - Peak Velocity: *5.2 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *100 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 45 mm Hg Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present. Left-to-right shunt across the interatrial septum at rest. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Mild to moderate ([**2-16**]+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Moderate (2+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions 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. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild to moderate ([**2-16**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is a central regurgitant flow with a vena contracta of 5mm, blunting of pulmonary venous flow both at rest and provocative maneuvers consistent with Moderate (2+) mitral regurgitation is seen. The amitral annulus was 38mm at the long axis and 32 mm at the commisural views. The left ventricle is not dilated. These findings were conveyed to Dr.[**Last Name (STitle) **] There is no pericardial effusion. Post_Bypass: LVEF 50% Patient is on epinephrine 0.02mcg/kg/min to facilitate weaning from the CPB> Thoracic aortic contour is intact. Moderate MR persists. There is a bioprosthetic valve seen in the native aortic position, stable and functioning well with a residual mean gradient of 9mm of Hg with no pathological perivalvular leaks. Mild TR. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2118-1-19**] 12:59 Brief Hospital Course: Mr [**Known lastname **] was a direct admission to the operating room where he had an redo sternotomy AVR on [**1-13**]. His bypass time was 104 minutes with a crossclamp of 75 minutes. Please see OR report for details. He tolerated the operation well and was transsferred to the ICU in stable condition on Epinephrine Neosynephrine and Propofol infusions. He did well in the immediate post-op period and on POD1 his sedation was stopped, however he was slow to awaken from anesthesia. He was also weaned from his vasoactive infusions. On POD2 he had a CT scan as he was still not fully awake, it showed no intracarnial abnormalities and finnally on POD3 he was more fully awake and extubated. he stayed in the ICU to monitor his neuro status and for further diuresis. On POD6 he was transfered to the general floor for further post-op care/recovery and addition physical therapy. On POD8 it was decided he was stable and ready for discharge to rehabilitation at [**Hospital 7661**] Health Care. Medications on Admission: Allopurinol 300' ASA 325' Vytorin 10/40 QD Xanax 1HS Lasix 20/prn Lopressor 12.5" Norvasc 5' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous AC and QHS as needed for FSBS>120. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Health - [**Location (un) 7661**] Discharge Diagnosis: s/p redo sternotomy AVR PMH: HTN, CAD s/p CABGx3, ^chol, CRI(2.4), BPH, Gout, Eye implants Discharge Condition: good Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medication as prescribed. Call for any fever, redness or drainage from wounds. Followup Instructions: Dr [**Last Name (STitle) 4783**] in [**3-20**] weeks Dr [**Last Name (STitle) **] in 4 weeks Completed by:[**2118-1-21**]

[ "585.9", "403.90", "276.0", "600.01", "414.00", "274.9", "285.9", "396.2", "599.69", "V13.01", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61", "00.13" ]

icd9pcs

[ [ [] ] ]

11048, 11125

9081, 10078

350, 392

11260, 11267

1424, 2407

11468, 11592

987, 1001

10221, 11025

3307, 3347

11146, 11239

10104, 10198

11291, 11445

1016, 1405

282, 312

3376, 9058

420, 664

686, 870

886, 971

3,650

122,337

27790

Discharge summary

report

Admission Date: [**2151-6-25**] Discharge Date: [**2151-7-6**] Service: CARDIOTHORACIC Allergies: Antihistamines Attending:[**First Name3 (LF) 1283**] Chief Complaint: Exertional Chest Pain Major Surgical or Invasive Procedure: [**2151-6-28**] - CABGx3 (Mammary artery to anterior descending artery, vein to obtuse marginal artery and vein to posterior descending artery) [**2151-6-25**] - Cardiac Catheterization History of Present Illness: 81 YO man dm, PVD, HTN, hypercholesterolemia is admitted after an episode of chest pain free hypotension during stress test. The patient reports h/o chest pain with exersion x 1 year which has completely resolved with protonix. Decided to get a stress test which was stopped due to hypotension. Patient denies SOB, edema, N/V. Patient sent for cath. Past Medical History: diabetes mellitus type 2 x5yrs PVD HTN Hypercholesterolemia Glaucoma Left retinal detachement s/p repair Social History: Retired. Lives with wife. Quit smoking 35 years ago. Family History: Mother with MI at age 73 Physical Exam: T 97.3 BP 117/58 P 71 R18 O2 95%RA GEN: Alert, NAD Cardio: RRR, nl S1, S2, no murmurs, rubs, gallops Chest: CTA bilaterally, no rhonchi, wheezes, rales Abd: SNTND, bowel sounds present Ext: No edema, cyanosis. 1+ DP, no femoral bruit Pertinent Results: [**2151-6-25**] 04:00PM GLUCOSE-131* UREA N-15 CREAT-0.9 SODIUM-140 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-25 ANION GAP-13 [**2151-6-25**] 04:00PM ALT(SGPT)-24 AST(SGOT)-17 ALK PHOS-62 AMYLASE-27 TOT BILI-0.6 [**2151-6-25**] 04:00PM WBC-5.2 RBC-4.17* HGB-12.9* HCT-36.6* MCV-88 MCH-30.9 MCHC-35.3* RDW-14.8 [**2151-6-25**] 04:00PM PLT COUNT-112* [**2151-6-25**] 02:00PM INR(PT)-1.6* [**2151-6-25**] - Cath Lab: 3V disease: LMCA to LAD ostium 90% stenosed. LCX 70% stenosis, RCA 90% stenosis. Mild ventricular dysfuction EF 44% with global hypokinesis [**2151-6-28**] ECHO PREBYPASS The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed. 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. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS Postbypass left ventricular function is slightly improved. LVEF~45-50%. MR is now trace. The study is otherwise unchanged from prebypass. [**2151-7-5**] CXR Resolving basilar atelectasis. Small pleural effusions. [**Last Name (NamePattern4) 4125**]ospital Course: Mr. [**Name13 (STitle) **] was admitted to the [**Hospital1 18**] on [**2151-6-25**] for further evaluation of his chest pain. He underwent a cardiac catheterization which revealed severe three vessel disease. Heparin was started for anticoagulation. Due to the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. He was worked-up in the usual preoperative manner and found to be suitable for surgery. On [**2151-6-28**], Mr. [**Name13 (STitle) **] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. he tolerated the procedure well and please see operative report for further details. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. By postoperative day one, Mr. [**Name13 (STitle) **] was awake, neurologically intact and extubated. He was transfused for postoperative anemia. He developed atrial fibrillation which was treated with amiodarone. On postoperative day three, he was transferred to the floor for further recovery. Mr. [**Name13 (STitle) **] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Coumadin was started as his atrial fibrillation persisted. Mr. [**Name13 (STitle) **] continued to make steady progress and was discharged home on postoperative day 9. Dr. [**Last Name (STitle) 656**] will follow his coumadin dosing for a goal INR of 2.0-2.5. Amiodarone will be 200mg twice daily for a week and then decreased to 200mg once daily thereafter. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: glyburide 7.5 mg po BId Metformin 500mg po TID lanoxen 0.125 po qhs cardura 4mg po qhs lipitor 20mg po daily protonix 40mg po daily aspirin 81 mg po daily prinovil 25mg po daily metoprolol 150mg po BID Alopurinol 70mg po daily Vit B6 Alphigan 1 drop to right eye daily cosop 1 drop to right eye daily xalatan 1 drop to right eye daily Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Glyburide 2.5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*1 vial* Refills:*2* 11. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*1 VIAL* Refills:*2* 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days: then decrease to 1 tablet (200 mg) daily until discontinued by Dr. [**Last Name (STitle) 656**]. Disp:*60 Tablet(s)* Refills:*0* 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: CAD PVD DM-2 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 pcp/cardiologist Dr. [**Last Name (STitle) 656**] in [**1-4**] weeks with Dr. [**Last Name (Prefixes) **] in 4 weeks Completed by:[**2151-7-8**]

[ "414.01", "V58.61", "285.9", "401.9", "443.9", "411.1", "425.4", "250.00", "427.31", "274.9", "287.5", "V17.3" ]

icd9cm

[ [ [] ] ]

[ "88.72", "37.22", "99.04", "88.56", "88.53", "36.12", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

6806, 6865

249, 437

6922, 6929

1331, 2747

1032, 1058

4916, 6783

6886, 6901

4557, 4893

6953, 7101

7152, 7304

1073, 1312

2798, 4531

188, 211

465, 818

840, 946

962, 1016

3,313

199,943

29530

Discharge summary

report

Admission Date: [**2194-2-4**] Discharge Date: [**2194-2-11**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Bactrim Attending:[**First Name3 (LF) 2932**] Chief Complaint: weakness Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] year old female presents with GI bleed in setting of elevated INR, and hypothermia/hypotension. Patient with h/o of recent pneumonia treated with levofloxacin and on coumadin 1mg qday for Afib. She was found at her rehab facility weak, slumped on bathroom floor. Noted to have loose heme positive stool over several days. WBC 18, INR >11. Treated with vitamin K 10mg po and levoflox 750mg po x1. Of note patient also with recent seizures since [**12-4**]. Seen by neurologist who ordered MRI and EEG. EEG nl. Recent swall eval with micro aspirations with thin liquids, and the patient has been on nectar thick liquids. In the ED the patient was noted to be hypothermic (Temp 33C) and mildly hypotensive 70's-90's. GUIAC+ stool. Given 10mg vitamin K. Given 1u pRBC and 2u FFP. CT Head neg for mass/bleed. CT torso with multilobar pna but without evidence of retroperitoneal bleed. She was admitted to the intensive care unit, at which time she denied fevers, chills, chest pain, shortness of breath, abdominal pain, dysuria. No cough but niece noted that patient was "gurgling" and that food sometimes "gets stuck" when she swallows Past Medical History: CHF h/o bradycardia Afib on low dose coumadin critical AS h/o breast ca s/p mastectomy in [**2176**]'s h/o zoster with post-herpetic neuralgia on R ribs HTN Hypothyroidism h/o MRSA UTI chronic diarrhea h/o aspiration s/p Pneumovax [**2194-12-25**] Social History: lives at nursing home; grand-niece is Health [**Name (NI) **] proxy Family History: NC Physical Exam: In ED: PE: VS T 93.0 P 96 BP 102/42 R 15 O2 98% on RA Gen - A+Ox3, NAD HEENT - OP clear, EOMI, PERRL Neck - supple, no LAD Chest - crackles at bases, scrape on R side of chest, mild bleeding, no erythema or pus Cor - RRR, sys murmur Abd - s/nt/nd +BS Ext - w/wp, no edema Rectal - GUAIC neg per ED Transfer to ICU: PE: VS 94.2 129/77 80 18 O2 95on 2L Gen - A+Ox3, NAD HEENT - OP clear, EOMI, PERRL; dryMM Neck - supple, no LAD Chest - crackles at right base Cor - RRR, sys murmur Abd - s/nt/nd +BS Ext - w/wp, no edema Pertinent Results: Admission: [**2194-2-4**] WBC-17.0 HGB-12.3 HCT-38.5 MCV-96 RDW-15.9 NEUTS-93.7 BANDS-0 LYMPHS-4.5* MONOS-1.4* EOS-0.2 BASOS-0.2 PT-150* PTT-131.9* INR(PT)->22.8 GLUCOSE-83 UREA N-60* CREAT-2.2* SODIUM-145 POTASSIUM-5.7* CHLORIDE-113* TOTAL CO2-17* LACTATE-2.4* U/A: NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-[**3-3**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**3-3**] Discharge: [**2194-2-10**] WBC-11.3 Hgb-12.1 Hct-34.5 MCV-87 RDW-15.8 Plt Ct-62 Neuts-93.7* Bands-0 Lymphs-4.5* Monos-1.4* Eos-0.2 Baso-0.2 PT-13.4* PTT-30.1 INR(PT)-1.2* Glucose-87 UreaN-26* Creat-1.3* Na-144 K-4.6 Cl-103 HCO3-34 Radiology: [**2-4**] CT torso w/o contrast: Patchy tree-in-[**Male First Name (un) 239**] opacities in the right upper lobe. There are more dense mixed consolidative and ground glass opacities in the lower lobes and within the right middle lobe. Trace pleural effusions. There are multiple prominent but relatively small mediastinal lymph nodes up to 7 mm in shortest dimension. Mild prominence of the central hepatic bile ducts without definite intrahepatic biliary ductal dilatation. The extrahepatic common duct measures up to 6 mm. The gallbladder is massively distended, measuring up to 13 cm in length. There is no definite surrounding inflammatory change, however, and no radiopaque stones are visualized. Particularly without intravenous contrast administration, further evaluation, however, is highly limited. The pancreatic head is poorly visualized but appears perhaps slightly enlarged and may have a double duct sign raising at least the suspicion of an underlying mass. The spleen and adrenal glands are unremarkable. Particularly the right kidney is highly atrophic, but there is also left renal cortical thinning. There are vascular calcifications noted but no aortic aneurysm. There is extensive involvement of the left ischium with Paget's disease and lesser involvement of the left ilium. The bones are diffusely demineralization. There is leftward convex scoliosis of the lumbar spine with degenerative changes, including intervertebral disc space narrowing and osteophytes throughout the lumbar spine, extending from the T11-T12 through the L5-S1 interspaces. There are posterior osteophytes from the level of T12- L1 through L3-L4. [**2-4**] CT head w/o contrast: There is no intracranial hemorrhage. There is no midline shift, mass effect or hydrocephalus. There are periventricular white matter hypodensities most consistent with chronic microvascular ischemic changes. There are small lacunes within the right cerebellar hemisphere. There is an air-fluid level in the right maxillary sinus with adjacent mucosal thickening. This fluid is of high density and could represent inspissated secretions vs. blood. No facial fractures are identified on these limited images. [**2-4**] CXR: : Bibasilar opacities concerning for pneumonia. Right lung base atelectasis. No congestive heart failure. No pleural effusion. [**2-4**] CT C spine: No acute fractures or dislocations. Multilevel degenerative changes with at least moderate spinal canal narrowing at C4-5 due to osteophytes and a central disc protrusion. [**2-5**] U/S: : Dilated gallbladder with stones in its lumen. No ericholecystic fluid, gallbladder wall thickening, or son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. Intra- or extra-hepatic biliary ductal dilation. The pancreas and pancreatic duct are not well assessed. [**2-10**] CXR: Moderate right and small-to-moderate left pleural effusions are unchanged. Bibasilar consolidation is present and slightly worse on the left in the interval. Multifocal poorly defined upper lobe opacities have slightly worsened and likely correspond to areas of bronchocentric opacification on recent CT torso. The constellation of findings is most consistent with a multifocal infection. [**2-10**] TTE: The left atrium is normal in size. The estimated right atrial pressure is 11-15mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. At least mild aortic valve stenosis is present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-31**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Significant aortic valve stenosis - ?mild. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild-moderate mitral regurgitation. Pulmonary artery systolic hypertension. Bilateral pleural effusions. Brief Hospital Course: [**Age over 90 **] year old female presents with GI bleed in setting of elevated INR and hypothermia/hypotension, found to have a multilobar aspiration pneumonia.. 1) GI bleed/acute blood loss anemia: This was most likely an upper source, given melena, in the setting of markedly elevated INR 22. She was initially admitted to the intensive care unit, where her INR was reversed with FFP and vitamin K. The gastroenterology service was consulted, but the patient and her health care proxy declined further work-up (EGD/colonoscopy). At time of discharge, her hematocrit was stable at 34.5. She was maintained off coumadin. 2) Sepsis due to aspiration pneumonia: In the ICU, the patient was fluid resuscitated and covered with Zosyn/vancomycin with stabilization of blood pressure. She had a speech and swallow evaluation, which recommended soft diet/thin liquids with no mixed consistencies. At time of discharge, she was on oxygen for comfort, 100% 2L NC. She was transitioned to oral antibiotics (cefpodoxime/metronidazole) to complete a 14 day course. 3) Bilateral pleural effusions/CHF: The patient developed bilateral pleural effusions, noted on chest X-ray [**2194-2-7**]. Given suspicion for fluid overload, she was gently diuresed with IV Lasix without significant change in size of effusions. Although these effusions could represent parapneumonic effusions, both the patient and her healthcare proxy declined thoracentesis, given their goal of comfort-oriented care (see below). At time of discharge, she was stable on 100% 2L NC; she will complete a 14 day antibiotic course as above. 4) Thrombocytopenia: The patient's platelet count dropped from 165 on admission to 62 (stable since [**2193-2-7**]). This may have been related to consumption from GI bleed versus sepsis-related bone-marrow suppression. The patient's fibrinogen was elevated, not consistent with DIC. The patient does not desire further blood draws and has decided to pursue hospice at rehab. 5) Atrial fibrillation: The patient was noted to have significant pauses on telemetry, however, she did not desire a pacemaker. She had a TTE which showed ?mild AS, 1+ AR, [**12-31**]+ MR, [**12-31**]+ TR, EF >55%. She was continued off coumadin given GI bleed (see above). 6) Seizure disorder: The patient has not had a seizure in over 2 weeks and recent EEG was without epileptiform activity. There had been concern that, given her history of cancer, she could have a metastatic focus in the brain that may have triggered her prior seizures. However, the patient did not desire further testing (MRI head, etc.) given her goal of comfort-oriented care. 7) Hypothyroidism: The patient was continued on her home dose of synthroid. 8) Acute renal failure: The patient's creatinine improved to 1.3 from 2.2 on admission with hydration. The acute renal failure was most likely due to ATN in the setting of sepsis. 9) Breast mass/pancreatic mass: These had been incidentally noted on prior imaging. The patient does not desire treatment or further diagnostic testing. 10) Goals of care: Extensive discussions were held with the patient and her health care proxy with regards to his goals of care. They would like to complete the planned course of antibiotics for her aspiration pneumonia, but do not desire further tests or invasive procedures (MRIs, thoracentesis, lab draws, biopsies). They decided to pursue hospice care, and the patient was discharged back to [**Hospital 100**] Rehab with hospice nursing services. Medications on Admission: Meds: tylenol prn atrificial tears fluticasone 110mcg 2puff qday Flonase 1 spray [**Hospital1 **] neurontin 400mg tid lactobacillus synthroid 50mcg qday lidocaine patch 5% tp qday oxycodone 2.5mg prn KCl 20meq qday bacitracin ointment to chest [**Hospital1 **] clotrimazole 1% [**Hospital1 **] to rectum . Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Polyvinyl Alcohol 1.4 % Drops [**Hospital1 **]: 1-2 Drops Ophthalmic PRN (as needed). 3. Erythromycin 5 mg/g Ointment [**Hospital1 **]: 0.5 inch Ophthalmic QID (4 times a day) for 7 days. 4. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q48H (every 48 hours). 7. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) neb Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 8. Cefpodoxime 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q12H (every 12 hours) for 6 days. 9. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day) for 6 days. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Primary: aspiration pneumonia Secondary: pleural effusions, blood loss anemia, gastrointestinal bleed, thrombocytopenia, congestive heart failure (left), acute renal failure Discharge Condition: Stable Discharge Instructions: Please follow-up as indicated below Followup Instructions: Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 70837**]) within 1-2 weeks following discharge [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**] Completed by:[**2194-2-11**]

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icd9cm

[ [ [] ] ]

[ "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

12141, 12206

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246, 253

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23955

Discharge summary

report

Admission Date: [**2176-8-15**] Discharge Date: [**2176-8-23**] Date of Birth: [**2116-12-6**] Sex: M Service: SURGERY Allergies: Heparin Sodium / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 974**] Chief Complaint: s/p Self amputation left hand Major Surgical or Invasive Procedure: [**2176-8-16**] Revision of left hand amputation History of Present Illness: 59 yo right hand dominant sales man (former builder) who presents 1-3 hours s/p intentional amputation of left hand via table saw. He was takne to an area hospital and transferred to [**Hospital1 18**] for further care. he was noted to be hypotensive to in the 80's systolic en route to the [**Hospital1 18**] ED. He has history of chronic median neuropathic pain of the left hand and reports that he could not take the pain any longer. Past Medical History: Chronic left hand pain s/p median nerve injury 4 yrs ago HTN Peripheral Vascular Disease Hypercholesterolemia Coagulopathy COPD/emphysema Social History: [**1-23**] ppd tobacco use for mnay years Married Physical Exam: Upon admission: 68 101/62 19 98% on 4L nasal oxygen 1. General - pale, A & O x 3 2. Heart - RRR, no MRG 3. Pulmonary - CTAB, no WRR 4. Abdomen - NTND, ABS 5. Ext - stump at left wrist packed and bandaged with adequate hemostasis, remaining ext NT, no edema, DP 2+ 6. Amputated hand - level of first carpal bones, ring removed, stored in bag in ice slurry, no additional trauma to hand Pertinent Results: [**2176-8-15**] 04:29PM GLUCOSE-157* LACTATE-3.9* NA+-141 K+-3.3* CL--102 TCO2-25 [**2176-8-15**] 04:15PM ASA-NEG ETHANOL-166* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2176-8-15**] 04:15PM WBC-10.9 RBC-4.06* HGB-13.2* HCT-40.3 MCV-99* MCH-32.4* MCHC-32.7 RDW-13.4 [**2176-8-15**] 04:15PM PT-13.6* PTT-24.0 INR(PT)-1.2* [**2176-8-15**] 04:15PM PLT COUNT-212 [**2176-8-15**] 04:15PM FIBRINOGE-195 Cardiology Report ECG Study Date of [**2176-8-15**] 4:14:42 PM Sinus rhythm. Prolonged Q-T interval. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 65 186 98 472/480 80 69 61 PA AND LATERAL CHEST ON [**2176-8-18**] AT 14:34 INDICATION: Low O2 sats. FINDINGS: There is no focal consolidation or effusion. Heart size is within normal limits and the pulmonary vascular markings are nondistended. IMPRESSION: No evidence for acute cardiopulmonary disease. HAND, AP & LAT. VIEWS LEFT Clip # [**Clip Number (Radiology) 61027**] Reason: TRAUMA, (P) LEFT HAND, AMPUTATION LEFT HAND, FRONTAL VIEWS: Radiographs are obtained separately of the patient's distal left upper extremity and the amputated left hand. There is amputation with straight edge through the distal carpal row. Along the distal portion of the left upper extremity, the distal carpal bones are displaced. Bandaging material and presumed tourniquet are noted. No definite retained radiopaque foreign body is seen. IMPRESSION: Status post amputation of the left hand through the distal carpal row. Brief Hospital Course: He was admitted to the Trauma service. Plastics consulted urgently for the left hand amputation and he was taken to the operating room for revision of the left hand amputation. There were no intraoperative complications. Postoperatively from a hemodynamic perspective his blood pressure has remained stable and his hematocrit is stable at 33.3 with no evidence of any acute bleeding from his injury site. His wound is currently covered with xeroform and ABD pad. Psychiatry was also consulted early on. He was placed on 1:1 supervision; CIWA scale was implemented. It was recommended that patient be hospitalized in an inpatient mental health facility once medically cleared. During his stay he was noted with intermittent low oxygen saturations and required supplemental oxygen; his saturations were noted to drop to high 80's% without any symptoms of shortness of breath or dyspnea. A Pulmonary consult was obtained at the request of Psychiatry because of concerns over his low saturations and his medical clearance for transfer to an inpatient psychiatric facility. It was felt that he likely had some pulmonary edema and recommended diuresis with Lasix which was successful. It was also felt that he was likely having a COPD flare and a 5 day course with Prednisone 40 mg was ordered. At time of this dictation he has 1 day left to complete the full course. His oxygen was eventually weaned off with initial saturations in the low 90's%. His PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 44170**] was contact[**Name (NI) **] to find out more about his past medical history; he notes that patient has a greater than 30 year history of tobacco use [**1-23**] ppd and that he does have a diagnosis of COPD/emphysema and that his baseline resting saturations run in low 90's. Of note during ambulation his saturations have dropped to 88-91% without any symptoms of shortness of breath/dyspnea or tachypnea. From this standpoint he is deemed medically stable for transfer to an inpatient psychiatric facility. Medications on Admission: Unable to confirm dosages at time of admission: --metoprolol --plavix --hydrochlorothiazide --diovan --neurontin --amlodipine Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 MG Subcutaneous DAILY (Daily). 3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 16. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 1 days: Has one more day left of a 5 day course of treament per recommendations of Pulmonary Medicine. 17. Lasix 20 mg Tablet Sig: [**12-22**] Tablet PO once a day for 4 days: [**Month (only) 116**] discontinue after last dose in 4 days. 18. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 19. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital1 18**] [**Hospital1 **] 4 Discharge Diagnosis: s/p Self amputation of left hand Discharge Condition: Hemodynamically stable, tolerating a regular diet, room air saturations stable and at baseline, pain adequately controlled, ambulating independently. Followup Instructions: Follow up next week in Plastics Hand Clinic; call [**Telephone/Fax (1) 3009**] for an appointment. Follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 44170**] at [**Hospital6 4620**] after discharge from inpatient mental health facitily for ongoing managment of your COPD/Emphysema. Pulmonary function tests are being recommended. If you wish you may follow up in Pulmonary clinic in 1 month at [**Hospital1 18**] with Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 612**]. Completed by:[**2176-8-23**]

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icd9cm

[ [ [] ] ]

[ "84.04" ]

icd9pcs

[ [ [] ] ]

7096, 7160

3077, 5103

337, 387

7237, 7388

1513, 3054

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7181, 7216

5129, 5257

1098, 1100

268, 299

415, 855

1114, 1494

877, 1016

1032, 1083

2,270

117,731

53854

Discharge summary

report

Admission Date: [**2118-12-28**] Discharge Date: [**2119-1-13**] Date of Birth: [**2043-12-6**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Chronic cholecystitis with gallstones and common bile duct stones Extensive incisional ventral hernia. Major Surgical or Invasive Procedure: Open cholecystectomy Ventral Hernia Repair with mesh buttress and component separation. Omentectomy Abdominoplasty History of Present Illness: This is a 75-year-old gentleman who recently presented with gallstone pancreatitis over a month ago. He was cared for by my associate Dr. [**First Name (STitle) **] [**Name (STitle) **] and at that time he received an endoscopic sphincterotomy for his common bile duct stone disease. He recovered well from this but required a cholecystectomy for his demonstrated gallstone disease. Furthermore, it was a clear to Dr. [**Last Name (STitle) **] that the patient had a significant ventral hernia problem from a prior abdominal aortic aneurysm repair many years ago. Past Medical History: PAST MEDICAL HISTORY: 1. Hepatitis B. 2. History of alcohol abuse. 3. Partial portal vein thrombosis. 4. Asthma. 5. Glaucoma. 6. Diverticulitis. 7. Hypertension. 8. Gout. 9. History of urinary tract infections. 10. Multiple SBO 11. gallstone pancreatitis PAST SURGICAL HISTORY: 1. Left hand surgery. 2. Status post infrarenal aortic aneurysm repair and appendectomy on [**2111-12-22**]. 3. endoscopic sphincterotomy for his common bile duct stone disease [**2118-11-30**] Social History: tobacco x11yrs h/o EtOH abuse Family History: NC Physical Exam: At admission VS: HR 74, BP 119/66 Gen: Well appearing, NAD Mental Status: no focal deficits, AA+O x 3 HEENT: neck supple, No LAD CV: RRR, S1, S2 Pulm: WNL Abd: a "Swiss cheese" abdomen. There are probably 5 or 6 significant hernia sacs that are protruding on each side of the midline incision; true pendulous redundant hernia sacs emanating from the abdominal wall. tender on palpation. Pertinent Results: [**2119-1-3**] 06:05AM BLOOD WBC-7.3 RBC-3.63* Hgb-11.3* Hct-34.9* MCV-96 MCH-31.1 MCHC-32.4 RDW-13.2 Plt Ct-316 [**2118-12-29**] 09:12AM BLOOD WBC-14.6* RBC-4.03* Hgb-12.9* Hct-37.9* MCV-94 MCH-31.9 MCHC-34.0 RDW-13.5 Plt Ct-206 [**2119-1-3**] 06:05AM BLOOD Glucose-112* UreaN-15 Creat-0.9 Na-140 K-4.9 Cl-104 HCO3-25 AnGap-16 [**2118-12-29**] 06:25AM BLOOD Glucose-145* UreaN-13 Creat-1.2 K-4.9 [**2119-1-1**] 02:00AM BLOOD CK(CPK)-1532* [**2118-12-30**] 11:58AM BLOOD ALT-26 AST-98* CK(CPK)-3295* AlkPhos-59 Amylase-26 TotBili-0.5 [**2118-12-31**] 04:05AM BLOOD CK-MB-71* MB Indx-1.6 cTropnT-<0.01 [**2119-1-3**] 06:05AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1 [**2118-12-30**] 08:56AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.3 [**2118-12-30**] 09:07AM BLOOD Glucose-142* Lactate-2.5* [**2119-1-2**] 01:06AM BLOOD Glucose-126* Lactate-1.7 CHEST (PORTABLE AP) [**2118-12-30**] 7:09 AM [**Hospital 93**] MEDICAL CONDITION: 75 year old man with acute asthma attack. REASON FOR THIS EXAMINATION: Please evaluate for fluid in airway, aspiration, possible cause of SOB Lung volumes are appreciably lower than they were on [**12-23**], a finding that does not correspond to bronchospasm. Mild cardiomegaly is worse. There is no pulmonary vascular congestion. The asymmetric vascular distribution, with deficiency in the right lung is longstanding. CHEST (PORTABLE AP) [**2118-12-31**] 5:56 AM Reason: ? RESPIRATORY DISTRESS FINDINGS: Again noted are diminished lung volumes, which are stable relative to [**12-30**], but represent acute change relative to [**12-23**]. These findings are not consistent with an asthma attack. No focal consolidation is identified. The cardiomediastinal silhouette is stable. The visualized osseous structures are unremarkable. IMPRESSION: Stable examination with low lung volumes and no superimposed consolidation. CHEST (PORTABLE AP) [**2119-1-2**] 8:36 AM [**Hospital 93**] MEDICAL CONDITION: 75 year old man with scattered rales and scattered rhonchi The heart size is mildly enlarged but stable. The mediastinal contours, width and position are unremarkable. The bibasilar atelectasis and small bilateral pleural effusion is unchanged within the limitation of the apical projection of this film. On [**1-4**] the patient continue to have respiratory distress. Whent to xray, and in the wiating room, coded. Massive PE was discovbered. the patient had 20 of pulseness electrical activity. CTA IMPRESSION: 1. Extensive bilateral pulmonary emboli as described above. 2. Patchy opacities in the left upper lobe, right upper lobe, right lower lobe, and left lower lobe. 3. Postoperative changes of the abdominal wall. 4. Mildly dilated loops of small bowel with no obvious transition point. C/W ileus. 5. Infrarenal abdominal aortic aneurysm with maximal AP dimension of approximately 4.1 cm. 6. Snall amount of fluid within the gallbladder fossa, likely postoperative Admitted to icu. No neuro response after. Hypotensive an in PEA for 20 minutes. Neurology consulted: CC: seizures HPI: The patient is a 75yo R-handed man with COPD, s/p AAA repair, who was admitted [**12-28**] for an open CCY/Ventral herniorrhaphy. He was brought to the TSICU w/ acute respiratory distress, ARF, oliguria on POD#1 ([**12-30**]). He improved and was sent to the floor. On POD#7 ([**1-4**]), he was sent for CXR where was found down. A code was called after about one minute. He did not have a pulse and did not breath. CPR was started and he was intubated at the site. Monitor showed PEA. After atropine and CPR for 20 minutes, he developed a pulse. Workup revealed a saddle embolus and R-popliteal embolus. He is maintained on a heparin drip. Since the code he has been remained intubated. His exam off propofol per team showed intact bs reflexes, but otherwise no response to noxious. When lowering the propofol in the evening of [**1-5**], head and bilateral arm jerking was seen, with eyes rolled backwards. This activity continued until the propofol was increased. A CT head was obtained which did not show a hemorrhage or acute pathology. He was loaded on an AED at that time. Sputum cultures grew enterobacter and pseudomonas for which he is being treated with cipro. We are now called to further assist in management and workup of seizures. No further seizure activity has been noted (but he has remained on propofol). ROS: -unable to obtain PAST MEDICAL HISTORY per OMR: 1. Hepatitis B. 2. History of alcohol abuse. 3. Partial portal vein thrombosis. 4. Asthma/COPD. 5. Glaucoma. 6. Diverticulitis. 7. Hypertension. 8. Gout. 9. History of urinary tract infections. 10. Multiple SBO no history of seizures PAST SURGICAL HISTORY: 1. Left hand surgery. 2. Status post infrarenal aortic aneurysm repair and appendectomy on [**2111-12-22**]. MEDICATIONS: -Heparin IV goal PTT 60-80. -Acetylcysteine 20% 1-10 ml NEB Q6H:PRN thick bronchial secretions -Insulin SC (per Insulin Flowsheet)Sliding Scale -Albuterol-Ipratropium [**2-14**] PUFF IH Q6H:PRN -Ipratropium Bromide Neb 1 NEB IH Q6H -Albuterol [**3-19**] PUFF IH Q4H:PRN -Magnesium Sulfate 2 gm / 100 ml D5W IV PRN Mg < 2.0 -Bisacodyl 10 mg PO/PR DAILY:PRN -Midazolam HCl 1-2 mg IV Q2H:PRN -Brimonidine Tartrate 0.15% Ophth. 1 DROP OU Q8H -Morphine Sulfate 2-4 mg IV Q4H:PRN -Calcium Gluconate 2 gm / 100 ml D5W IV PRN I Ca < 1.12 -Norepinephrine 0.02-0.28 mcg/kg/min IV DRIP TITRATE TO maintain map>65 -Ciprofloxacin 400 mg IV Q12H -Pantoprazole 40 mg IV Q24H -Dolasetron Mesylate 12.5 mg IV Q8H:PRN -Phenytoin 1000 mg IV ONCE Duration: 1 Doses -Dorzolamide 2% Ophth. Soln. 1 DROP OU TID -Potassium Chloride 40 mEq / 100 ml SW IV PRN K < 3.9 -Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION -Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO SEDATION -Fluticasone-Salmeterol (250/50) 1 INH IH [**Hospital1 **] -Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] ALLERGIES: NKDA SOCIAL HISTORY: tobacco x11yrs h/o EtOH abuse FAMILY HISTORY: n.c EXAM (on propofol) VITALS: T99.6 HR103 BP108/55 RR23 sO2 97% CVP 9-10. GEN: intubated HEENT: mmm; NECK: no LAD; no carotid bruits; neck supple LUNGS: vented bs HEART: Regular rate and rhythm, normal S1 and S2, no murmurs, gallops and rubs. ABDOMEN: normal bowel sounds, soft, nontender, nondistended EXTREMITIES: edema; pulses MENTAL STATUS: Intubated; eyes closed; not responding to voice or noxious. CRANIAL NERVES: II: No blink to threat. Pupil R 3-->2.5; L 2.5-->2. III, IV, VI: eyes midline; oculocephalic reflex absent (no dolls) V: corneal present on R, not L; no response to nasal tickle. VII: Face symmetrical. VIII: - IX: gag present. XII: - [**Doctor First Name 81**]: - MOTOR SYSTEM: Normal bulk. Tone decreased throughout. No adventitious movements, no tremor, no asterixis. No shaking. No spontaneous movement. No response to noxious. No posturing. SENSORY SYSTEM: Triple reflex in both LE to noxious. No response in UE. REFLEXES: B T Br Pa Pl Right 2 2 2 1 - Left 2 2 2 2 - Toes: mute bilaterally. COORDINATION: deferred GAIT: deferred LABS and IMAGING: Micro: [**12-30**]: BCx P; Scx PSEUDOMONAS AERUGINOSA, ENTEROBACTER CLOACAE (pan [**Last Name (un) 36**]); UCx NG. Imaging: [**1-4**]: C/A/P CT: Extensive bilateral pulmonary emboli. Patchy opacities in the left upper lobe, right upper lobe, right lower lobe, and left lower lobe. Mildly dilated loops of small bowel with no obvious transition point. Followup recommended. Infrarenal abdominal aortic aneurysm with maximal AP dimension of approx 4.1 cm. Fluid within the gallbladder fossa. [**1-4**] LE U/S: R popliteal thrombus, not completely occlusive. pH7.47 pCO236 pO295 HCO327 BaseXS2 Type:Art freeCa:1.12 Lactate:1.4 144 112 19 AGap=11 ------------< 130 4.4 25 1.2 Ca: 8.0 Mg: 1.8 P: 3.1 WBC12.4 PLT211 Hct26.5 PT: 14.8 PTT: 64.1 INR: 1.3 CT head [**1-6**]: There is no intracranial hemorrhage. There is no midline shift, mass effect or hydrocephalus. The [**Doctor Last Name 352**]-white matter differentiation is preserved. There are no fractures. Incidental note is made of carotid artery calcifications and scattered areas of mucosal thickening throughout the ethmoid and maxillary paranasal sinuses. IMPRESSION: No CT evidence of an acute infarct. ASSESSMENT: The patient is a 75yo R-handed man with COPD, s/p AAA repair, who was admitted [**12-28**] for an open CCY/Ventral herniorrhaphy. On [**1-4**], he coded (x 20 minutes) and has remained comatose since that time. Workup revealed a saddle embolus and R-popliteal embolus. He is maintained on a heparin drip. In addition he is being treated for infection with cipro. In the evening of [**1-5**], seizure activity was noted as the propofol was being lowered, resolving after increase of propofol. On exam he is comatose, with at least partially intact bs reflexes (not taken off propofol as he was not loaded on AED). CT head does not show evidence of a hemorrhage and [**Doctor Last Name 352**]/white matter is preserved. Although little information has been documented regarding the seizure, it is possible that he has been seizing due to anoxic brain injury. Alternativly, he may have shown myoclonus which is also frequently seen in this setting. Given the duration of PEA, prognosis is guarded. PLAN: -load on dilantin 20mg per kg; check level; start dosing at 100mg iv TID and continue to follow trough levels in am; please also check albumin. Though propofol will work for now, he will need other AED to be able to wean off vent. -infectious/metabolic workup: please check LFTs (especially as he is being loaded on dilantin), and amylase, lipase; would panculture -please get bed side EEG; based upon the results may need to add AEDs -seizure precautions; ativan PRN seizures (once weaned off propofol) -treat fever aggressively with tylenol -avoid fluoroquinolones and flagyl as these decrease seizure threshold (pt currently on cipro which should be changed) -MRI/MRA/MRV head once stable; MRV to rule out sinus thrombosis in setting of recent thrombosis (DVT and PE); this would further affect prognosis -consider LP to rule out herpes encephalitis (as it is treatable) though rather unlikely -will follow with you Addendum: bedside EEG; taken off propofol, had just been loaded on dilantin; developing burst suppression pattern; then spike-slow wave activity that increased in frequency, leading to pre-status pattern. Clinically, started the initial spike waves co-incided with head nods and bilateral arm jerks. These movements became more prominent in line with increased activity on EEG. Pt put back on propofol. Further recs: -keep pt on propofol over the weekend; may repeat bedside EEG on [**1-8**] -we will be available over the weekend if family would like to discuss findings with us [**First Name8 (NamePattern2) 39215**] [**Last Name (NamePattern1) **] Neurology R-3 [**Numeric Identifier 90765**] Disc with Dr. [**Last Name (STitle) **] [**Name (STitle) 467**], attending Addendum by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, PHD on [**2119-1-6**]: I have seen Mr [**Known lastname 2470**] with Dr [**Last Name (STitle) 110494**] and agree with her note, findings on exam, and recommendations. I have gone over the details of the history, reviewed the EEG, and concur that most likely Mr [**Known lastname 2470**] has sustained a hypoxic brain damage result in current status epilepticus. However, even if unlikely, there are some imperative diagnoses worth considering in the differential as they are potentially treatable causes of the clinical picture that have not been ruled out. First, the possibility of a CNS infection is worth considering. A bacterial meningitis seems most unlikely given the history and the clinical picture. However, a viral encephalitis might be worth considering. In this context an LP would help rule this out. Second, a vascular event, e.g. a venous thrombosis, could be ruled out by MRI, including MRA and MRV. An MRI would also help assess the damage caused by the likely hypoxic insult. In parallel to these considerations, a family conference to address the poor prognosis of the present clinical situation and obtain guidance regarding status seems important. Thanks for the consultation. We will follow with you. MRI of the brain IMPRESSION: No definite evidence of dural sinus thrombosis. In particular, no definite signs of deep venous thrombosis EEG FINDINGS: ABNORMALITY #1: Throughout the recording the background rhythm remained slow and of very low voltage in all areas. The low voltage background was punctuated by brief bursts of generalized slowing without epileptiform features. After 10 minutes or so the slowing was more prominent and the background less suppressed. There were frequent brief jerks of the patient's head to the left (corroborated by video recording). There were very brief sharp features at these times, but these appeared most likely to represent movement artifact. Jerks became more frequent after a few minutes, some appeared to involve shoulder muscles as well. In addition, however, there were brief spikes with a generalized distribution and bifrontal emphasis, as well though these did not correlate well with jerks. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: No normal waking or sleeping morphologies were seen. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Markedly abnormal portable EEG due to the very suppressed background at the beginning of the recording and due to the regular slow background later, all with frequent myoclonic jerks and movement artifact but also with independent and increasingly frequent generalized spikes later in the recording, as well. The background slowing with suppression suggests medication effect although widespread cortical dysfunction from anoxia can produce similar findings. The head jerking activity corroborated by video did not appear to be epileptic, but it was myoclonic and likely results from the same underlying process, presumed anoxia. Later in the recording there were other spikes that became more frequent. Thus, this tracing does not indicate ongoing seizures at the time but suggests that seizures could arise later. Also, the jerking activity appears most likely to represent anoxic myoclonus rather than a seizure, per se. The above movements did not appear epileptic in origin. They can be suppressed with some of the same medications used for seizures, if that is appropriate clinically. OBJECT: GENERALIZED SEIZURE ACTIVITY. STATUS POST CARDIAC ARREST AND PULMONARY EMBOLIS. patient loaded with Dilatin, place on depakote. No improvement. Family meeting called. Pt wishes expresed to proxy in the pass. Pt made CMo expired on [**2119-1-13**] 330 am Brief Hospital Course: He was admitted for an Open CCY and Ventral Herniorrhaphy. Resp: He had expiratory wheezes. He was ordered for nebulizer treatments. On POD 2, he was noted to have some respiratory distress consistent with an asthma attack. He was tachypnic and using lots of accessory muscles. The Respiratory therapists was called and the patient received nebulizer treatments and a non-rebreather face mask. His RR was 24 and he was 96% on a NRB. He received 100mg Hydroxcortizone. He was transferred to the SICU for closer monitoring. A CXR showed lung volumes are appreciably lower than they were on [**12-23**], a finding that does not correspond to bronchospasm. Mild cardiomegaly is worse. There is no pulmonary vascular congestion. The asymmetric vascular distribution, with deficiency in the right lung is longstanding. A Abd x-ray showed no evidence of obstruction or free air. A blood gas showed pO2146* pCO246* pH7.24*1 calTCO221 Base-7. He acidosis ws persistent. He was started on Bipap PRN. His respiratory acidosis began to correct slowly and he was transfered to the floor on POD 5. Abd: He had a midline abdominal incision. He had 3 JP drains in the lower abdomen. His JP drains were hooked-up to wall suction. His abdomen was still firm and slightly distended on POD 5 and he reported -flatus. Pain: Epidural was started initially. He then was on a PCA with good pain control. CV: In the PACu his HR was in the 70's and BP was 110-120/80's. On POD 6, his HR was in the low 100's and he had a couple short burst to the 170's; BP was 130/80. He was started back on his home Lisinopril 10mg qd and Lopressor 25 mg [**Hospital1 **]. ID: He was started on Kefzol. A sputum sample from [**12-30**] showed Pseudomonas A., and Enterobacter C. He was switched to from Kefzol to Vanco/Levo. FEN: He was started on sips on POD 1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ On [**2119-1-4**], he went to radiology for a CXR and Abdominal X-ray. He was found by the radiologist unresponsive. A code was called after he had been donw for 10 minutes. He did not have a pulse and did not breath. Monitor showed PEA. After atropine and CPR for 20 minutes, he developed a pulse. He was intubated at the site. Workup revealed a saddle embolus and R-popliteal embolus. He is maintained on a heparin drip. Since the code he has been remained intubated. His exam off propofol per team showed intact bs reflexes, but otherwise no response to noxious. When lowering the propofol in the evening of [**1-5**], generalized tonic clonic seizure activity was noted. This activity continued until the propofol was increased. A CT head was obtained which did not show a hemorrhage or acute pathology. He was loaded on an AED at that time. Sputum cultures grew enterobacter and pseudomonas for which he is being treated with cipro. We are now called to further assist in management and workup of seizures. No further seizure activity has been noted (but he has remained on propofol). [**1-4**] CT A/P: bilateral pulm emboli/saddle embolus in left main pulm artery/right side. Athrosclerosis of Aorta/Coronary arteries. [**1-4**] BLE U/S: R popliteal vein thrombus, not completely occlusive. [**1-6**]: no CT evidence of acute infarct. [**1-7**] MRI: ischemia, no DVT Medications on Admission: Albuterol prn, ASA 81' qd, Atrovent, Lisinopril 10', Zestril, Advair, Verapamil, Alphagan eye drops, trusopt eye drops, multi vit. Discharge Disposition: Expired Discharge Diagnosis: Cholecystitis Ventral Hernia Respiratory Distress Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Experied Completed by:[**2119-1-13**]

[ "415.11", "070.30", "453.41", "496", "345.3", "574.70", "348.1", "278.00", "401.9", "518.5", "274.9", "553.21", "584.5", "997.2", "427.5" ]

icd9cm

[ [ [] ] ]

[ "96.72", "99.60", "93.90", "38.93", "53.61", "96.04", "54.4", "51.22", "96.6" ]

icd9pcs

[ [ [] ] ]

20369, 20378

16875, 20187

424, 545

20472, 20482

2128, 3004

20538, 20578

8050, 8383

4045, 6759

20399, 20451

20214, 20346

20506, 20515

6782, 7987

1720, 1779

275, 386

3112, 4008

573, 1140

8475, 16852

8398, 8459

1184, 1418

8003, 8034

54,006

130,060

13851

Discharge summary

report

Admission Date: [**2197-4-17**] Discharge Date: [**2197-5-9**] Date of Birth: [**2133-11-30**] Sex: F Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamide Antibiotics) / Flexeril / Quinine / Amaryl / Opioids-Morphine & Related / OxyContin / Fish Derived / Vancomycin / Oxacillin / Augmentin Attending:[**First Name3 (LF) 8587**] Chief Complaint: osteomyelitis Major Surgical or Invasive Procedure: [**4-22**] 1. Removal of implant (deep), right leg. 2. Deep bone biopsy, right ankle. 3. Application of vacuum-assisted closure sponge. [**4-24**] 1. Debridement skin to bone approximately 30 cm in total. 2. Debridement skin to subcutaneous tissue around pressure ulcer right foot. 3. Application of vacuum-assisted closure sponge right ankle. [**4-28**] Irrigation and debridement of right open ankle and exchange of vacuum sponge. [**5-1**] Irrigation and debridement of right open ankle and exchange of vacuum sponge. History of Present Illness: 63 yo woman with history of breast cancer, HTN, HLD, type 2DM, severe osteoporosis who is s/p ankle fracture which has required multiple surgeries now complicated by osteomyelitis. The patient has been on and off antibiotics for the last year because of recurrent soft tissue infections. The patient was being treated at [**Hospital3 20284**] Center since [**2197-4-12**]. She initially presented with right foot and leg pain, swelling, tenderness, redness and drainage. She also reports fever and chills. This injury started two years ago when she had a fracture of the ankle complicated by cellulitis and osteomyelitis. She has had open reduction and internal fixation and excision of the distal fibula. There, she was seen by Vascular and Orthopedic surgery there who recommended BKA. The patient has a history of MRSA in the past. She was started on daptomycin, wound and blood cultures with group B strep. . Currently, the patient is anxious to hear what our ortho dept has to say. She has no complaints. She did have a foley catheter placed for retention, for unclear reasons. She would like to attempt to have this removed. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: h/o breast cancer, s/p chemotherapy, radiation in [**2196-2-29**] Psoriasis SVT Hypothyroidism hypertension hyperlipidema Type 2 DM Social History: Has custody of her grandson. Married. The patient lives with her daughter. She is able to get around with a cane for short distances and motorized wheelchair for longer distances. She denies tobacco, ETOH and illicit drug use. Family History: NC Physical Exam: VS: T 99.4 HR 84 BP 107/64 RR 18 O2 95% on RA BG 160 GENERAL: Well-appearing female in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. HEART: RRR, no MRG, nl S1-S2. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: right foot internally rotated, two large circular lesions on lateral aspect of foot (over fifth metatarsal) and ankle (superior to malleolus) with surrounding warmth and erythema, no edema. no purulence, venous stasis changes LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-1**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait. Pertinent Results: OSH records: Wound culture [**2197-4-12**] Beta strep Group B (heavy), MRSA (moderate) Wound culture [**2197-4-14**] Beta strep Group B (moderate) Blood culture [**2197-4-13**] Beta strep Group B [**1-31**], sensitive to ampicillin, levofloxacin, clindamycin, erythromycin, penicillin, ceftriaxone, vancomycin, ertopenem . STUDIES: Foot/ankle x-ray: Gas in the lateral soft tissues may be related to the large ulcer over teh base of the fifth metatarsal. There is no obvious osetomyelitis of the distal lower leg and the ankle where there has been interval resection of the fibula and fusion of the posterior articulations. There is a 27mm ulcer over a nonunion at the base of the fifth metatarsal where a nonhealing fracture can be seen with sclerosis of the bony margins. There are degenerative changes of the first MP joint. No new abnormalities are seen. Chronic complex lucency within the proximal shaft of teh first metatarsal is stable. This reflects a remote osteotomy seen in [**2195**]. No osteomyelitis can be seen. Advanced imaging could be considered. . Bone scan: increased uptake right foot and ankle on all 3 phases consistent with osteomyelitis. This involves the distal tibia and also the lateral aspect of the foot/ankle presumably in the location of the cuboid bone and base of fifth metatarsal. . CT: Bony erosive and destructive changes with adjacent abscess collection as noted above consistent with osteomyelitis. There is involvement of the tibiotalar joint and the base of the fifth metatarsal, where there is a non-healing fracture.. Abscess collection is identified along the lateral aspect of teh left lower leg, left ankle, dorsal lateral aspect of teh foot as well as teh lateral aspect of the foot. Promient air fluid level is identified along the lateral aspect of the ankle. Brief Hospital Course: 63 yo woman with history of breast cancer, HTN, HLD, type 2DM, severe osteoporosis, s/p ankle fracture transferred for management of osteomyelitis. . # Osteomyelitis/Bacteremia: The patient has osteomyelitis secondary to multiple orthopedic surgeries of the ankle and foot related to a fracture two years ago. The patient reports that she has been on and off antibiotics for the last year. At the OSH, she was found to be bacteremic with GBS. Wound cultures grew MRSA and GBS, imaging was consistent with osteomyelitis. PICC line placed at OSH on the day after positive blood cultures. Subsequent blood cultures here have been negative, with one exception of coag neg staph likely contaminent. Vascular, Ortho, Podiatry and ID consulted. The patient was started on daptomycin for treatment of both pathogens. Enbrel for psoriasis was held. The patient went to the OR on [**2197-4-22**] for wash out with Orthopaedics and was transfered to that service. Please operative note for the full details. The patient was maintained on Daptomycin until [**5-4**] and was transistioned to Vanco/Cefep as recommended by Infectious disease. Patient had irrigation and debridement and VAC changed performed in the OR on [**2-12**], [**5-1**] - please see operative reports for full details. There was an attempt to change Cefepime to Ertapenem on [**5-7**], however the patient became nauseated. On [**5-8**], Ertapenem was trialed again with Zofran pre-medication which was well tolerated. # Urinary retention: The patient arrived to our hospital with a foley in place. She reported the inability to void at the OSH. Foley was removed and she was able to void without difficulty. Likely secondary to narcotics and diabetic neuropathy. . # Anemia: Secondary to anemia of chronic disease. Remained stable. # Paroxysmal SVT: Continued diltiazem. However, patient's BP and HR were low at OSH so metoprolol decreased from 75mg TID to 25mg [**Hospital1 **], which was continued during this hosptial stay. . #. Hypertension: Continued diltiazem, metoprolol (at lower dose as above) At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, 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: Tamoxifen 20mg daily Simvastatin 20mg daily Aspirin 81mg daily B12 Calcium citrate Diltiazem 30mg QID ETANERCEPT twice a week GABAPENTIN 900mg TID, 1200mg QHS POTASSIUM CHLORIDE 20 mEq [**Hospital1 **] Levothyroxine 50mcg daily METFORMIN 1000 mg daily METOPROLOL TARTRATE 75 mg three times a day OMEPRAZOLE 20mg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 7. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. tamoxifen 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 15. metformin 500 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 16. metformin 500 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 17. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 18. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) 750 mg Intravenous Q 12H (Every 12 Hours) for 2 months: Vanco Trough needs to be drawn weekly and communicated to [**Hospital **] Clinic . Disp:*[**Telephone/Fax (1) 41567**] mg * Refills:*0* 19. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40 mg Subcutaneous Q24H (every 24 hours). Disp:*30 40 mg * Refills:*2* 20. ertapenem 1 gram Recon Soln Sig: One (1) 1 gram Recon Soln Injection Q24 () for 2 months. Disp:*60 1 gram Recon Soln(s)* Refills:*0* 21. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Infected right open ankle with osteomyelitis Discharge Condition: Stable. Alert and Oriented Discharge Instructions: Activity: - Touch down weight bearing right leg in boot. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - You have also been given Additional Medications to control your pain. Please allow 72 hours (Monday through Friday, 9am to 4pm) for refill of narcotic prescriptions, so plan ahead. There will be no prescription refils on Saturdays, Sundays, or holidays. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. Physical Therapy: Touch down weight bearing right leg in boot. Treatments Frequency: Vac changes every three days with monitoring of wound on lateral ankle. Wet-to-dry dressings daily on lateral ulcer on foot. Vancomycin 750mg IV q 12hrs x 2 months. Vanco trough was 26.1 on [**5-8**] PM on 1000mg Q12, dose decreased to 750mg q12hours on [**5-9**] AM. Please draw Vanco trough before 4th dose and fax to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. She will need to have weekly CBC w/diff, Chem 10, LFTs, and Vanco trough drawn and then communicated with the [**Hospital **] Clinic (Dr. [**Last Name (STitle) 9461**] All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] Followup Instructions: Please follow-up in [**Hospital 13308**] clinic in three weeks with [**Doctor Last Name **]. Please call [**Telephone/Fax (1) 9769**] for an appointment. Please follow-up with Infectious Disease clinic w/ Dr. [**Last Name (STitle) **] at [**Hospital Unit Name **] ([**Doctor First Name **]), BASEMENT on [**5-18**] at 1:30 pm. Please follow-up with Infectious Disease w/ Dr. [**Last Name (STitle) 9461**] at [**Hospital Unit Name **] ([**Doctor First Name **]), BASEMENT on [**5-31**] at 10 am. [**Hospital **] Clinic number is [**Telephone/Fax (1) 3395**] if concerns with the appointment. Completed by:[**2197-5-10**]

[ "790.7", "253.6", "038.9", "401.9", "995.91", "733.00", "696.1", "357.2", "E929.3", "730.17", "250.60", "730.07", "041.85", "998.32", "707.13", "707.09", "041.12", "244.9", "V09.91", "733.82", "E878.1", "736.79", "682.6", "041.02", "707.20", "996.67", "731.3", "905.4", "424.1" ]

icd9cm

[ [ [] ] ]

[ "77.47", "86.28", "77.48", "78.67", "80.87" ]

icd9pcs

[ [ [] ] ]

10445, 10497

5543, 7960

433, 964

10586, 10615

3694, 5520

12587, 13209

2811, 2816

8329, 10422

10518, 10565

7986, 8306

10639, 11694

2831, 3675

11712, 11757

11779, 12562

380, 395

992, 2390

2412, 2546

2562, 2795

325

155,989

52064

Discharge summary

report

Admission Date: [**2190-1-5**] Discharge Date: [**2190-1-16**] Date of Birth: [**2132-6-6**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Metastatic duodenal cancer Major Surgical or Invasive Procedure: OPERATIVE PROCEDURE: 1. Pylorus-preserving pancreaticoduodenectomy. 2. Open cholecystectomy. 3. Right hepatic lobectomy History of Present Illness: Dr. [**Known lastname 107769**] is a 57-year-old patient with a known adenocarcinoma in the duodenum causing recurrent gastrointestinal bleeding and recurrent anemia. She has had exhaustive preoperative evaluation which has demonstrated also the presence of a single metastasis in the liver. For palliation, if not curative ntent, I recommended that she undergo a combined Whipple procedure to try to get the primary tumor out to eliminate the bleeding and impending obstruction of the duodenum. I also convened with Dr. [**Last Name (STitle) **] of our hepatobiliary surgery team to consider resection of the metastatic disease in the liver, as there is no other evidence of systemic metastases. Past Medical History: PAST MEDICAL HISTORY: Significant only for known cyst in the breast. Brief Hospital Course: Patient went to the operating room on [**2190-1-5**]. Please see the OMR note for operative details. There were no unanticipated intra-operative complications, and the patient lost approximately one liter of blood and received three units PRBCs during the procedure. 2 19-French [**Doctor Last Name 406**] drains were placed to liver bed and pancreatic biliary anastomoses locations. Post-operatively she went to the surgical ICU. Her pain was controlled with epidural and PCA. On POD1 INR was 2.0 and the patient received 2 units of FFP. POD1 liver US also demonstrated normal spectral analysis and color Doppler evaluation of the vasculature of the residual left hepatic lobe. On POD2 she received another 2 units FFP for INR 1.9, and since transaminases remained elevated another liver ultrasound. Ultrasound was normal-"Again, seen are widely patent main and left portal veins with appropriate direction of flow. The left hepatic vein and hepatic artery are also patent and patency and appropriate direction of flow. Again, the left hepatic artery demonstrates a resistive index of 0.60. There is no biliary ductal dilatation. here is no free fluid. The inferior vena cava is widely patent." POD3 the G-tube was clamped and half-strength J-tube feedings were begun. Patient was also transferred out of the unit to the floor on POD3. TF were slowly advanced and on POD4 she was advanced to sips as well as transitioned to oral pain medications. Foley catheter was removed from the bladder on POD5 and tube feeds were cycled at night. Lasix was given on POD5 and the patient began to mobilize significant fluid accumulation, especially in the lower extremities. By POD5 she was also tolerating full liquids and was doing well ambulating around the floor and working with physical therapy. Her central line was removed on POD6 and she was transitioned to all oral medications per the "Whipple Protocol". Her electrolytes were aggressively repleted and intermittent doses of lasix were helpful in gaining euvolemia. She continued to have some trouble with nausea that was controlled with antiemetics but was troublesome nonetheless. JP drains were removed before discharge, and the patient was begun on a 7 day course of cefazolin for a superficial cellulitis. She was discharged to home with services on POD10. She was afebrile, tolerating a full diet and ambulating without difficulty. Her wounds were healing nicely and she was instructed on proper G and J tube care. She has follow-up as outlined below. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*100 Tablet(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO once a day. Disp:*120 Capsule, Sustained Release(s)* Refills:*2* 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a day for 7 days. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Metastatic duodenal cancer Discharge Condition: Stable Discharge Instructions: Please call the office or the emergency room if you develop fever greater than 101.5, your wounds become red, swollen or begin draining pus or you develop severe nausea or vomiting. Please take the full 7 day course of antibiotics, as well as all other medications prescribed. Do not drive while taking narcotic pain medications, and use a stool softener such as colace while you are taking the pain medication. You may shower when you get home but avoid tub bathing for 3 weeks. No heavy lifting or activity for at least 6 weeks. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 468**] in the office in [**2-8**] weeks. Please call ahead of time to make an appointment. ([**Telephone/Fax (1) 27734**]. Completed by:[**2190-3-10**]

[ "285.1", "196.2", "152.0", "424.0", "197.7" ]

icd9cm

[ [ [] ] ]

[ "50.3", "99.07", "51.22", "52.7", "99.04" ]

icd9pcs

[ [ [] ] ]

4777, 4826

1302, 3815

338, 460

4897, 4906

5489, 5691

3838, 4754

4847, 4876

4930, 5466

272, 300

488, 1187

1231, 1279

67,474

104,348

3221+55459

Discharge summary

report+addendum

Admission Date: [**2186-6-24**] Discharge Date: [**2186-7-4**] Date of Birth: [**2131-12-23**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2777**] Chief Complaint: Chief Complaint: L 4th toe gangrene . Reason for ICU Transfer: Hypoxemic Respiratory Failure Major Surgical or Invasive Procedure: [**2186-6-27**]: 1. Ultrasound-guided puncture of right common femoral artery. 2. Contralateral second-order catheterization of left external iliac artery. 3. Abdominal aortogram. 4. Serial arteriogram of left lower extremity. 5. Balloon angioplasty of left superficial femoral artery x3, one in the proximal superficial femoral artery, one in the mid superficial femoral artery, one in the very distal superficial femoral artery. 6. Stent placement along the superficial femoral artery x4. [**2186-6-29**]: 1. Radical debridement of left foot down to [**Month/Day/Year 500**]. 2. Application of negative pressure wound therapy. History of Present Illness: Ms. [**Known lastname **] is a 53yo female with IDDM, HTN, CAD s/p prior stents to OM, CKD with baseline creatinine of 1.9, and COPD who presented to OSH with foot pain, now s/p amputation of the L 4th toe for gangrene and transferred to the MICU post-op for hypoxemic respiratory failure. . The pt cut herself on the bottom of her foot 2 weeks ago. She had pain on the dorsum of her foot for three days prior to admission with redness and bluish discoloration of that region. She received unasyn and vancomycin at an OSH and transferred to [**Hospital1 18**] ED for further evaluation. Her SpO2 was noted to be 92% on RA upon transfer. Podiatry was consulted who performed beside debridement of left fourth toe gangrene and planned for amputation in OR on [**2186-6-24**]. Her labs were notable for a WBC of 16.4, glucose of 435 with UA showing no ketones, and creatinine of 1.4 with sodium of 132. She was given cipro (vanc and unasyn given at OSH). She was admitted to medicine overnight and kept NPO and continued on vanc/cipro/flagyl. . She was tachypnic prior to intubation this morning with desaturations to the 80s on RA. She was intubated and throughout the case had desaturations to the 80s which took 10-15min to come back up to the 90s. During weaning of sedation, she began to cough and desaturate, and further weaning was not attempted. Her ABG was 7.23/62/74 and temp was 38 intraoperatively. She received a total of 600mL crystalloid during the case and was on phenylephrine at 0.6 at time of transfer to the PACU. Her SBPs ranged 80s-200s during the case. Estimated blood loss was <30cc. There was less bleeding than expected and the plan was to consult vascular for possible further interventions. Her Propofol was kept at 100. She received Vanc and Flagyl intra-op and is still receiving Cipro as well. FS was in the 300s in the PACU, and she was given 3 units of Humalog. Her last vent settings in the PACU were AC 500/100/10/7, with overbreathing of the vent. Last PACU vitals were 99.1, 118/48, 98, 19, 100%. . Of note, per her husband, in [**2185-12-17**], she was treated for PNA, CHF, and an MI. She was in a medically-induced coma for 2 weeks at [**Hospital6 15083**] in [**Hospital1 1559**], and required HD [**1-18**] volume overload. She is on nocturnal O2 but per report had a negative sleep study at some point. . In the ICU, she is intubated and sedated. Past Medical History: 1. CAD s/p PCI in [**2179**]/[**2176**] (Please see cath report for anatomy) 2. IDDM complicated by neuropathy 3. Hypertension 4. COPD 5. HTN 6. HL 7. CKD 8. Anxiety 9. Depression 10. OA 11. Thoracic radiculopathy 12. Chronic pain 13. Chronic sinusitis 14. h/o of R toe cellulitis 15. h/o PNA 16. s/p R breast cyst exicision [**2179**] Social History: - Tobacco: 1ppd x 33 yrs, current - Alcohol: denies - Illicits: denies Lives with husband and teenage son. Homemaker. Family History: Father with MI in 50s, CABGx2, paternal grandmother with CVA, DM. Otherwise non-contributory. Physical Exam: ON ADMISSION: Vitals: T: 98.2 BP: 151/70 P: 83 R: 18 O2: 89% General: Intubated, sedated, not following commands HEENT: Sclera anicteric, ETT in place, pupils constricted and minimally reactive but equal Neck: supple, JVP not seen [**1-18**] habitus, Mallampati [**2-17**]. Lungs: Diffuse rhonchi, no rales or wheeze. CV: Regular rhythm, slightly fast, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: slightly cool distal LE, somewhat sluggish cap refill, non-palpable distal pulses, palpable femoral b/l, L foot with drsg [**Name5 (PTitle) **] [**Name5 (PTitle) **] [**Name5 (PTitle) **]: Streaky erythema over medial LLE, border marked On Discharge: Gen: Obese female in nad, alert and oriented x 3, normal affect Heent: PERRLA, oropharynx pink and moist Neck: Supple, no jvd Lungs: CTA bilat CV: RRR Abd: Obese, soft, +bs, no m/t/o Ext: Warm, well perfused. Left 4th digit is amputated with open wound from met head resection. Wound is pink without drainage or surrounding erythema. Pulses: DP/PT - dopplerable bilat Pertinent Results: ADMISSION LABS: [**2186-6-24**] 12:50AM BLOOD WBC-16.4*# RBC-4.59 Hgb-14.5# Hct-41.2 MCV-90 MCH-31.5 MCHC-35.2* RDW-13.8 Plt Ct-409 [**2186-6-24**] 12:50AM BLOOD Neuts-85.6* Lymphs-8.9* Monos-3.5 Eos-1.0 Baso-1.0 [**2186-6-24**] 12:50AM BLOOD PT-12.1 PTT-24.4 INR(PT)-1.0 [**2186-6-24**] 12:50AM BLOOD Glucose-435* UreaN-34* Creat-1.4*# Na-132* K-4.4 Cl-96 HCO3-21* AnGap-19 [**2186-6-24**] 03:45PM BLOOD ALT-20 AST-29 CK(CPK)-68 AlkPhos-107* TotBili-0.3 [**2186-6-24**] 03:45PM BLOOD CK-MB-3 cTropnT-<0.01 [**2186-6-24**] 03:45PM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9 [**2186-6-24**] 12:50AM BLOOD CRP-264.4* [**2186-6-24**] 11:43AM BLOOD Type-ART Rates-/12 Tidal V-600 FiO2-100 O2 Flow-6 pO2-74* pCO2-62* pH-7.23* calTCO2-27 Base XS--2 AADO2-587 REQ O2-95 Intubat-INTUBATED Vent-CONTROLLED [**2186-6-24**] 11:43AM BLOOD Glucose-311* Lactate-1.6 Na-133* K-4.7 Cl-99* calHCO3-27 MICROBIOLOGY: [**6-24**] Foot wound Cx: Staph aureus coag positive, moderate growth. IMAGING: - [**6-24**] foot XR: Soft tissue defect about the base of the fourth toe, but no radiographic evidence for osteomyelitis. If clinical concern for osteomyelitis persists, MR [**First Name (Titles) **] [**Last Name (Titles) 500**] scan may be considered. - [**6-24**] BL LE US: No evidence DVT in either lower extremity. Only one posterior tibial vein seen bilaterally and one peroneal vein seen on the right, calf vein thrombosis can therefore not be entirely excluded -[**6-25**] CXR: CHF with interstitial edema, probably slightly better compared with [**2186-6-24**]. Bibasilar collapse and/or consolidation, slightly worse compared with [**2186-6-24**]. [**2186-6-24**] 12:50AM BLOOD WBC-16.4*# RBC-4.59 Hgb-14.5# Hct-41.2 MCV-90 MCH-31.5 MCHC-35.2* RDW-13.8 Plt Ct-409 [**2186-6-24**] 03:45PM BLOOD WBC-18.0* RBC-4.28 Hgb-13.2 Hct-38.0 MCV-89 MCH-30.8 MCHC-34.7 RDW-13.7 Plt Ct-427 [**2186-6-24**] 11:03PM BLOOD Hct-35.6* [**2186-6-25**] 04:03AM BLOOD WBC-13.1* RBC-3.95* Hgb-12.5 Hct-35.2* MCV-89 MCH-31.6 MCHC-35.5* RDW-13.9 Plt Ct-354 [**2186-6-26**] 08:00AM BLOOD WBC-14.0* RBC-4.24 Hgb-13.1 Hct-39.1 MCV-92 MCH-31.0 MCHC-33.6 RDW-13.6 Plt Ct-404 [**2186-6-27**] 07:40AM BLOOD WBC-10.3 RBC-4.04* Hgb-12.6 Hct-36.9 MCV-91 MCH-31.1 MCHC-34.1 RDW-13.5 Plt Ct-416 [**2186-6-28**] 07:05AM BLOOD WBC-11.9* RBC-4.24 Hgb-13.1 Hct-37.2 MCV-88 MCH-30.8 MCHC-35.1* RDW-13.8 Plt Ct-428 [**2186-6-29**] 06:25AM BLOOD WBC-12.7* RBC-4.03* Hgb-12.1 Hct-36.6 MCV-91 MCH-30.1 MCHC-33.2 RDW-13.8 Plt Ct-454* [**2186-6-30**] 06:55AM BLOOD WBC-13.3* RBC-4.08* Hgb-12.5 Hct-37.1 MCV-91 MCH-30.8 MCHC-33.8 RDW-13.5 Plt Ct-451* [**2186-7-1**] 07:45AM BLOOD WBC-14.1* RBC-4.07* Hgb-12.4 Hct-35.9* MCV-88 MCH-30.4 MCHC-34.6 RDW-13.9 Plt Ct-533* [**2186-7-2**] 05:45AM BLOOD WBC-12.5* RBC-3.84* Hgb-11.9* Hct-34.7* MCV-90 MCH-31.0 MCHC-34.4 RDW-13.8 Plt Ct-509* [**2186-7-2**] 05:45AM BLOOD WBC-12.5* RBC-3.84* Hgb-11.9* Hct-34.7* MCV-90 MCH-31.0 MCHC-34.4 RDW-13.8 Plt Ct-509* [**2186-7-4**] 05:55AM BLOOD WBC-11.5* RBC-3.87* Hgb-12.1 Hct-35.1* MCV-91 MCH-31.4 MCHC-34.6 RDW-13.9 Plt Ct-658* [**2186-6-24**] 12:50AM BLOOD Glucose-435* UreaN-34* Creat-1.4*# Na-132* K-4.4 Cl-96 HCO3-21* AnGap-19 [**2186-6-24**] 03:45PM BLOOD Glucose-311* UreaN-30* Creat-1.3* Na-134 K-4.9 Cl-101 HCO3-21* AnGap-17 [**2186-6-25**] 04:03AM BLOOD Glucose-112* UreaN-29* Creat-1.3* Na-137 K-3.8 Cl-103 HCO3-22 AnGap-16 [**2186-6-26**] 08:00AM BLOOD Glucose-180* UreaN-30* Creat-1.3* Na-143 K-3.9 Cl-103 HCO3-24 AnGap-20 [**2186-6-27**] 07:40AM BLOOD Glucose-373* UreaN-27* Creat-1.3* Na-141 K-4.0 Cl-106 HCO3-22 AnGap-17 [**2186-6-28**] 07:05AM BLOOD Glucose-186* UreaN-23* Creat-1.1 Na-140 K-4.6 Cl-104 HCO3-24 AnGap-17 [**2186-6-29**] 06:25AM BLOOD Glucose-223* UreaN-22* Creat-1.1 Na-140 K-4.1 Cl-106 HCO3-21* AnGap-17 [**2186-6-30**] 06:55AM BLOOD Glucose-396* UreaN-21* Creat-1.1 Na-134 K-4.2 Cl-101 HCO3-23 AnGap-14 [**2186-7-1**] 07:45AM BLOOD Glucose-262* UreaN-24* Creat-1.1 Na-134 K-4.4 Cl-103 HCO3-22 AnGap-13 [**2186-7-2**] 05:45AM BLOOD Glucose-297* UreaN-25* Creat-1.1 Na-135 K-4.7 Cl-105 HCO3-22 AnGap-13 [**2186-7-3**] 06:30AM BLOOD Glucose-205* UreaN-21* Creat-1.1 Na-140 K-4.5 Cl-108 HCO3-21* AnGap-16 [**2186-6-24**] 03:45PM BLOOD CK-MB-3 cTropnT-<0.01 [**2186-6-24**] 11:03PM BLOOD CK-MB-2 cTropnT-0.01 [**2186-6-25**] 04:03AM BLOOD CK-MB-2 cTropnT-0.01 [**2186-6-24**] 03:45PM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9 [**2186-6-25**] 04:03AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.0 [**2186-6-26**] 08:00AM BLOOD Calcium-9.5 Phos-2.9 Mg-2.1 [**2186-6-27**] 07:40AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.9 [**2186-6-28**] 07:05AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8 [**2186-6-29**] 06:25AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.7 [**2186-6-30**] 06:55AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.8 [**2186-7-1**] 07:45AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8 [**2186-7-2**] 05:45AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.7 [**2186-7-3**] 06:30AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0 [**2186-6-24**] 12:50AM BLOOD CRP-264.4* [**2186-6-27**] 07:40AM BLOOD Vanco-23.4* [**2186-6-29**] 11:15AM BLOOD Vanco-22.2* [**2186-6-30**] 06:55AM BLOOD Vanco-8.4* [**2186-7-1**] 07:45AM BLOOD Vanco-7.8* [**2186-7-2**] 07:20PM BLOOD Vanco-15.5 [**2186-6-24**] 12:20 am BLOOD CULTURE **FINAL REPORT [**2186-6-30**]** Blood Culture, Routine (Final [**2186-6-30**]): NO GROWTH. [**2186-6-24**] 12:50 am BLOOD CULTURE **FINAL REPORT [**2186-6-30**]** Blood Culture, Routine (Final [**2186-6-30**]): NO GROWTH. [**2186-6-24**] 11:00 am FOOT CULTURE LEFT FOOT - 4TH TOE CULTURE. **FINAL REPORT [**2186-6-26**]** GRAM STAIN (Final [**2186-6-24**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. WOUND CULTURE (Final [**2186-6-26**]): STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [**2186-6-24**] 3:45 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2186-6-26**]** MRSA SCREEN (Final [**2186-6-26**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. [**2186-6-24**] 5:28 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2186-6-26**]** GRAM STAIN (Final [**2186-6-24**]): [**10-10**] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2186-6-26**]): NO GROWTH. [**2186-6-29**] 9:00 am TISSUE Site: FOOT 4TH LEFT METATARSAL HEAD. GRAM STAIN (Final [**2186-6-29**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2186-7-2**]): STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 326-0163L [**2186-6-24**]. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. ANAEROBIC CULTURE (Final [**2186-7-3**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2186-6-24**] 02:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 [**2186-6-24**] 02:30AM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2186-6-24**] 02:30AM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 [**2186-6-24**] 02:30AM URINE Mucous-RARE [**2186-6-24**] 02:30AM URINE Hours-RANDOM [**2186-6-24**] 02:30AM URINE Uhold-HOLD Radiology Report FOOT AP,LAT & OBL LEFT Study Date of [**2186-6-24**] 12:25 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] FA2 [**2186-6-24**] 12:25 PM FOOT AP,LAT & OBL LEFT; -76 BY SAME PHYSICIAN [**Name Initial (PRE) 7417**] # [**Clip Number (Radiology) 15084**] Reason: s/p debridement [**Hospital 93**] MEDICAL CONDITION: 54 year old woman s/p partial amp 4th left toe REASON FOR THIS EXAMINATION: s/p debridement Final Report LEFT FOOT, THREE VIEWS REASON FOR EXAM: Status post partial amputation of fourth left toe and debridement. Comparison is made with prior study performed 11 hours earlier. In the interim, there has been partial amputation distal to the metatarsophalangeal joint of the fourth toe. There are no other interval changes. Radiology Report ART EXT (REST ONLY) Study Date of [**2186-6-27**] 10:11 AM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] FA2 [**2186-6-27**] 10:11 AM ART EXT (REST ONLY) Clip # [**Clip Number (Radiology) 15085**] Reason: evaluate peripheral arterial disease [**Hospital 93**] MEDICAL CONDITION: 54 year old woman with ? PVD REASON FOR THIS EXAMINATION: evaluate peripheral arterial disease Final Report BILATERAL ARTERIAL DOPPLER CLINICAL INFORMATION: 54-year-old female with 20 years of diabetes mellitus. The patient has neuropathy in both feet and the hands. Recent amputation of the left fourth toe performed. ABIs, Doppler waveforms and PVRs were obtained bilaterally at rest. ABIs, right PT 0.50, DP 0.51, left PT 0.66, left DP 0.51. Segmental pressures, Doppler waveforms, and PVRs are significantly decreased bilaterally from the thighs down, left greater than right. In addition, on the left side, there is additional infrapopliteal disease. IMPRESSION: Findings suggest bilateral inflow disease with moderate depression of the ABIs at rest on both sides. It was confirmed by the waveforms, pressures and Doppler. In addition, there appears to be a superimposed disease in the infrapopliteal region on the left. Radiology Report FOOT AP,LAT & OBL LEFT PORT Study Date of [**2186-6-29**] 9:50 AM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] FA5 [**2186-6-29**] 9:50 AM FOOT AP,LAT & OBL LEFT PORT Clip # [**Clip Number (Radiology) 15086**] Reason: L 4th met head resection cut [**Hospital 93**] MEDICAL CONDITION: 54 year old woman s/p removal of L 4th residual proximal phalanx & met head. REASON FOR THIS EXAMINATION: L 4th met head resection cut Final Report INDICATION: Status post removal of the fourth proximal phalanx. COMPARISON: [**2186-6-24**]. THREE VIEWS LEFT FOOT: Patient is status post amputation at the level of the fourth metatarsal neck with an overlying VAC and soft tissue changes. Remainder of the digits are grossly unremarkable. There is no acute fracture appreciated. Small plantar calcaneal spur is noted. Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [**2186-7-3**] 2:14 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] FA5 [**2186-7-3**] 2:14 PM CHEST PORT. LINE PLACEMENT Clip # [**Clip Number (Radiology) 15087**] Reason: 46cm right picc. tip? [**Hospital 93**] MEDICAL CONDITION: 54 year old woman with new picc REASON FOR THIS EXAMINATION: 46cm right picc. tip? Final Report INDICATION: A 54-year-old woman with new PICC line. COMPARISON: Chest radiograph from [**2186-6-25**]. ONE VIEW OF THE CHEST: The lungs are well expanded and clear. The cardiac silhouette is top normal. The mediastinal silhouette and hilar contours are normal. No pleural effusion or pneumothorax is present. A right-sided PICC line terminates with its tip in the distal SVC. Brief Hospital Course: Ms. [**Known lastname **] is a 53-year-old female with IDDM, HTN, CAD s/p prior stents to OM, CKD with baseline creatinine of 1.9 and COPD who is admitted with left fourth toe gangrene and ascending lymphangitis, now intubated s/p amputation for hypoxemic respiratory failure and with hypotension. . # Hypoxemic Respiratory Failure: The etiology of her respiratory failure is unclear; the DDx includes COPD exacerbation vs CHF vs pneumonia. Her CXR post-op appears suggests volume overload. The patient is an active smoker as well, and likely has some component of OSA which may also be contributing. Leukocytosis and fever suggest infectious component contributing, nothing to suggest aspiration. ACS also possible given cardiac hx, and P.E. was also on the differential. She was given standing ipratropium and albuterol MDIs and broad spectrum antibiotics with Vanc/Cefepime/Flagyl for HCAP. Sputum and blood cultures were sent. Tidal volumes of 6mg/kg were given because of the risk of ARDS. No diuresis was induced given her tenuous BP, and IVF were minimized. An ACS workup was done as below. Respiratory status improved on the floor and she was satting well without oxygen at the time of discharge . # Hypotension: Her BPs very labile during her toe amputation procedure, and in the MICU she was requiring phenylephrine to maintain MAP >65. This could be a medication effect from propofol in the setting of positive intrathoracic pressure. It could also possibly be related to ARDS and sepsis given toe infection and leukocytosis, fever. ACS is also possible given CAD history causing cardiogenic shock. Her sedation was changed from propofol to fentanyl/midazolam, and she was weaned from phenylephrine to keep MAP>60. Over her hospital stay she remained off pressors and was placed back on her home antihypertensive regimen which she tolerated well. . # Left fourth toe gangrene/ascending lymphangitis: She is now s/p amputation of 4th toe by podiatry, s/p LLE angio showng SFA occlusion s/p balloon PTA SFA and stent x 4, and L 4th met head resection. A wound VAC was attempted after met head resection but given the location of the wound was not working effectively. Wet to dry dressings were initiated and her wound showed appropriate progress. She is discharged with daily wet to dry dressings. Given her mrsa wound culture data, a PICC line was placed and she was discharged on vancomycin. Her insurance was only active through the end of [**Month (only) 205**], and thus she will get IV vanco through [**7-15**]. At that time she will transition to PO bactrim [**Hospital1 **] x 4 weeks. # CAD: She is at risk for MI, which could be contributing to hypoxemia and hypotension. She had 3 sets of negative cardiac enzymes. We continued her ASA 325mg PO daily, atorvastatin 80mg PO daily, and held metoprolol and nitro patch in the setting of hypotension. Once BPs were stable, her antihypertensives were restarted. Nitro patch was not restarted in house, but it is recommended she follow up with her PCP and cardiologist within 10 days of discharge. . # Hypertension: She was initially hypotensive, so we held zestril and metoprolol and lasix. As she improved metoprolol was resumed. AT the time of discharge her BP's were consistently >130 and her lasix and lisinopril were resumed. # IDDM: She was hyperglycemic in house and [**Last Name (un) **] diabetes team was consulted. Her Lantus was increased to 90 units QHS and an agressive humalog sliding scale was titrated. At the time of discharge her glucose was stable. . # Hyponatremia: This was mild at 132 on admission, and it is improving now. Her Na returned to [**Location 213**]. . # COPD: Her COPD likely contributed to her resp. failure. We held her home Advair and tiotripium and gave her MDIs as above. Once respiratory status improved back to baseline home meds were resumed. . #. CKD: Her creatinine was at 1.4 and trended down to 1.1 , and remained there for most of her hospitalization . #. Chronic pain: Pain was well controlled with oral and iv narcotics while in house. She is stable on an oral regimen at the time of discahrge . #. Chronic sinusitis: stable; she was given Flonase nasal spray. She is discharged in stable condition, home with VNA services. She is touch down heel weight bearing on her LLE and maintains this without difficulty. She will follow up with vascular and podiatry in 1 week. She is instructed to follow up with her PCP and cardiologist in the next 1-2 weeks. Medications on Admission: Gabapentin 600 mg po TID Metoprolol XL 100 mg po qdaily Lantus 80 units qhs Zestril 10 mg po qdaily Lipitor 80 mg po qdaily Lasix 40 mg po qdaily Advair 50/500 inh [**Hospital1 **] Spiriva 18 mcg inh qdaily Nitro 0.2 mg/hr patch daily 12 hrs on/12 hrs off Nitro 0.4 mg SL q4 prn chest pain Fluticasone 50 mcg inh [**Hospital1 **] Oxycodone 5 mg po q4 prn pain Albuterol 90 mcg inh [**Hospital1 **] Senna 8.6 mg po BID Colace 100 mg po BID Thiamine 100 mg po qdaily MVA po qdaily Aspirin 325 mg po qdaily Tylenol 500 mg po BID Fish oil Discharge Medications: 1. vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750) Recon Soln Intravenous Q 12H (Every 12 Hours) for 2 weeks: until [**7-15**]. Disp:*qs Recon Soln(s)* Refills:*0* 2. Outpatient Lab Work Please draw Chem 7, Vanc trough q week 3. 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. 4. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 5. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 6. Lantus 100 unit/mL Solution Sig: Ninety (90) units Subcutaneous at bedtime: this is a higher dose than you were previously on. 7. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day. 8. sliding scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose 0-70mg/dL -----Proceed with hypoglycemia protocol---- 71-150mg/dL 0Units 0Units 0Units 0Units 151-200mg/dL 8Units 8Units 10Units 0Units 201-250mg/dL 10Units 10Units 12Units 2Units 251-300mg/dL 12Units 12Units 14Units 3Units 301-350mg/dL 14Units 14Units 16Units 4Units 351-400mg/dL 16Units 16Units 18Units 5Units > 400mg/dL [**Name8 (MD) 15088**] M.D.------------------- 9. Zestril 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day. 13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 15. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO DAILY (Daily). 17. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): call pcp for refills. Disp:*30 Tablet(s)* Refills:*2* 18. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 21. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. 22. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: while on narcotics . 23. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while on narcotics. 24. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 25. Nitro if your cardiologist recocmmended that you be on a nitro patch or take sub lingual nitro prn for chest pain, please resume those meds as prescribed 26. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a day for 4 weeks: you should start this medication when your vancomycin has completed . Disp:*56 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Ovrelook VNA Discharge Diagnosis: Left lower extremity ischemia with gangrene, and osteomyelitis left foot. 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: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? You will be on IV vancomycin for 2 weeks. After you complete that course you will start oral bactrim ds twice daily for 4 weeks. Please continue all other medications you were taking before surgery. We have increased your lantus dose and adjusted your sliding scale regimen. ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**1-19**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may only touch down weight bear on your left heel. DO NOT bear weight through your left foot! ?????? Your groin incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining. Your left foot wound should be packed with wet to dry dressing daily by the VNA. ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until cleared by surgeon, and no longer on pain meds. ?????? Call and schedule an appointment to be seen in [**2-17**] weeks for post procedure check and ultrasound What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2186-7-10**] 8:05 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2186-7-12**] 11:45 Completed by:[**2186-7-4**] Name: [**Known lastname 2471**],[**Known firstname 2472**] Unit No: [**Numeric Identifier 2473**] Admission Date: [**2186-6-24**] Discharge Date: [**2186-7-4**] Date of Birth: [**2131-12-23**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 726**] Addendum: Final pathology from [**6-29**] did show acute osteomyelitis as below. Pertinent Results: Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 8**] [**Known lastname 2474**],[**Known firstname 2472**] [**2131-12-23**] 54 Female [**-1/2907**] [**Numeric Identifier 2473**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 455**] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 2475**]/mtd SPECIMEN SUBMITTED: basic 4th proximal phalanx, 4th metatarsal head left. Procedure date Tissue received Report Date Diagnosed by [**2186-6-29**] [**2186-6-29**] [**2186-7-4**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2476**]/ttl Previous biopsies: [**-1/2833**] LEFT FOOT 4TH TOE. DIAGNOSIS: I. "Basic 4th proximal phalanx" (A): Bone and articular cartilage with acute osteomyelitis. II. "4th metatarsal head left" (B): Bone and articular cartilage with focal osteomyelitis. Discharge Disposition: Home With Service Facility: Ovrelook VNA Discharge Diagnosis: Left lower extremity ischemia with gangrene, and acute osteomyelitis left foot. [**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**] Completed by:[**2186-7-19**]

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icd9cm

[ [ [] ] ]

[ "86.22", "00.40", "88.42", "88.48", "84.11", "39.50", "00.48", "77.89", "39.90", "38.97", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

30686, 30729

17413, 21891

397, 1049

25904, 25904

29750, 30663

28948, 29731

3984, 4079

22476, 25720

16906, 16938

30750, 30990

21917, 22453

26087, 28352

28378, 28925

4094, 4094

13016, 13825

4881, 5251

281, 359

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1077, 3466

5287, 12983

4108, 4867

25919, 26063

3488, 3827

3843, 3968

2,187

106,962

8425

Discharge summary

report

Admission Date: [**2129-9-7**] Discharge Date: [**2129-10-25**] Date of Birth: [**2087-11-5**] Sex: M Service: MICU CHIEF COMPLAINT: The patient is a 41 year old morbidly obese gentleman who came to the hospital in the setting of cellulitis of the left leg with hypotension requiring fluid resuscitation and desaturation. HISTORY OF PRESENT ILLNESS: The patient is a 41 year old with a history of diabetes mellitus, morbid obesity, asthma, obstructive sleep apnea and coronary artery disease. He was admitted to the [**Hospital3 4527**] Hospital in [**Location (un) 620**] on [**2129-9-4**], for cellulitis and sepsis. He had cut his left leg with a saw blade on [**2129-9-2**], and subsequently developed erythema of the leg. On [**2129-9-4**], he awoke with fever, chills and rigors and went to [**Hospital3 4527**] where he was noted to have a temperature of 104 degrees and also appeared to be uncomfortable and short of breath. His saturations were 92% in room air and improved to 97 to 98% with four liters nasal cannula. His blood pressure at that time ranged from 120/60 to 150/90. He was admitted to the Intensive Care Unit in the [**Hospital3 29718**]. For the left leg cellulitis, he was started on Vancomycin, Clindamycin and Levofloxacin. His blood pressure subsequently dropped to 80 systolic and the patient was started on Neo-Synephrine infusion and had aggressive fluid resuscitation. The left leg cellulitis seemed to improve and the Neo-Synephrine was weaned off. On [**2129-9-6**], the patient was noted to have increasing respiratory distress. Chest x-ray showed evidence of pulmonary edema which was treated with Lasix. There was some response initially but the respiratory distress was not relieved. He was placed on CPAP and then a nonrebreathing mask but the saturations were still in the low 90s with arterial oxygen tension of 62 to 74 mmHg. At this point, the patient was transferred to the [**Hospital1 188**]. In the MICU, he was intubated by awake fiberoptic intubation. Oxygenation seemed to improve with assist control ventilation and the FIO2 was gradually weaned from 80% to 60% oxygen. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Type 2 diabetes mellitus with increasing insulin requirement, diabetic neuropathy. 3. Chronic pain with possible opioid dependence. 4. Hypertension since age of 19. 5. Coronary artery disease. 6. Obstructive sleep apnea requiring CPAP for more than ten years. 7. Asthma. 8. Osteoarthritis. PAST SURGICAL HISTORY: 1. Quadriceps tendon repair in [**2125**]. 2. Carpal tunnel release, bilaterally. 3. Status post hydrocele repair which was complicated by postoperative cellulitis. 4. Status post left ankle surgery. MEDICATIONS ON ADMISSION: 1. Levofloxacin 500 mg intravenously once a day. 2. Avandia one q8hours. 3. Celexa 40 mg twice a day. 4. Vancomycin two grams twice a day. 5. Clindamycin 600 mg intravenously q8hours. 6. Verapamil 480 mg twice a day. 7. Aspirin 81 mg once a day. 8. Tylenol 1000 mg p.r.n. 9. Motrin 800 mg q8hours. 10. Percocet two tablets q6hours. 11. Rhinocort p.r.n. 12. Flovent and Serevent inhalers as required. 13. Neo-Synephrine. 14. [**Doctor First Name **]. 15. Oxymetazoline. 16. Remeron 30 mg h.s. 17. Mexiletine 400 mg twice a day. 18. Tegretol 150 mg twice a day. 19. Neurontin 1200 mg q8hours. 20. Heparin 10,000 subcutaneous b.i.d. 21. Zestril 40 mg b.i.d. ALLERGIES: Cephalosporins and Morphine Sulfate. FAMILY HISTORY: Father has hypertension. Mother had emphysema at the age of 63. SOCIAL HISTORY: The patient lives alone. He is on disability. He smokes a pipe or cigar occasionally. No history of ethanol or intravenous drug use. PHYSICAL EXAMINATION: Temperature is 98.9, heart rate 100 beats per minute, normal sinus rhythm, blood pressure 86/33 and respiratory rate was 30. After intubation he was ventilated on pressure support of 20 with a PEEP of 10 and he was on 100% oxygen. He was sedated with Propofol and Lorazepam. The pupils are equal, reactive to light. Extraocular movements are intact. Neck was obese, unable to see the jugular venous pressure. Pulmonary - There was no wheeze. Distant breath sounds are heard. Crackles at the bases. Cardiac - regular heart sounds, S1 and S2, sounds distant, no murmur appreciated. The abdomen is obese, soft, nontender, bowel sounds heard, abdominal wall was edematous. Extremities 3+ peripheral edema left leg, torso edematous with palpable pulses. Skin - erythema left ankle above the cut. Neurologic - alert and appropriate despite the low oxygen saturation. LABORATORY DATA: White cell count was 12.2, hematocrit 36.6, platelets 211,000. Sodium 143, potassium 3.9, chloride 99, bicarbonate 31, blood urea nitrogen 26, creatinine 0.7, blood sugar 136. Creatinine kinase was 96 and troponin was negative. Arterial blood gases on 100% oxygen pH 7.47, pCO2 47, pO2 90. Chest x-ray was of poor quality and diffuse alveolar infiltrate suggestive of pulmonary edema and congestive heart failure. could not rule out adult respiratory distress syndrome. Ultrasound of the lower limbs showed normal compressibility of the lower limb veins which was negative for deep vein thrombosis. Electrocardiogram shows normal sinus rhythm with normal axis, with no evidence of ischemia. HOSPITAL COURSE: 1. Cardiac - Hemodynamic instability requiring inotropics initially. He was monitored with a PA catheter. The inotropes were gradually weaned. After the initial course of hemodynamic instability, there was a face of hypertension where the blood pressure was difficult to control requiring increasing the doses of the antihypertensive medications. There was one episode of fast atrial fibrillation with hemodynamic instability which required cardioversion. 2. Pulmonary - The patient required awake fiberoptic intubation for control of airway. Initially the oxygen requirements were very high with FIO2 of 1. Over a period of time, the oxygenation was weaned from 100% to 60 to 40%. During this two to three week period, the oxygenation was labile and this was treated by intense physical therapy and nebulizers. The oxygenation gradually improved. Percutaneous tracheostomy was performed on [**2129-9-27**]. The oxygenation improved gradually and for the past two weeks, there has been no evidence of respiratory distress. Adequate oxygenation was maintained over the tracheostomy mask with 40% oxygen. The saturations are 100% and the carbon dioxide levels have been ranging from 35 to 45 mmHg during this time. 3. Renal - Aggressive diuresis during the MICU stay. The patient was treated with Lasix 20 to 80 mg p.r.n. and a negative balance of one liter to 1.5 liters was maintained to wean from the ventilator. There was one episode of prerenal failure which improved spontaneously and he did not require dialysis or hemofiltration during his stay in the MICU. 4. Gastrointestinal - Due to the long-standing diabetes mellitus, he was prone for recurrent gastroparesis. He tolerated only forced pyloric feeds. There was one episode of coffee ground vomitus but the patient had a stable hematocrit and therefore did not need an endoscopy. 5. Endocrine - Very large insulin requirements and poorly controlled diabetes mellitus. The patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consultation and he was started on U-500 regular insulin, now has a better blood sugar control. 6. Hematology - The patient's hematocrit has been stable during his MICU stay and he did not require any transfusions during the hospital stay. 7. Infectious disease - Methicillin resistant Staphylococcus aureus positive and positive blood cultures. Methicillin resistant Staphylococcus aureus positive fungal cystitis. He was Methicillin resistant Staphylococcus aureus positive in sputum on [**2129-10-19**]. Clostridium difficile positive on [**2129-9-10**], and on [**2129-10-6**]. This is being treated with Flagyl at present. On [**2129-10-17**], the C. difficile toxin assay was negative. 8. Musculoskeletal - Back pain which has gradually resolved and received physical therapy. 9. Nutrition - The patient required prolonged parenteral nutrition due to the gastroparesis but now he has a postpyloric tube and he is on enteral feeds. 10. Prophylaxis - He is on Heparin 5000 units subcutaneous b.i.d., on Protonix 40 mg intravenously once a day. MEDICATIONS ON DISCHARGE: 1. Flagyl 500 mg nasogastric b.i.d., today is day 17 of a 21 day course. 2. Haldol 2 mg nasogastric b.i.d. 3. Fentanyl patch 25 mcg per hour. 4. Aspirin 81 mg nasogastric once a day. 5. Remeron 30 mg nasogastric h.s. 6. Heparin 5000 units subcutaneous b.i.d. 7. Celexa 10 mg nasogastric b.i.d. 8. Lopressor 100 mg nasogastric three times a day. 9. Zestril 40 mg nasogastric once a day. 10. PhosLo two tablets nasogastric twice a day. 11. Nystatin swish and spit topical b.i.d. 12. Reglan 20 mg intravenous three times a day. 13. Lorazepam 2 mg p.r.n. h.s. 14. Albuterol and Atrovent nebulizers as required p.r.n. q.i.d. 15. Lotrimin cream between toes b.i.d. 16. Trapidil to rash in the left lower limb b.i.d. 17. Half strength Respalor plus 80 grams ProMod as tube feeds with a goal of 70 cc/hour. 18. U-500 regular insulin, 0.12 ccs or 12/100 q8hours subcutaneous. 19. Sliding scale Humalog as required. DISCHARGE STATUS: The patient is ready for transfer to rehabilitation facility, probably [**Hospital1 **], in the near future. CONDITION ON DISCHARGE: He is alert, awake and afebrile. He has stable blood pressure and is in normal sinus rhythm. The patient is comfortable with tracheostomy mask with 40% oxygen. He needs suction regularly and he has a good cough. He is awake and oriented, follows simple instructions, communicates by nodding. He can move all his limbs. He had a swallowing study done and trial but he failed this assessment because of aspiration of colored water and aphonia. He also had an ENT consultation in this regard and the cords are able to move but he is unable to phonates due to no leak around the tracheostomy tube. The tracheostomy tube was not changed for fenestrated tube due to anatomical difficulty and relatively young tracheostomy tract. The patient is prone for gastroparesis. It is very essential to check the position of the feeding tube tip periodically and be certain that it is postpyloric. The patient was assessed for a percutaneous endoscopic gastrostomy placement or jejunostomy tube placement, but these procedures could not be performed either by gastroenterology or interventional radiology because of the body mass. The patient's admission weight was 197 kilograms and his discharge weight as of today is 158 kilograms. The exact date of discharge and the facility to which the patient will be discharged is unclear but once this is finalized, there will be an addendum to this discharge summary. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2129-10-24**] 18:56 T: [**2129-10-24**] 19:29 JOB#: [**Job Number 29719**]

[ "008.45", "250.00", "482.41", "428.0", "427.31", "682.6", "536.3", "038.19", "518.81" ]

icd9cm

[ [ [] ] ]

[ "88.72", "31.1", "33.22", "96.04", "99.15", "42.23", "96.72" ]

icd9pcs

[ [ [] ] ]

3488, 3554

8455, 9500

2756, 3471

5337, 8429

2525, 2730

3731, 5320

155, 345

374, 2159

2181, 2502

3571, 3708

9525, 11194

42,243

111,059

41124

Discharge summary

report

Admission Date: [**2157-5-5**] Discharge Date: [**2157-5-9**] Date of Birth: [**2092-8-26**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1234**] Chief Complaint: descending thoracic aortic aneurysm Major Surgical or Invasive Procedure: [**2157-5-5**] - Total percutaneous thoracic aneurysm stent graft repair, with Zenith TX2 30-120, bilateral femoral artery access using ultrasound guidance, bilateral catheter in the aorta, stent graft repair of descending thoracic aortic aneurysm, thoracic and abdominal aortography History of Present Illness: The patient is a 64-year old male who has a penetrating aortic ulcer or a focal dissection that has become aneurysm which has increased in size. He was not a candidate for open surgery. He was admitted for descending thoracic aortic aneurysm repair. Past Medical History: PMH: thoracic aortic aneurysm, history of pulmonary emboli (s/p IVC filter), h/o infected infrarenal aortic aneurysm/aortitis, bacterial meningitis (S. pneumoniae), anterior spinal artery infarct, colonic diverticulosis, diabetes mellitus, hypertension, hyperlipidemia, thoracic vertebral fracture PSH: s/p IVC filter, s/p infrarenal aortobiiliac reconstruction ([**4-/2155**]), s/p umbilical hernia repair, s/p eye laser surgery for macular edema Social History: From the [**Country 13622**] Republic, lives alone but his daughter lives nearby; retired from work, ceased smoking 20-years prior, denies alcohol use Family History: no history of premature coronary artery disease Physical Exam: VITALS: Afebrile, vitals signs stable. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. Neck supple without lymphadenopathy. CVS: Regular rate and rhythm, without murmurs, rubs or gallops. S1 and S2. No evidence of carotid bruits. RESP: Clear to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No masses or peritoneal signs. EXTR: The right lower extremity is warm well-perfused and is without erythema, drainage or edema. The left lower extremity is warm well-perfused and is without erythema, drainage or edema. Percutaneously closed groin incisions clean, dry and intact without hematoma or drainage. PULSE EXAM: weakly palpable DP pulses bilaterally Pertinent Results: [**2157-5-7**] 02:39AM BLOOD WBC-7.7 RBC-3.06* Hgb-9.7* Hct-28.5* MCV-93 MCH-31.5 MCHC-33.8 RDW-13.6 Plt Ct-255 [**2157-5-7**] 02:39AM BLOOD PT-13.9* PTT-25.2 INR(PT)-1.2* [**2157-5-7**] 02:39AM BLOOD Glucose-154* UreaN-9 Creat-1.0 Na-137 K-3.9 Cl-104 HCO3-22 AnGap-15 [**2157-5-7**] 02:39AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.9 Brief Hospital Course: NEURO/PAIN: The patient was maintained on IV pain medication in the immediate post-operative period and transitioned to PO narcotic medication with adequate pain control on POD#0-1. The patient remained neurologically intact and without change from baseline during their stay. The patient remained alert and oriented to person, location and place. His neurologic exam following the procedure was assessed frequently and was reassuring. A lumbar drain was placed pre-op to maintain cerebral perfusion pressures for neurologic cord protection. The patient had CSF removed to maintain 10 cmH20 of pressure. The lumbar drain was removed on POD#2 without issue. Initially the patient was maintained in the cardiovascular ICU with transfer to the VICU when stable. CARDIOVASCULAR: The patient remained hemodynamically stable intra-op and in the immediate post-operative period. The patient was maintained on IV anti-hypertensive medication (Nitroglycerin IV gtt) in the immediate post-op period to maintain SBP between 120-160 mmHg, with transition to their oral home anti-hypertensives on POD#[**1-27**]. Their vitals signs were closely monitored with telemetry. A beta-blocker was initiated, as well as a statin medication upon admission, The patient did well following their vascular procedure. The patient was closely monitored with serial pulse exams in the post-op period. If appropriate, doppler signaling was frequently assessed in the involved extremity. Their post-op pulse exam demonstrated bilaterally dopplerable DP pulses. The patient's cardioprotective dose of Aspirin was continued post-op. The patient was restarted on his home dosing of Coumadin of 2.5-5 mg PO daily on POD#2. His PCP will [**Name9 (PRE) 702**] his INR in clinic on discharge and he will continue his Coumadin medication. RESPIRATORY: The patient was extubated in the immediate post-op period successfully. The patient had no episodes of desaturation or pulmonary concerns. The patient denied cough or respiratory symptoms. Pulse oximetry was monitored closely and the patient maintained adequate oxygenation. GASTROINTESTINAL: The patient was NPO following their procedure and transitioned to sips and a clear liquid diet on POD#2. The patient experienced no nausea or vomiting. The patient was transitioned to a regular/cardiac healthy diet on POD#3 and IV fluids were discontinued once adequate PO intake was established. GENITOURINARY: The patient's urine output was closely monitored in the immediate post-operative period. A Foley catheter was placed intra-operatively and removed on POD#2, at which time the patient was able to successfully void without issue. The patient's intake and output was closely monitored for UOP > 30 mL per hour output. The patient's creatinine was stable. The Foley catheter was replaced for some mild urinary retention on POD#3 and he was sent with a Foley leg bag with PCP [**Name9 (PRE) 702**] for [**Name Initial (PRE) **] void trial. HEME: The patient's post-op hematocrit was stable and trended closely. The patient remained hemodynamically stable and did not require transfusion. The patient's coagulation profile remained stable, patient was on Coumadin. The patient had no evidence of bleeding from their incision. ID: The patient showed no signs of infection and remained afebrile in the post-op period, with the exception of a low-grade temperature on POD#1. Blood cultures were unrevealing. Their white count was stable post-operatively and their incision was closely monitored for any evidence of infection or erythema. The patient received only standard peri-operative antibiotics, and did not require further antibiotics post-op. ENDOCRINE: The patient's blood glucose was closely monitored in the post-op period with Q6 hour glucose checks. Blood glucose levels greater than 120 mg/dL were addressed with an insulin sliding scale. Home hypoglycemic medications were held while the patient was NPO--these medications were resumed with a sliding insulin scale once oral intake was tolerated. PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ TID for DVT/PE prophylaxis and encouraged to ambulate immediately post-op once cleared by physical therapy. The patient also had sequential compression boot devices in place during immobilization to promote circulation. GI prophylaxis was sustained with Protonix/Famotidine when necessary. The patient was encouraged to utilize incentive spirometry, ambulate early and was discharged in stable condition. He will continue with outpatient PT services. Medications on Admission: Amitryptiline 10 mg', Gabapentin 900 mg''', Glipizide 5 mg'', Metoprolol 50 mg'', Simvastatin 20 mg', Warfarin 4 mg', Zolpidem 5 mg', Docusate 100 mg', Ferrous gluconate 325 mg''', Senna 8.6 mg'' 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. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 5. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 13. warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day: 2.5 mg daily (Monday, Tuesday and Wednesday), 5 mg daily (Thursday through Sunday). Disp:*50 Tablet(s)* Refills:*2* 14. Outpatient Lab Work Please have Foley catheter/leg bag removed by your PCP for void trial 15. Outpatient Physical Therapy Discharge Disposition: Home Discharge Diagnosis: Descending thoracic aortic aneurysm 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: THORACIC AORTIC STENT GRAFT: Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**1-27**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**3-30**] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2157-6-14**] 1:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2157-6-14**] 2:15 You have an appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Tuesday, [**2157-5-10**] at 11:15 AM. Your INR will be checked and a voiding trial will commence.

[ "V46.3", "250.00", "562.10", "780.62", "272.4", "V58.61", "401.9", "V12.42", "788.29", "V12.51", "441.01" ]

icd9cm

[ [ [] ] ]

[ "39.73", "88.42" ]

icd9pcs

[ [ [] ] ]

9050, 9056

2798, 7346

337, 623

9136, 9136

2444, 2775

11817, 12316

1560, 1610

7592, 9027

9077, 9115

7372, 7569

9319, 11237

11263, 11794

1625, 2425

262, 299

651, 903

9151, 9295

925, 1376

1392, 1544

79,596

169,658

39067

Discharge summary

report

Admission Date: [**2198-5-8**] Discharge Date: [**2198-5-16**] Date of Birth: [**2123-7-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 2080**] Chief Complaint: BRBPR and abdominal pain Major Surgical or Invasive Procedure: Sigmoidoscopy History of Present Illness: Mr. [**Known lastname 86607**] is a 74 yo Spanish-speaking M w/ h/o CVA and residual L hemiparesis and dysphagia being transferred to the ICU for SVT to 180s and resulting hypotension as well as BRBPR. On MICU assessment, unable to obtain hx from pt (he has slurred speech at baseline) but after [**Location (un) 1131**] his admission note, it seems that he was admitted early this am for BRBPR with associated abd pain at NH for the last week. Of note, the pt usually gets his care at [**Hospital1 2025**] but was "diverted" to [**Hospital1 18**] overnight. . Per admission note: On ED assessment, pts vitals were T 99.4 (Tmax 100.9) HR 92 BP 138/80 RR 16 99%. Labs, including blood cultures, were drawn. Active T&S sent. CT abdomen and pelvis was completed which showed no acute intra-abdominal provess to explain the pt's abdominal pain. 2 18 gauge PIVs in place. 1 L NS and acetaminophen 650 mg po x 1 given. Spiked fever 100.9 so given Ciprofloxacin 400 mg IV x 1 and Flagyl 500 mg IV x 1. This was notable narrowed on floor arrival to cipro only with a u/a suspicious for UTI. . This am, his foley was changed by nursing. At 830, his heartrate progressively accelerated from 80s to 140s over half an hour. He recieved a IVF bolus. He also recieved 1mg morphine IV and then vomitted and was given zofran. He also got pr tylenol for temp of 100.3. Pt had 1 bloody BM at 850 and another prior to ICU transfer. Pt became tachycardic to 180s at 10am and dropped pressures to SBP 68. He was given more fluids for a total 2L NS. He spontaneously broke within several minutes and at time of ICU evaluation was back to rates in the 140s with SBP 150s. GI was called just prior to ICU transfer and recommended NGT with lavage to decide on need for EGD vs bleeding scan. His temp also continued to rise to 102 prior to ICU transfer. . On arrival to the ICU, pt c/o all over abd pain. Otherwise unable to obtain hx. Past Medical History: CVA with residual L hemiparesis and dysphagia Hypertenson Diabetes mellitus Social History: Lives in nursing home, and per his daughter has liver there since his CVA last year. No current alcohol/smoking. Family History: NC Physical Exam: Vitals - T: 98 BP: 130/70 HR: 82 RR: 20 02 sat: 95% RA GENERAL: elderly gentleman with L arm flexed in NAD HEENT: EOMI anicteric, OP - not visualized, L facial droop, no cervical LAD CARDIAC: RRR nl S1, S2, no m/r/g LUNG: CTAB, no wheezes/rhonchi/rales ABDOMEN: ND, decreased BS, diffusely tender, voluntary guarding, no rebound EXT: no c/c/e, LLE with 0/5 strength, LUE with 0/5 strength NEURO: L facial droop, L hemiparesis in upper and lower extremities, slurred speech DERM: no rashes RECTAL: soft brown stool with BRB mixed Pertinent Results: Admission Labs: [**2198-5-7**] 09:20PM PT-13.8* PTT-22.6 INR(PT)-1.2* [**2198-5-7**] 09:20PM PLT COUNT-271 [**2198-5-7**] 09:20PM WBC-8.4 RBC-5.11 HGB-13.7* HCT-41.5 MCV-81* MCH-26.7* MCHC-32.9 RDW-14.4 [**2198-5-7**] 09:20PM LIPASE-89* [**2198-5-7**] 09:20PM ALT(SGPT)-11 AST(SGOT)-17 LD(LDH)-204 ALK PHOS-71 TOT BILI-0.6 [**2198-5-8**] 01:09AM LACTATE-1.3 Discharge Labs [**2198-5-15**] 07:50AM BLOOD WBC-6.1 RBC-4.72 Hgb-13.1* Hct-37.9* MCV-80* MCH-27.7 MCHC-34.4 RDW-15.0 Plt Ct-290 [**2198-5-15**] 07:50AM BLOOD Glucose-89 UreaN-9 Creat-0.9 Na-139 K-3.4 Cl-104 HCO3-26 AnGap-12 Imaging: CT Abd/Pelvis: IMPRESSION: 1. No acute intra-abdominal process to explain the patient's abdominal pain and rectal bleeding. 2. Scattered renal cysts, measuring up to 1.4 cm bilaterally. 3. Mild aortic atherosclerosis, without aneurysm. 4. Multilevel spondylosis \ GI Bleeding Study: IMPRESSION: No GI bleeding during the time of study TTE: There is mild (non-obstructive) focal hypertrophy of the basal septum. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. No aortic regurgitation is seen. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: No vegetations or clinically-significant regurgitant valvular disease seen (suboptimal-quality study). Vigorous biventricular systolic function. Sigmoidoscopy: IMPRESSION: Normal mucosa upto 60 cm but quality of prep was poor Grade 2 internal hemorrhoids Otherwise normal sigmoidoscopy to 60 cm Recommendations: Return to floor Findings cannot explain patient's degree of bleeding Patient will need a colonoscopy as an outpatient Brief Hospital Course: Mr. [**Known lastname 86607**] is a 74 yo Spanish-speaking M w/ h/o CVA and residual L hemiparesis and dysarthria admitted to floor briefly for BRBPR and abdominal pain, developed 1 episode of BRBPR +SVT +hypotension, found to have polymicrobial bacteremia and likely ischemic bowel now with no further episodes of BRBPR or hypotension. BRBPR: Had one episode prior to admission and one episode on floor prior to being transferred to the MICU. Received one unit of rbcs in the unit. Hematocrit stable with no further episodes of bleeding. LGIB likely precipitated by intermittent bowel ischemia given initially elevated lactate, episode of hypotension and abdominal pain. Non diagnostic bleeding scan and sigmoidoscopy performed showed grade II hemorrhoids, which would not explain the severity of bleed the patient had. Patient was not able to tolerate the prep and a full colonoscopy could not be performed. This will need to be addressed in the outpatient. Fever/sepsis due to bacteremia- Initially noted in the MICU. Blood cultures grew Enterococcus faecalis and E. coli. Urine culture also grew enterococcus and E. coli, so likely etiology is urosepsis. Patient was also positive for C. diff. IV flagyl started and since the patient was improving on this regimen alone, po vancomycin was not started. Empirically started on vancomycin and zosyn. Once sensitivities were final this was transitioned to Zosyn only per ID recommendations. He is to continue zosyn for a full 14 day course and flagyl to be continued through the zosyn course and an additional seven days after. TTE was performed which was negative for vegetations. PICC was placed prior to discharge to continue these antibiotics in his nursing home. C. diff associated diarrhea: as above. Patient was given Flagyl to overlap with course of Zosyn. SVT- Noted upon second episode of BRBPR. Rates in the 180s, and appeared sinus tachycardia on ekgs. This was likely felt to be secondary to acute blood loss and brief episode of hypotension. Once his hematocrit was stable, he had no further episodes of tachycardia. Hypertension: Patient with history of hypertension on three different medications; captopril, amlodipine, and metoprolol. These were held in setting of hypotension and GI bleed. Over his hospital course his blood pressure became more elevated. Metoprolol was re-introduced without complications. His other two medications should be titrated back while in rehab as blood pressure can tolerate. h/o CVA- stable. No seizure activity noted during admission. Continued home keppra dosage. Continued home Baclofen. Plavix was initially held in setting of GI bleed, since this was stabilized, his home plavix was re-introduced. Code: Full per patient's daughter, his health care proxy Medications on Admission: Methylphenidate 5 mg po daily Plavix 75 mg po daily Amlodipine 10 mg po daily Captopril 100 mg po TID Baclofen 5 mg po TID Metoprolol tartrate 50 po TID Ranitidine 150 mg po qhs Loperamide 2 mg po q2 hours prn MVI 1 tablet po daily Colace 100 mg po TID Citalopram 20 mg po daily Keppra 1000 mg po BID Remeron 15 mg po qhs Albuterol prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Piperacillin-Tazobactam 4.5 g IV Q8H 12. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 16 days. 16. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 17. Piperacillin-Tazobactam 4.5 gram Recon Soln Sig: 4.5 grams Intravenous every eight (8) hours for 9 days: Last Day: [**2198-5-24**]. 18. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 19. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 16 days: Please only give this if patient not able to tolerate PO form. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home Discharge Diagnosis: Primary: Lower GI bleed likely secondary to transient ischemic colitis Grade II internal hemorrhoids Enterococcus and E. coli Bacteremia secondary to urosepsis SVT Secondary: CVA c/p left sided hemiparesis Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted because you had bright red blood in your rectum. You were very sick and were closely monitored in the ICU. You received one unit of blood. Your bleeding stopped. A sigmoidoscopy was performed which only showed hemorrhoids. This could have possibly been the cause, but you will need a full colonoscopy in the outpatient to further evaluate your colon. You also developed an infection in your blood, urine and bowels. You were started on antibiotics and should continue these as directed. You should continue your medications as prescribed with the following important changes: 1. Zosyn stop [**2198-5-24**] 2. Flagyl 500 mg every twelve hours. Stop: [**2198-5-31**] 3. HOLD Captopril 100 mg three times per day in setting of recent GI bleed, but this should be titrated back as you can tolerate 4. HOLD Amlodipine 10 mg daily in setting of recent GI bleed, but this should be titrated back as you can tolerate Followup Instructions: You have the following appointments scheduled: Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2198-7-4**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 10314**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage If you leave your nursing home, you should contact your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment. [**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 64415**]

[ "401.9", "438.13", "584.9", "285.1", "438.82", "008.45", "038.0", "455.0", "599.0", "276.2", "250.00", "787.20", "995.91", "557.9", "438.20", "427.89", "038.42" ]

icd9cm

[ [ [] ] ]

[ "96.07", "38.93", "48.23" ]

icd9pcs

[ [ [] ] ]

10493, 10564

5479, 8249

340, 356

10827, 10827

3111, 3111

11959, 12583

2542, 2546

8636, 10470

10585, 10806

8275, 8613

11005, 11936

2561, 3092

276, 302

384, 2296

3128, 5456

10842, 10981

2318, 2396

2412, 2526

23,061

194,030

10432

Discharge summary

report

Admission Date: [**2130-9-24**] Discharge Date: [**2130-9-28**] Date of Birth: [**2054-8-10**] Sex: F Service: MEDICINE Allergies: Penicillins / Hydrocortisone Attending:[**First Name3 (LF) 11495**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: none - negative MRCP, CT abdomen History of Present Illness: 76y/o F w/ a PMH of CAD who presents with chest pain. She was in her USOH today until she went to the mall with her daughter and developed the acute onset of pressure-type central chest pain and nausea while walking. She sat down w/out relief of her pain and the pain lasted for several hours w/out change until it slowly faded in our ED. She took NTG in the mall w/out any relief of her pain and got NTG and ASA in the ED w/out relief either. She had a recent stress test in [**Month (only) 205**]/[**Month (only) 216**] that was normal per her report. Her previous anginal equilivant has been pressure chest pain across her entire chest w/ associated SOB. During this current episode, she denies SOB and further denies recent cough, HA, dysuria, abdominal pain, diarrhea, URI symptoms, diaphoresis, palpatations, or paresthesias. She has had no history of trauma to the chest although she does not a L rib pain that started acutely after she lifted a bag and heard a snap. This pain is pleuritic in nature and easily reproducible w/ palpation. . In our ED, her EKG showed frequent PVCs but no ST changes. She received ntg/asa/levaquin as above. In the context of giving her NTG in the ED, there was a ? drop in her BP that responded well to fluids. On the floor she was normotensive and pain-free. Past Medical History: 1) CAD - negative stress 8/06 per patient 2) Tremor (unclear etiology) 3) Macular degeneration 4) s/p cholecystectomy and biliary stenting with removal ([**2128**]) 5) GERD 6) Hearing loss 7) Hypothyroidism Social History: Lives alone in [**Location (un) 86**], has 3 children. She denies tobacco, drug, or alcohol use. Physical Exam: 99.8, 110/52, 90, 18, 93%RA Gen: Elderly WF lying in bed in NAD HEENT: MM dry, O/P clear, EOMI CV: Frequent PVC, no M/R/G, no tenderness to palpation Lungs: Bibasilar crackles, significant L anterior rib tenderness ~t6 Abd: S/NT/ND, +BS, -HSM Ext: Chronic LE edema, no rashes Neuro: CN intact, strength symmetrical, intention tremor Pertinent Results: 139 103 19 AGap=12 -------------< 94 3.8 28 0.8 CK: 185 MB: 4 Trop-*T*: <0.01 ALT: 16 AP: 128 Tbili: 0.6 Alb: AST: 23 LDH: Dbili: TProt: [**Doctor First Name **]: 113 Lip: 25 Other Blood Chemistry: proBNP: 381 91 4.9 \ 13.4 / 176 / 38.6 \ N:87 Band:4 L:5 M:1 E:1 Bas:0 Metas: 1 Myelos: 1 [**2130-9-28**] 05:00AM BLOOD ALT-5 AST-4 CK(CPK)-67 AlkPhos-20* TotBili-0.4 [**2130-9-26**] 06:10AM BLOOD ALT-20 AST-29 CK(CPK)-92 AlkPhos-124* Amylase-60 TotBili-0.6 [**2130-9-25**] 06:10AM BLOOD ALT-15 AST-22 LD(LDH)-203 CK(CPK)-107 AlkPhos-104 Amylase-60 TotBili-0.6 [**2130-9-24**] 09:05PM BLOOD CK(CPK)-120 [**2130-9-24**] 02:45PM BLOOD ALT-16 AST-23 CK(CPK)-185* AlkPhos-128* Amylase-113* TotBili-0.6 [**2130-9-24**] 5:30p Color Straw Appear Clear SpecGr 1.027 pH 6.5 Urobil Neg Bili Neg Leuk Neg Bld Neg Nitr Neg Prot Neg Glu Neg Ket Neg Discharge labs: [**2130-9-28**] 05:00AM BLOOD WBC-4.5 RBC-3.74* Hgb-11.7* Hct-32.7* MCV-88 MCH-31.3 MCHC-35.8* RDW-13.8 Plt Ct-158 [**2130-9-28**] 04:00PM BLOOD PT-15.0* PTT-142.2* INR(PT)-1.3* [**2130-9-25**] 06:00PM BLOOD FDP-10-40 [**2130-9-28**] 05:00AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-141 K-4.3 Cl-108 HCO3-24 AnGap-13 [**2130-9-27**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [**2130-9-26**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [**2130-9-25**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [**2130-9-24**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] [**2130-9-24**] 2:45 pm BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Preliminary): [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 1810 ON [**9-25**].. REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 1810 ON [**9-25**].. ANAEROBIC GRAM NEGATIVE ROD(S). FURTHER IDENTIFICATION TO FOLLOW. BETA LACTAMASE POSITIVE. MCRP: Air in biliary system, no abscess or stenosis, hepatic cysts seen, no source of bacteremia Cardiology Report ECG Study Date of [**2130-9-24**] 3:15:44 PM Sinus rhythm Atrial premature complexes Nonspecific precordial/anterior T wave abnormalities No previous tracing available for comparison Cardiology Report ECG Study Date of [**2130-9-26**] 9:52:56 AM Atrial fibrillation with rapid ventricular response Diffuse ST-T wave abnormalities - are nonspecific but cannot exclude in part ischemia - clinical correlation is suggested Since previous tracing of [**2130-9-24**], rapid atrial fibrillation and further ST-T wave changes now present CTA CHEST W&W/O C &RECONS [**2130-9-24**] 4:22 PM 1. No evidence of pulmonary embolism or aortic dissection. 2. Slightly prominent infundibulum along the medial aortic arch, apparently the origin of a small vessel, of doubtful clinical significance. 3. Mildly prominent mediastinal lymph nodes, and right hilar lymph nodes. 4. Bibasilar atelectasis. 5. Pneumobilia, with slight prominence of the visualized central hepatic bile ducts. Correlation with clinical history and laboratory data is recommended. 6. Breast calcifications. Usual mammographic screening is recommended. CT PELVIS W&W/O C [**2130-9-25**] 2:33 PM 1. No explanation of the patient's symptoms. 2. Central biliary ductal dilatation and pneumobilia. 3. Hepatic cyst. Small low attenuations in the liver, too small to characterize. 4. Small bilateral pleural effusions. Cardiology Report ECHO Study Date of [**2130-9-27**] Preserved global and regional biventricular systolic function. Mild-moderate mitral regurgitation. Moderate tricuspid regurgitation. Pulmonary artery systolic hypertension. Based on [**2120**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: 1) Gram negative bacteremia: patient presented with symptoms suspicious for rigor but she was afebrile. Blood cultures were drawn and the anaerobic bottle grew gram negative rods, which are consistent with possible anaerobic gut organisms. She was treated with levofloxacin and flagyl while in the hospital and asymptomatic since presentation. CT of the abdomen/pelvis and MRCP were negative for identifying a source of infection. The ERCP service was contact[**Name (NI) **] and felt that without symptoms and with a normal MRCP, that ERCP was not necessary. Her LFT's were stable at discharge. She was discharged on 14 day total course of antibiotics. 2) Atrial fibrillation: She was noted to go into A fib two days into hospitalization, with rapid response to 150-180's and associated hypotension. She was transferred to the CCU and spontaneously converted a few hours after entering A fib following fluid boluses, metoprolol, and 150 mg of amiodarone. TSH/free T4 were normal. She was in NSR since that time, and will be set up with an event monitor at her cardiologist's office the day following discharge. Her propranolol daily dose was changed to atenolol for longer duration of action and to avoid multiple doses during the day. She was also maintained on heparin while hospitalized and started on coumadin for CHADS2 score of at least 2 at discharge, which will be managed by her PCP's office. She was not felt to need a bridge to coumadin and the heparin was discontinued at discharge. 3) Chest pain/CAD: CTA of the chest, EKG, and cardiac enzymes are negative. Her chest pain was felt to possibly be secondary to stable angina, or was possibly secondary to paroxysmal A fib. She was maintained on statin, Imdur (changed to once daily), atenolol, and started on a low dose of lisinopril. 4) Hypothyroidism: she was continued on synthroid. TSH/free T4 were normal. 5) Code - She was DNR/DNI Medications on Admission: Propanolol 160 mg PO qd Isosorbide 60 mg PO bid Lipitor 40 mg PO qd Minocyline 100 mg PO qd ASA 81 mg PO qd Zantac 75 mg PO prn Hydrocodone prn cough Synthroid 88 mcg qd Vit C Vit E occuvite Centrum silver Discharge Medications: 1. Outpatient Lab Work Please draw PT/INR on Monday [**10-2**], and fax results to Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 19292**] fax [**Telephone/Fax (1) 34504**]. 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Minocycline 50 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO twice a day as needed for indigestion. 6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*1 bottle* Refills:*3* 13. Warfarin 1 mg Tablet Sig: Three (3) mg PO once a day: PT/INR should be followed regularly on this medication and dose adjusted appropriately, starting 3-4 days after first dose. Disp:*150 pills* Refills:*2* 14. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 11 days. Disp:*22 Tablet(s)* Refills:*0* 15. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 11 days. Disp:*33 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Street Address(1) 19127**] [**Hospital3 400**] Discharge Diagnosis: anaerobic gram negative rod bacteremia, unclear source atrial fibrillation, resolved after fluid/amiodarone atypical chest pain hypothyroidism Discharge Condition: patient was feeling well and stable for discharge, in normal sinus rhythm at a rate of 80. Discharge Instructions: You are being discharged on the following new medications: atenolol, ciprofloxacin, metronidazole (flagyl), and coumadin (warfarin). Take your ciprofloxacin/metronidazole until gone. It is very important that your PT/INR (coumadin level) are checked on Monday [**2130-9-28**], and as recommended by Dr. [**Last Name (STitle) 4251**] thereafter. If you have fevers, chills, chest pain, or other concerns, please return to the ED or contact your PCP. Followup Instructions: Please go to Dr.[**Name (NI) 34505**] office on Friday [**2130-9-29**] at 9:30 AM for cardiac monitor placement. His phone number is [**Telephone/Fax (1) 34506**]. Please follow up with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 19292**] in approximately 1-2 weeks following discharge. She should follow your coumadin levels (goal INR [**12-30**]), and also follow up your final cultures in [**1-28**] days by calling the Microbiology lab at [**Hospital1 18**]: [**Telephone/Fax (1) 4645**]. You also have these appointments scheduled: Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2130-11-1**] 10:50 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16051**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2130-12-29**] 11:00

[ "413.9", "427.31", "790.7", "530.81", "244.9", "414.01", "786.59" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10261, 10341

6341, 8247

301, 335

10528, 10620

2380, 3254

11119, 12035

8504, 10238

10362, 10507

8273, 8481

10644, 11096

3271, 3965

2026, 2361

251, 263

3995, 6318

363, 1665

1687, 1897

1913, 2011

19,185

103,196

16572

Discharge summary

report

Admission Date: [**2195-11-30**] Discharge Date: [**2195-12-25**] Date of Birth: [**2118-5-13**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: carotid stenosis Major Surgical or Invasive Procedure: rt. CEA with patch [**2195-12-1**] PEG placement [**2195-12-11**] Trach placement [**2195-12-11**] History of Present Illness: 77y/o male s/p left CEA, known to Dr. [**Last Name (STitle) 1391**] with followup carotid u/s q6months. Hospitalized [**10-19**] with stroke . manfested by left hemiparesis, visual changes OS ( neglect) and difficulty swallowing with aspiration. Swallowing has impproved with speech thearphy. Presents for rt. crotid endarectomy. Has been wheel chair bound since stroke. ROS: hx cad with arrythmia hx aspiration hx c. diff treated with flagyl x 1 week hx BPH with nocturnal frequency denies: headaches, seizzures, syncopy, PND<Orthopnea, palpa,pneumonia, asthma, claudication or DVT now admitted for elective CEA Past Medical History: CVA [**2183**], [**10-19**] CAD ,s/p IWMI hx GI bleed [**8-19**] s/p EGD/colonoscopy @ [**Last Name (un) 11560**] Gen. results?? BPH cardiomyopathy ef 30% hx VT s/p left CEA [**2190**] CAGB"Sx4 [**2184**] AICD [**2193**] Social History: retired [**Doctor Last Name **] married lives with spouse wheel chair bound Habits: smoking d/c [**2187**] previous 2ppd x years ETOH: denies Family History: unknown Physical Exam: Vital signs: 96.0-71-20 b/p 110/70 oxygen saturatiion 93% room air Wt.: 85.5 Kg general: oriented x3 mild dysarthia HEENT:normal cephalic tongue midline Lungs: clear to ausculattion >a/P chest diameter Heart: regular rate rythmn. no mumur abd: begnin rectal: enlagred prostate smooth. guiac negative stool PV: feet pink warm pulses 2+ symmetrical intaact Neuro: oriented x3 CN intact, Motor sensory intact. strength 5+/5+ bilaterally upper and lower. hand grasp rt.5+/5+, lt. hand grasp 4+/5+ Romberg not tested DTR"S 2= plantar rt. down, let up wt. 85.5 KG Pertinent Results: [**2195-11-30**] 11:56PM WBC-6.9 RBC-4.65 HGB-13.8* HCT-41.2 MCV-89 MCH-29.6 MCHC-33.5 RDW-13.5 [**2195-11-30**] 11:56PM PLT COUNT-180 [**2195-11-30**] 11:56PM PT-12.8 PTT-32.0 INR(PT)-1.0 [**2195-11-30**] 08:59PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025 [**2195-11-30**] 08:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2195-11-30**] 11:56PM GLUCOSE-89 UREA N-23* CREAT-0.9 SODIUM-144 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-27 ANION GAP-13 [**2195-11-30**] 11:56PM CALCIUM-9.8 PHOSPHATE-3.3 MAGNESIUM-1.9 Brief Hospital Course: [**2195-11-30**] admitted and prepared for surgery. [**12-1**] s/p rt. CEA with patch, neck rexploration and carotid exploration with intraoperative angiogram. Acute stroke. Neuro consulted. [**2195-12-2**] POD#1 speech and swallow consluted. recommended NPO . [**2195-12-3**] POD#2 hypoxic unresponsive intubated and transfered to ICU. head CT rt, MCA stroke. sapiration?? began on Vanco ,levo flagyl. [**2195-12-5**] POD# 4 sputum c/s gram postive organisms and gran negative organisms. Zosyn began for aspiration pneumonia. VANCO?LEVO?Flagyl discontinued. Failed extubation secondary to secreations re in;tu;bated. TPN began. [**2195-12-9**] POD# 6 u/s of left arm for swelling negative for DVT. [**2195-12-11**] POD# 8 c diff sent, positive flagyl restarted. PEG placed. Tracheostomy with #8 portex placed. Zosyn d/c'd. [**2195-12-13**] POD# [**10-17**] TPN discontinued. tube feeds began. Trach mask all day!! sputum culture for persistant temp. GNR levo restarted/ Vancomyci for blood c/s of GPC.CVL d/c'd [**2195-12-16**] POD# 13/5 Transfered to VICU. PT/OT consults [**2195-12-21**] POD# 18/10 o2 weanening began. tolerating tube feeds. [**2195-12-22**] POD# 19/11 continues to progress. await rehab. bed [**2195-12-24**] POD# 21/13 still with secreations and could not be evaluated by speech and swallow at this time. Will need eval at rehabilitation. [**2195-12-25**] POD# 22/14 discharged to rehabilitation stable Medications on Admission: asa 81mgm plavix 75mgm iron 325mgm toporl xl 50mgm proscar 5mgm folic acid 2mgm beconase NU cozaar 50mgm [**Hospital1 **] combivent MDi pudd 2 [**Hospital1 **] zeta 10mgm HS Discharge Medications: 1.Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One (1) Spray Nasal QD (). 3. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4-6H (every 4 to 6 hours) as needed. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-16**] Drops Ophthalmic PRN (as needed). 8. Acetaminophen 160 mg/5 mL Elixir Sig: 325-360 mgm PO Q4-6H (every 4 to 6 hours) as needed for fever. 9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 14. Insulin Reg (Human) Buffered 100 unit/mL Solution Sig: as directed Injection every six (6) hours: glucoses <70 [**1-16**] amp D50% glucoses 71-120/no insuin glucoses 121-140/2u glucoses 141-160/4u glucoses 161-180/6u glucoses 181-200/8u glucoses 201-220/10u glucoses 221-240/12u glucoses 241-260/14u glucoses 261-280/16u glucoses 281-300/18u glucoses 301-320/20u glucoses 321-340/22u glucoses 341-360/24u glucoses 361-380/26u glucoses 381-400/28u glucoses > 400 [**Name8 (MD) 138**] Md. 15. Tears Naturale Drops Sig: One (1) gtts Ophthalmic four times a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: carotid stenosis rt. s/p RT. CEA postoperative rt. MCA stroke respiratory failure s/p trach aspiration s/p PEG aspiration pneumonia , treated with Zosyn C. diff, treated rt. neck hematoma, resolved Discharge Condition: improved, stable Discharge Instructions: trach care per routine Followup Instructions: 4 weeks Dr. [**Last Name (STitle) 1391**]. call for appoiontment. [**Telephone/Fax (1) 1393**] Completed by:[**2195-12-25**]

[ "401.9", "600.00", "433.10", "272.0", "507.0", "008.45", "428.0", "V45.02", "997.02", "V45.81", "518.5" ]

icd9cm

[ [ [] ] ]

[ "88.41", "96.04", "96.71", "38.02", "96.6", "99.15", "38.93", "43.11", "31.1", "96.72", "38.12" ]

icd9pcs

[ [ [] ] ]

6215, 6295

2746, 4174

333, 435

6537, 6555

2112, 2723

6626, 6753

1508, 1517

4399, 6192

6316, 6516

4200, 4376

6579, 6603

1532, 2093

277, 295

463, 1078

1100, 1323

1339, 1492

27,390

138,706

25352

Discharge summary

report

Admission Date: [**2135-4-18**] Discharge Date: [**2135-4-19**] Date of Birth: [**2066-3-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: near total occlusion left ICA Major Surgical or Invasive Procedure: Left Carotide stent placement History of Present Illness: HPI: 67yoM O2-dependant COPD, CAD, htn, DMII s/p R ICA stenting in [**2133**] with L ICA initially medically managed given concern for distal embolization during stenting. He developed GI bleed 6 months ago on coumadin and was re-eval by vascular with recommendation for L ICA stent. He underwent uncomplicated stenting today.Noted to have 99% stenosis with stent placed with residual 10% stenosis. Had vagal episode with SBPs in 50s, but asymptomatic, admitted to CCU for observation Past Medical History: 1. COPD, on home oxygen 2L continuously 2. Anxiety 3. Depression 4. Sleep apnea: cpap 5. acute renal failure 6. Diabetes Type II 7. Hypertension 8. Appendectomy 9. Tonsillectomy 10. Back surgery [**36**]. CAD s/p ptca [**35**] yrs BU 12. ? seizures 13. ? syncope 14. Atrial fibrillation s/p cardioversion (?[**8-18**] at [**Hospital1 **]) 15. Parasympathetic nervous system dysfunction 16. "Unusual syndrome of abnormal sensation/movement in penis Social History: Pt retired (used to work for oxygen device company) and lives with his mother in [**Name (NI) 13360**]. Has 5 children ages 43 to 30 years old. Previously smoked 3-4 packs/day x 45 years gradually decreasing for past 8 years to ~6 cigs/day. Patient states he quit alcohol 30 years ago. Prior crack/cocaine x 2 yrs. Quit a few yrs ago. Family History: Mother CABG [**14**], alive 92. Father died at of pancreatic cancer at age 72. Physical Exam: VS: T 98, BP 98/60, HR 71, RR 16, 95 5 NC comfortable, AO x3 subtle L carotid bruit RRR,S1 S2 clear ,no MRG CTA -B abd soft nt,nd ext: no lower extremity edema right femoral bruit Pertinent Results: [**2135-4-18**] 08:45AM PT-11.8 INR(PT)-1.0 [**2135-4-19**] 03:47AM BLOOD Hct-29.5* [**2135-4-19**] 03:47AM BLOOD PT-13.1 PTT-24.1 INR(PT)-1.1 [**2135-4-18**] 08:45AM BLOOD PT-11.8 INR(PT)-1.0 [**2135-4-19**] 03:47AM BLOOD Glucose-111* UreaN-37* Creat-1.7* Na-140 K-4.4 Cl-107 HCO3-23 AnGap-14 [**2135-4-19**] 03:47AM BLOOD Calcium-9.5 Phos-4.3 Mg-1.9 . Right Femoral Ultrasound: [**2135-4-19**] Patent right common femoral artery without evidence of pseudoaneurysm, AV fistula, or hematoma. . [**2135-4-18**] 1. A patent left proximal common carotid artery. 2. Widely patent left external carotid artery. 3. The left internal carotid artery had a critical 99% stenosis spanning 2-3 cm approximately 1 cm distal to its origin. Successful stenting of the internal carotid artery stenosis was performed with a 10-mm Wallstent followed by a 5-mm balloon angioplasty of the stent with resultant widely patent flow through the common carotid, internal carotid and external carotid arteries with minimal 10% residual stenosis in the center of the stent. Brief Hospital Course: A/P: 67yoM O2-dependant COPD, htn, DMII, ?syncopal hx admitted for coronary angiography, revealed near 100% L-ICA, >95% R-ICA, s/p R-ICA stenting x2, admitted to CCU for tight BP control post procedure. . # PVD/CAD - significant L/R-ICA disease, with multiple ulcerations and dissections of R-ICA artery, now s/p stent placement x2 to R-ICA . On this admission he had placement of a L-ICA stent. Given his cerebral vessels decreased capacity to autoregulate, the degree of hypoperfusion was limited with dopamine. MAPs remained between 80 and 120 and his dopamine was subsequently discontinued. He continued to receive aspirin, plavix, metoprolol, and ezetemibe on discharge.He was noted to have a right femoral artery bruit on arrival the CCU. A right femoral ultrasound did not reveal any pseudoanuerysm, hematoma or AV fistula. he will follow up with Dr [**Last Name (STitle) **] as an outpatient. . # DM - continued glyburide, avandia . # Hypercholesterolemia - continued ezetemibe, atorvastatin . # COPD/OSA - continued advair, albuterol nebs prn, cpap. . # Shoulder pain: continued percocet. Medications on Admission: 1. Advair disc 250/50 INH 2 puffs [**Hospital1 **] 2. Albuterol/atrovent nebulizer 4 times daily 3. Amlodipine 2.5mg daily 4. Aspirin 325mg daily 5. Avandia 4mg daily 6. Clorezepate 7.5mg 2 pills 3 times daily 7. Effexor 75mg [**Hospital1 **] 8. Gemfibrizol 600mg daily 9. Glipizide 2.5mg daily 10. Lisinopril 10mg daily 11. Metoprolol succinate ER 100 q d 12. Omega 3 tid 13. Uroxatral 10mg daily 14. Vitamin b12 1daily 15. Plavix 75mg daily 16. Lipitor 40mg daily 17. Lidocaine 2 % solution PRN 18. Lidociaine 4% liquid PRN 19. lidocaine 5% cream PRN 20. Lidocaine patch PRN . oxycodone 5-325 q 6 prn omeprazole 40 q d alprazolam 1mg q4 prn flomax 0.4 at bedtime diltiazem 30 qd (last filled [**2135-3-17**]) Discharge Medications: 1. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: Two (2) puffs Inhalation twice a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day. 4. Effexor 75 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-12**] Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 7. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Omega-3 Fish Oil Oral 10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical DAILY () as needed for PRN neuropathy. 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for shoulder pain. 13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 14. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 15. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day. 16. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 17. Flaxseed Oil Oral Discharge Disposition: Home Discharge Diagnosis: Primary - Carotid artery stenosis Secondary - Diabetes Type II Hypertension Chronic obstructive pulmonary disease Hypercholesterolemia History of atrial fibrillation Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to hospital for stenting of your carotid artery. Your procedure was complicated by a brief episode of hypotension (low blood pressure) requring medications to raise you blood pressure. This is a common side effect of your procedure. Medication changes: 1. Your amlodipine, diltiazem, and lisinopril were stopped temporarily as your blood pressure was low after your procedure. You will need to follow up with your primary care doctor for a blood pressure check and discuss with him if you should restart these medications. 2. Please continue to take plavix 75 mg daily and aspirin 325 mg daily as well as your other home medications (except as listed above). Followup Instructions: You will need to follow up with Dr. [**Last Name (STitle) **] in one month. You will be contact[**Name (NI) **] with the appointment. You need to follow up with your primary docotor, Dr. [**Last Name (STitle) 6700**] ([**Telephone/Fax (1) 6699**]), on Thursday [**4-21**] at 2:30 pm for a blood pressure check and to discuss restarting your blood pressure medications.

[ "433.10", "V45.82", "414.01", "250.00", "327.23", "401.9", "272.0", "496", "443.9" ]

icd9cm

[ [ [] ] ]

[ "00.40", "00.45", "00.61", "88.41", "00.63" ]

icd9pcs

[ [ [] ] ]

6395, 6401

3133, 4234

344, 375

6612, 6612

2025, 3110

7467, 7841

1729, 1809

4996, 6372

6422, 6591

4260, 4973

6760, 7014

1824, 2006

7034, 7444

275, 306

403, 889

6627, 6736

911, 1360

1376, 1713

1,283

121,527

50532

Discharge summary

report

Admission Date: [**2128-5-3**] Discharge Date: [**2128-5-7**] Date of Birth: [**2059-11-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 68 year old man with a complicated past medical history including congenital heart disease, chronic AF s/p AV ablation, on coumadin and worsening systolic and diastolic heart failure who presents with shortness of breath, fever and chills. For the past week at home he has had cold symptoms including nasal congestion and cough. Today he had worsening dyspnea, new fever and malaise, so he called his PCP who referred him to the ER for further evaluation. . In the ED, initial vs were: 100.4, 84, 114/68, 24, 89% on RA. He initially required a NRB with improvement in his oxygen saturation so that he was able to be weaned to 5LNC with sats in the high 90's. He was febrile in the ER to 101. A CXR was done that showed mild pulmonary vascular congestion, with a small RLL consolidation that was read as atelectasis vs. pneumonia. EKG was v-paced that was reportedly unchanged from prior. Labs were notable for a white count of 11.2 with 88.6% neutrophils, a BNP of [**Numeric Identifier **], which was up from 5487 on [**2128-4-22**], a Cr of 2.2 (near baseline) and a lactate of 3.0. He was given ceftriaxone, levofloxacin and 2L NS (given his elevated lactate) and admitted to the ICU for further management. VS on transfer were: 98.8, 79, 101/63, 26, 100% on 5LNC. . On the floor initially his VS were: 99, 84, 101/65, 19 and 95% on RA. Also of note his current weight is 237lbs, which is up from his dry weight of 221lbs. He says that he feels like he started gaining some fluid a few days when he was starting to feel sick. Although currently denies any orthopnea/PND. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Congenital heart disease: Primum ASD with cleft mitral valve, ASD repair in [**2099**], MVR in [**2118**] with porcine valve. 2. Chronic atrial fibrillation, AV ablation, failed amiodarone, on warfarin. 3. BiV ICD. 4. Systolic and diastolic heart failure with LVEF of 45-50%. 5. Worsening right ventricular dilatation and hypokinesis with moderate-to-severe tricuspid regurgitation. 6. PEA/V-fib arrest in the past secondary to enterococcal bacteremia, endocarditis. 7. Hyperthyroidism, amiodarone induced. 8. Gout. 9. Chronic kidney disease. 10. Osteoporosis. 11. Past hypertension. Social History: no current tobacco, quit [**2082**]. 3+ drinks daily vs. weekly. Lives with wife, has daughter, son and 3 grandchildren. He is a businessman who liquidates retail stores Family History: His mother died of coronary artery disease. His grandmother died of some cancer at the age of 98. His father died of colon cancer at the age of 68. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . PE on discharge: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at earlobe. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, slight crackles at bases, no wheezing, egophony at right base ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2. Pertinent Results: [**2128-5-3**] 08:30PM GLUCOSE-199* UREA N-61* CREAT-2.2* SODIUM-137 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-25 ANION GAP-18 [**2128-5-3**] 08:30PM CK(CPK)-103 [**2128-5-3**] 08:30PM cTropnT-0.02* [**2128-5-3**] 08:30PM CK-MB-3 proBNP-[**Numeric Identifier **]* [**2128-5-3**] 08:30PM CALCIUM-8.8 PHOSPHATE-4.6* MAGNESIUM-2.2 [**2128-5-3**] 08:30PM WBC-11.2*# RBC-4.14* HGB-13.3* HCT-39.8* MCV-96 MCH-32.2* MCHC-33.5 RDW-16.2* [**2128-5-3**] 08:30PM NEUTS-88.6* LYMPHS-5.9* MONOS-4.0 EOS-0.9 BASOS-0.6 [**2128-5-3**] 08:30PM PLT COUNT-245 [**2128-5-3**] 08:30PM PT-23.8* PTT-26.0 INR(PT)-2.2* Lactate 3.0 . Urine: [**2128-5-3**] 09:14PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2128-5-3**] 09:14PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2128-5-3**] 09:14PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-0 [**2128-5-3**] 09:14PM URINE HYALINE-29* Urine culture pending . Blood cultures 5/16 pending Sputum: Gram stain and culture - contaminated, multiple mixed flora . Rapid viral swab - not enough epithelial cells . CXR on admission: Single AP upright portable view of the chest was obtained. The patient is status post median sternotomy. A left-sided AICD is again seen with leads extending to the expected positions of the right ventricle and coronary sinus. Abandoned pacer lead again noted on the right. Mild pulmonary vascular congestion is seen. Subtle right base opacity is seen, which may relate to atelectasis, although early pneumonia is not entirely excluded. There is marked enlargement of the cardiac silhouette, given differences in technique in inspiration, likely similar to the prior study. . . ECHO The left atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. Overall left ventricular ejection fraction is mildly depressed (LVEF= 45 %) due primarily to right ventricular predominance and interventricular dependence resulting in dyssynergic interventricular septal displacement, rather than actual contractile dysfunction of the left ventricular myocardium. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. . . . Labs at discharge: Brief Hospital Course: 68 y/o M with a complicated cardiac past medical history who presents with dyspnea, rigors and chills after a week of cold symptoms, found to have a possible RLL PNA on CXR. . #) Hypoxia: CXR with possible RLL infiltrate, patient has clinical symptoms of pneumonia including cough and fever so was presumptively treated for CAP with ceftriaxone and levofloxacin for 5 day course (completed in hospital and patient did not have fevers for 4 days prior to discharge) However, CXR findings and elevated BNP also concerning for pulmonary vascular congestion, which could have been exacerbated by the 2L of IVF given in the ER and dietary indiscretions recently. Sputum cultures were contaminated as were repeat DFAs and patient diuresed well with 80mg IV lasix twice daily on the day of admission. Supplemental oxygen was weaned off. He was diuressed with Torsemide IV Daily thereafter. His weights showed a decrease from admission weight of 237 --> 235 on discharge (likely error due to different scales as patient was diuresed net 5L on this admission). He was continued on a low sodium diet. He was discharged on 120mg PO Torsemide once daily. He was markedly less short of breath on discharge. . #) Acute on Chronic Biventricular Heart Failure: Followed by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] as outpatient. Appeared hypervolemic on exam with significant ascites and some lower extremity edema. BNP elevated above any prior measurements in our system and CXR with mild pulmonary congestion are both consistent with heart failure. Mildly elevated lactate that resolved during hospital admission; hyaline casts and BUN:Cr ratio were felt due to poor forward flow from acute HF, not volume depletion - this resolved with diuresis also. The patient was first diuresed with lasix and home spironolactone, restricted dietarily per above. On leaving the MICU, it was felt that the patient may benefit from right heart cath to evaluate atrial pressures. The patient was diuresed as above and he is scheduled for Right heart cath next Monday [**5-7**]. He was discharged home over the weekend and instructed to return on Monday and not the eat or drink after 8am on Monday morning. . #) Atrial Fibrillation: chronic, s/p AV ablation, followed by Dr. [**Last Name (STitle) **] as an outpatient. Coumadin was restarted in house and INR was 1.6 on discharged but his coumadin was held on discharge until Right heart cath on monday afternoon. . #) CKD: Cr on admission was 2.2, appeared to be near his recent baseline which has fluctuated between 1.8 and 2.6 in the past 3 months. Creatinine also improved during hospitalization with diuresis, suggestive of passive congestion component to his impaired renal function. His creatinine was 1.9 on discharge. . #) Osteoporosis: continued home calcium and vitamin D . . . . ######################################################### . Transitional issues: . 1. Right heart catheterization: Patient will be NPO monday morning and will return to [**Hospital Ward Name **] 4 for Right heart cath to evaluate pressures / to ascertain whether he would benefit from pulmonary vasodilation. It was unclear on this admission whether he should be placed on an ACE-i for heart failure (given his increased creatinine) and whether he should be placed on an aspirin (given that he does not have previous CAD). 2. Pneumonia: Patient completed a 5-day course of levaquin (3 doses q48hrs given renal function) and was not discharged on antibiotics. He had been afebrile for 4 days prior to discharge. Medications on Admission: Allopurinol 150 mg daily Lexapro 20 mg daily metoprolol succinate 200 mg daily Viagra as needed Zocor 20 mg daily spironolactone 25 mg daily torsemide 60 mg twice a day warfarin ???5mg T,Th,Sun and 7.5mg M,W,F,Sat Ambien as needed for sleep calcium with vitamin D multivitamin daily. Discharge Medications: 1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 4. Viagra Oral 5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 7. torsemide 20 mg Tablet Sig: Six (6) Tablet PO once a day. 8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. zolpidem Oral Discharge Disposition: Home Discharge Diagnosis: Primary: -Pneumonia -Acute on chronic systolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the [**Hospital3 **] Medical Center for a shortness of breath. You were found to have a pneumonia. You were also experiencing an exacerbation of your chronic heart failure. You were treated with two antibiotics and were diuresed several liters. You should also note that your torsemide dosage has changed. You should START: - Torsemide 120mg in the morning . You should HOLD: - Coumadin (while awaiting your Right heart cardiac catheterization next Monday [**5-10**]) Please take all your other medications as prescribed prior to your hospitalization. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please note the following: Cardiac Catheterization @ 2:00pm in [**Hospital Unit Name 105230**] (to be accessed through [**Hospital Ward Name 121**]-building) - Please DO NOT eat or drink anything after 8am on the day of your procedure (Monday) - You should take your medications in the morning prior to your procedure with sips of water -You will be done by late afternoon/early evening and will require a ride home (please arrange for this) - If you have questions please contact: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 22225**] Also, please call Dr.[**Name (NI) 3536**] office to schedule a follow up appointment in the next 1-2 weeks.

[ "427.31", "V12.53", "733.00", "486", "V15.1", "274.9", "V58.61", "584.9", "414.00", "585.9", "428.0", "428.43" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12469, 12475

7895, 10802

318, 324

12580, 12580

4739, 5876

13421, 14080

3242, 3392

11789, 12446

12496, 12559

11481, 11766

12731, 13398

3407, 3877

3891, 4720

10823, 11455

1978, 2426

271, 280

7872, 7872

352, 1959

5890, 7851

12595, 12707

2448, 3038

3054, 3226

27,602

160,354

42954

Discharge summary

report

Admission Date: [**2185-7-13**] Discharge Date: [**2185-7-19**] Service: MEDICINE Allergies: Hydrochlorothiazide Attending:[**First Name3 (LF) 99**] Chief Complaint: Transferred from [**Hospital3 417**] Hospital for Respiratory Failure Major Surgical or Invasive Procedure: Central Venous Line Bronchoscopy History of Present Illness: This is an 84 yof with hx of CAD s/p MI, HTN, Hyperlipdemia, PVD, PE s/p IVC filter placement, Coomb's positive hemolytic anemia, possible CHF who was transferred to [**Hospital1 18**] for respiratory failure. Per report, Ms. [**Known lastname 7111**] developed SOB at [**Hospital **] rehab and was taken to [**Hospital3 417**] Hospital. At the OSH, she was intubated for worsening respiratory distress. She was treated with Lasix, nitro paste, solumedrol. ?Abx written on transfer which include Vancomycin 1gm daily, Cipro 500mg daily and Primaxin (imipenim and cilastatin) 250mg q6h. In the ED: Temp 98.8, HR 84, BP 123/56, RR 14, 100% on mechanical Ventilation. Patient became hypotensive with initiation of Fentanyl Versed with SBP 70s. Per report, she was given 2L IVF boluses with minimal response. PICC was placed and patient was started on Levophed with good response. She was sent for CTA chest which was negative for PE but was concerning for bilateral PNA and possible RLL cavitation. Pt was then started on Vanco/Levo/Ceftaz. She was transferred to MICU for further care. On transfer, patient was intubated and sedated. Unable to obtain history. Past Medical History: CAD s/p MI HTN Hyperlipidemia PVD DVT PE s/p IVC filter placement Coomb's positive Hemolytic Anemia HIT? CHF? Social History: Occupation: Retired factory worker Drugs: Tobacco: Alcohol: Other: Widowed, has 2 sons Family History: Father died of MI at 55. Mohter died at 46 with CAD. Physical Exam: Tmax: 36.8 ??????C (98.2 ??????F) Tcurrent: 36.8 ??????C (98.2 ??????F) HR: 94 (88 - 97) bpm BP: 119/72(72) {76/15(70) - 141/72(80)} mmHg RR: 23 (16 - 24) insp/min SpO2: 95% Heart rhythm: SR (Sinus Rhythm) General Appearance: No(t) Well nourished, Thin, Intubated, sedated Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal tube Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t) Rub Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Absent), (Left DP pulse: Absent) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Rhonchorous: Bilateral anterior lung fields) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t) Clubbing Musculoskeletal: Muscle wasting Skin: Warm, Stage II decubitus ulcer on sacrum Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated, Tone: Not assessed Pertinent Results: Admission labs, [**2185-7-13**]: WBC-6.7 RBC-3.34* Hgb-10.2* Hct-29.8* MCV-89 MCH-30.5 MCHC-34.1 RDW-17.3* Plt Ct-103*# Neuts-76* Bands-16* Lymphs-4* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-0 PT-13.1 PTT-22.7 INR(PT)-1.1 Fibrino-550* Ret Aut-2.2 Glucose-270* UreaN-37* Creat-0.4 Na-138 K-2.7* Cl-96 HCO3-33* AnGap-12 ALT-32 AST-24 LD(LDH)-556* AlkPhos-147* Amylase-47 TotBili-1.0 proBNP-[**Numeric Identifier 92706**]* cTropnT-0.06* Calcium-6.7* Phos-3.5 Mg-2.5 VitB12-GREATER TH Hapto-324* Type-ART pO2-89 pCO2-47* pH-7.48* calTCO2-36* Base XS-9 Lactate-2.4* . Labs, [**2185-7-19**]: WBC-2.7* RBC-3.95* Hgb-11.3* Hct-33.8* MCV-86 MCH-28.6 MCHC-33.4 RDW-19.1* Plt Ct-35* Neuts-85* Bands-1 Lymphs-8* Monos-2 Eos-0 Baso-0 Atyps-1* Metas-3* Myelos-0 NRBC-1* PT-14.6* PTT-32.7 INR(PT)-1.3* Fibrino-648*# Glucose-156* UreaN-60* Creat-0.9 Na-141 K-4.1 Cl-109* HCO3-18* AnGap-18 Calcium-7.7* Phos-5.1* Mg-2.3 Type-ART Temp-36.4 pO2-66* pCO2-37 pH-7.28* calTCO2-18* Base XS--8 Lactate-3.2* . Portable TTE (Complete) Done [**2185-7-14**]: The left atrium is normal in size. The patient is mechanically ventilated. The IVC is small, consistent with an RA pressure of <10mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed (LVEF= 50 %). The estimated cardiac index is normal(>=2.5L/min/m2). Diastolic function could not be assessed. 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 a small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality. The left ventricle appears to be small, mildly hypertrophied, and has mildly depressed overall systolic function. Diastolic function is unable to be assessed, but mostly likely diastolic dysfunction is present. . CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2185-7-13**] 3:10 AM: CTA CHEST: There is no evidence of pulmonary embolus. Heart size is mildly enlarged with moderate coronary artery atherosclerosis, most severe in the left anterior descending artery. The endotracheal tube terminates at the level of the carina. There is extensive bilateral consolidation and bronchoalveolar opacity with air bronchograms that mostly spares the periphery, with left lower lobe collpase noted. A 3 cm well circumscribed focus containing air (3:60) in the right upper lobe likley represents a bullae. Although this exam was not optimized for subdiaphragmatic diagnosis, diffuse ascites is noted. IMPRESSION: 1. No PE. 2. Diffuse bilateral airspace opacity likely represents infection, although CHF is a possiblity. 3. Endotracheal tube terminates at the level of the carina and can be withdrawn several centemeters. . UNILAT UP EXT VEINS US RIGHT PORT Study Date of [**2185-7-16**] 4:53 PM: FINDINGS: Grayscale and color Doppler images of right and left subclavian, axillary, brachial, basilic and cephalic veins and right internal jugular vein were obtained. The images of the left internal jugular vein were not obtained due to patient positioning and overlying dressing. There is an occlusive thrombus in the right axillary vein, which does not compress and does not demonstrate color flow. The remainder of the vessels are patent, and demonstrate normal flow and compressibility. There may be a collateral vessel adjacent to the thrombosed right axillary vein. IMPRESSION: Occlusive right axillary vein thrombus, with reconstitution of flow in the subclavian. Left internal jugular vein not imaged. . Cultures: [**2185-7-13**] 12:08 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [**2185-7-13**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2185-7-16**]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S MEROPENEM------------- 1 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S . BRONCHIAL WASHINGS Procedure Date of [**2185-7-14**]: Bronchial Lavage (Left): NEGATIVE FOR MALIGNANT CELLS. Fungal forms morphologically consistent with Aspergillus seen. Rare cells with viral inclusions suspicious for CMV is seen. Note: Dr. [**Last Name (STitle) 92707**] [**Name (STitle) **] reviewed the case and agrees. Special stains include GMS and immunostain for CMV will be performed on cytospin slides and the results be reported in an addendum. Brief Hospital Course: This is an 84 yof with hx of CAD s/p MI, HTN, Hyperlipdemia, PVD, PE s/p IVC filter placement, Coomb's positive hemolytic anemia, possible CHF who was transferred to [**Hospital1 18**] for respiratory failure. # Respiratory Failure: Patient presented to [**Hospital1 18**] intubated in respiratory failure presumed [**1-1**] CHF, however on presentation here CTA chest shows bilateral consolidations concerning for PNA. - PNA: Patient started on empiric antibiotics in the ED. Of note, BNP elevated to [**Numeric Identifier 4731**]. Patient was alternately on Vanco, zosyn, levofloxacin and ceftazadime. Sputum cultures came back positive for pseudomonas sensitive to meropenem and antibiotics were changed to meropenem on [**2185-7-18**]. BAL was performed and cytology showed CMV and aspergillus for which she was started on voriconozole. - Patient was cont Assist Control ventilation with ARDS protocol. Was alternately tachycardic and hypotensive on the vent and on [**2185-7-18**] did develop a PTX. CT surgery placed a chest tube and the lung re-inflated. BPs came up and HR went down slightly although she continued to be tachycardic with rates in the 130s. - On [**2185-7-19**] her respiratory status continued to deteriorate. While her lungs remained inflated and the PTX did no recur, she developed severe subcutaneous emphysema, falling HCT, WBC, and PLT, and increasing pressure support needs. A family meeting was held and her family decided to disconnect her from the ventilator. She died within minutes. . # Hypotension: Likely [**1-1**] sepsis and intravascular hypovolemia in setting of albumin of 1.0. A-line was placed for more accurate BPs. Patient was bolused with IVF as needed and placed on levophed and several attempts were made to wean this off but patient has continued to require pressors. # CAD s/p MI: Hx of MI. ASA 81mg NG tube. Held statin, BB, ACEi # CHF: Patient with history of CHF. TTE showed EF 50%. Held Lasix, Aldactone, ACEi, BB in setting of hypotension. # DM: on metformin at home. Held metformin while in ICU. QID fingersticks. Insulin gtt for glucose control # PE: ?history of IVC filter placement. Pt did not tolerate pneumoboots (got ecchymoses bilaterally on lower extremities), no Heparin given ?HIT and coagulopathy and thrombocytopenia. # Coomb??????s + Hemolytic Anemia: Followed by Hematology at [**Hospital1 **], on Solumedrol 60mg IV daily. continued Solumedrol daily. Patient had no coombs positivity on testing here and steroids were weaned off. # HTN: hold home BB, ACEi, Lasix, Aldactone, Diltiazem #. Pan-cytopenia: Unclear etiology but may be related to MDS. Patient has been followed by heme-onc both here and at the OSH. BM biopsy deferred in setting of an acutely ill patient with poor hemodynamics. Patient's counts did come up eventually. Medications on Admission: Folic acid 1mg daily Lisinopril 40mg daily Lopressor 50mg PO TID Sodium potassium phosphate 250mg packet [**Hospital1 **] Cyanocobalamin 1000mcg [**12-1**] tab daily mag oxide 400mg PO BID Methylprednisolone 60mg IV daily diltiazem 60mg q6h Triple Mix mouthwash Lansoprazole solutab 30mg gtube daily Lasix 40mg IV daily Aldactone 25mg gtube daily Vanco 1gm IV Cipro 500mg Primaxin 250mg IV q6h Guafenesin Accuzyme 34mc topical [**Hospital1 **] Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Pneumonia positive for Pseudomonas and Asparagillus, pancytopenia, sepsis, pneumothorax, subcutaneous emphysema. Discharge Condition: Deceased Discharge Instructions: none Followup Instructions: none Completed by:[**2185-7-19**]

[ "707.03", "117.3", "512.1", "038.9", "518.81", "078.5", "V58.67", "484.6", "484.1", "276.52", "412", "428.0", "284.1", "998.81", "995.92", "401.9", "250.00", "482.1", "414.01" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "34.04", "33.24" ]

icd9pcs

[ [ [] ] ]

11612, 11621

8246, 11072

295, 330

11777, 11787

2971, 8223

11840, 11875

1799, 1855

11583, 11589

11642, 11756

11098, 11560

11811, 11817

1870, 2952

186, 257

358, 1532

1554, 1674

1690, 1783

29,083

186,399

33585

Discharge summary

report

Admission Date: [**2143-2-13**] Discharge Date: [**2143-2-21**] Date of Birth: [**2062-3-6**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: 1. ERCP with sphincterotomy, stent placement 2. Laproscopic cholecystectomy History of Present Illness: 80yo female s/p ERCP @ [**Hospital3 **] which was unsuccessful for presumed choledocholithiasis found on MRCP last Tuesday after RUQ u/s was done prior to that for RUQ pain was equivocal. Pt has had intermittent fevers, but was not given abx. Also had rigors at that time but all resolved. Denies postprandial pain. Notes had "attacks" x 3 beginning early [**Month (only) 404**]. Tolerating POs, but c/o +N/V yesterday and today. Past Medical History: MedHx: HTN, GERD, hyperlipidemia, goiter, hiatal hernia, diverticulitis SurgHx: Total thyroidectomy, TAH, appendectomy Social History: Denies tobacco/drug use. Infrequent EtOH. Family History: Noncontributory Physical Exam: VS 101.6 86 149/69 18 96% on 2L NC NAD, AAOx3, uncomfortable PERRLA, EOMI RRR Abd soft, distended/tympanic, TTP RUQ. +[**Doctor Last Name 515**] sign. No rebound/guarding Ext w/o C/C/E Pertinent Results: [**2143-2-13**] 06:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-NEG . [**2143-2-13**] 06:10PM BLOOD WBC-19.7* RBC-4.16* Hgb-11.8* Hct-36.4 MCV-88 MCH-28.3 MCHC-32.3 RDW-13.1 Plt Ct-331 [**2143-2-14**] 01:26AM BLOOD WBC-15.4* RBC-3.32* Hgb-9.4* Hct-27.6* MCV-83 MCH-28.4 MCHC-34.2 RDW-13.5 Plt Ct-261 [**2143-2-15**] 12:47AM BLOOD WBC-17.6* RBC-3.32* Hgb-9.3* Hct-28.8* MCV-87 MCH-27.9 MCHC-32.2 RDW-13.2 Plt Ct-272 . [**2143-2-13**] 06:10PM BLOOD Glucose-124* UreaN-20 Creat-1.2* Na-141 K-4.1 Cl-106 HCO3-25 AnGap-14 [**2143-2-15**] 12:47AM BLOOD Glucose-133* UreaN-16 Creat-1.3* Na-140 K-4.1 Cl-109* HCO3-22 AnGap-13 . [**2143-2-13**] 06:10PM BLOOD ALT-157* AST-181* LD(LDH)-258* AlkPhos-358* Amylase-[**2076**]* TotBili-2.8* DirBili-2.3* IndBili-0.5 [**2143-2-14**] 01:26AM BLOOD ALT-113* AST-102* AlkPhos-266* Amylase-1110* TotBili-1.2 DirBili-0.7* IndBili-0.5 [**2143-2-15**] 12:47AM BLOOD ALT-75* AST-40 AlkPhos-228* Amylase-264* TotBili-0.5 . [**2-16**] MRCP: INDICATION: Failed MRCP. Evaluate gallbladder and common bile duct. COMPARISON: Comparison was made with the previous CT from [**2143-2-13**]. TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5 Tesla magnet, including dynamic high-resolution 3D imaging, obtained prior to, during, and after the uneventful intravenous administration of 0.1 mmol/kg of gadolinium-DTPA. 2D and 3D reformations and subtraction images were generated on an independent workstation. MRI ABDOMEN FINDINGS: There is a large hiatal hernia. The liver is visualized and is of normal signal intensity. Note is made of multiple lesions of high signal intensity scattered throughout the liver on the T2- weighted imaging that do not enhance post-administration of contrast and are consistent with cysts. No focal enhancing lesions within the liver. The spleen is visualized and is normal. The adrenals are normal. Some cysts are seen in relation to the right kidney that are simple in nature. A septated cyst in seen in the lower pole of the left kidney that is septated. This cyst measures 3.1 cm x 3.3 cm (series 8, image 30). It does not demonstrate enhancement post administration of contrast. The pancreas is poorly visualized as a non-breathhold imaging technique was employed. The common bile duct is enlarged at 12 mm. Note is made of multiple calculi within the common bile duct. Two small calculi are seen in the mid common bile duct (series 8, image 20) and three further calculi are seen in the distal CBD (series 8, image 21). The distalmost calculus is seen at the distal CBD, and may be causing the obstruction. No evidence of any pancreatic ductal dilatation. The bowel where visualized is normal. Degenerative changes noted in the lumbar spine with dextroconvex scoliosis. No evidence of any free fluid. 2D and 3D reformations provided multiple perspectives for the dynamic series. Note is made of bilateral pleural effusions and associated atelectasis. IMPRESSION: 1. Choledocholithiasis and apparent distal CBD obstruction with resultant intrahepatic and extra- hepatic bile duct dilatation. 2. Renal cysts with septated left interpolar cyst, but no nodularity or enhancement noted. 3. Degenerative change in the spine and some scattered hemangiomata. 4. Incompletely evaluated pancreas due to non-breathhold technique. Brief Hospital Course: This is a 80yo female who was transferred from [**Hospital3 **] with choledocholithiasis and probable cholangitis s/p failed ERCP with resultant mild pancreatitis. Pt was initially admitted to the SICU and was transferred to the floor on HD#3 as her clinical status improved. . *) Cholangitis: Pt was started on zosyn IV. She was seen by GI, who recommended holding off on ERCP in light of her clinical improvement during the short time since her transfer. She had an MRCP on HD#3 which showed 4 stones in the common bile duct. She underwent ERCP with successful removal of the stones, as well as sphincterotomy and stent placement on HD#5. As her labs and exam continued to improve, she also underwent overall uncomplicated laproscopic cholecystectomy on HD#6. Please see full operative note for details. . *) Postoperative course: Postoperatively, she required re-intubation secondary to decreased respiratory drive. She remained intubated for approximately 6 hours postop, during which time she received lasix for pulmonary edema. Her EKG was unchanged and 3 sets of cardiac enzymes for negative. She was able to be successfully extubated and postoperative course was otherwise uncomplicated. Her diet was slowly advanced postoperatively and she tolerated a regular diet prior to discharge. Pain was well controlled with an oral regimen. . *) Mild pancreatitis: Pt was kept NPO until HD#3, when she began to tolerate liquids and her symptoms improved. . Pt was discharged home on HD#9/POD#3 in stable condition to follow up with Dr. [**Last Name (STitle) **]. Medications on Admission: Synthroid, atenolol, Nexium, celebrex, glucosamine Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 6. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) packet PO once a day. Disp:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Cholangitis, mild post-ERCP pancreatitis Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily * No heavy lifting (>[**10-16**] lbs) for 6 weeks. Followup Instructions: Please call Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 2799**]) to schedule an appointment to have your stent removed, unless you are able to have it removed at [**Hospital3 **]. You can call Dr.[**Name (NI) 77830**] office to schedule a follow up appointment.

[ "530.81", "574.71", "553.3", "401.9", "576.1", "593.2", "285.9", "577.0", "244.0", "518.5", "272.4" ]

icd9cm

[ [ [] ] ]

[ "51.23", "51.87", "51.88", "96.04", "96.71", "51.85" ]

icd9pcs

[ [ [] ] ]

7019, 7025

4721, 6285

327, 405

7110, 7119

1327, 4698

8576, 8871

1081, 1098

6386, 6996

7046, 7089

6311, 6363

7143, 8553

1113, 1308

273, 289

433, 864

886, 1006

1022, 1065

66,110

174,356

40805

Discharge summary

report

Admission Date: [**2193-8-16**] Discharge Date: [**2193-8-20**] Date of Birth: [**2127-12-1**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Abnormal stress test, shortness of breath Major Surgical or Invasive Procedure: [**2193-8-16**] Aortic valve replacement with a [**Street Address(2) 17009**]. [**Hospital 923**] Medical Biocor Epic tissue valve. History of Present Illness: 65 year old male with a possible history of Rhuematic Fever as a child. He has known aortic stenosis and was recently cathed and had LAD stent placed in [**12/2192**] in preparation for shoulder surgery but surgery was deferred again. He was sent for a surveillance stress test where he reports he developed upper back pain associated with shortness of breath. This stress echo was abnormal. He was referred for repeat right and left heart catheterization. He was found to have critical aortic stenosis and is now being referred to cardiac surgery for an aortic valve replacement. Past Medical History: Aortic stenosis Coronary artery disease s/p LAD BMS x 1 and RCA stent BMS x 2, ISR LAD [**12-17**] treated with 2 Promus stents Dysplipidemia Heart Murmur since age 9 Syncope [**2181**] Hypertension Hypothyroidism MVA in [**2161**] with multiple fractures in chest Full thickness tear in right rotator cuff Kidney Stones Severe Anxiety/Depression Social History: Race:Caucasian Last Dental Exam:upper plate with lower native teeth, has no seen a dentist in [**2-8**] years, will make an appointment to see Dentist and have clearance faxed to office Lives with:Wife Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 89156**] Occupation:works for state police as clerk - but has not returned to work waiting shoulder surgery Cigarettes: Smoked no [] yes [x] Hx:quit [**2157**], smoked [**1-7**] ppd for 5-6 years Other Tobacco use:denies ETOH: prior heavy alcohol use in his earlier years, Occasionally has glass of scotch or glass of wine Illicit drug use:denies Family History: Premature coronary artery disease- Mother with CABG in her 50's and redo CABG at 64, Father with severe hypertension and died in his 80's, brother just had CABG at age 66. [**Name (NI) **] brother has had stents placed. Physical Exam: Pulse: 75 Resp: 16 O2 sat: 98/RA B/P Right: 141/87 Left: 149/86 Height: 6'3" Weight: 233 lbs General: No acute distress 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 [x] grade [**3-12**] holosystolic Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none 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 and Left: Transmitted murmur Brief Hospital Course: Mr. [**Known lastname 89157**] was a same day admit and on [**8-16**] he was brought to the operating room where he underwent an aortic valve replacement. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta-blockers and diuretics and gently diuresed towards his pre-op weight. Post-op day two his chest tubes were removed and he was transferred to the step-down unit for further care. Epicardial pacing wires were removed on post-op day three.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 in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Acetaminophen 500 mg PO Q6H:PRN pain 2. Quinapril 20 mg PO BID 3. Fish Oil (Omega 3) 1000 mg PO BID 4. ALPRAZolam 0.5 mg PO TID:PRN anxiety 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Sodium Chloride Nasal [**1-7**] SPRY NU DAILY:PRN dry 7. Atorvastatin 20 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Nitroglycerin SL 0.4 mg SL PRN chest pain 10. Clopidogrel 75 mg PO DAILY plavix is changed during the post-op period you will be changed back to prasugrel by your surgeon in the next couple of months. 11. Omeprazole 20 mg PO DAILY 12. Aspirin 325 mg PO DAILY 13. Loratadine *NF* 10 mg Oral daily 14. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. ALPRAZolam 0.25-0.5 mg PO TID:PRN anxiety 3. Aspirin EC 81 mg PO DAILY if extubated 4. Atorvastatin 20 mg PO DAILY RX *atorvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Clopidogrel 75 mg PO DAILY plavix is changed during the post-op period you will be changed back to prasugrel by your surgeon at your post-op visit. RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Ferrous Sulfate 325 mg PO DAILY 9. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain RX *Dilaudid 2 mg 1 tablet(s) by mouth every four (3) hours Disp #*50 Tablet Refills:*0 10. Metoprolol Tartrate 25 mg PO BID hold for SBP<90, HR<55 RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 11. Potassium Chloride 20 mEq PO BID Duration: 7 Days RX *Klor-Con M10 10 mEq 10 mEq(s) by mouth twice a day Disp #*7 Tablet Refills:*0 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 13. Fish Oil (Omega 3) 1000 mg PO BID 14. Loratadine *NF* 10 mg Oral daily 15. Multivitamins 1 TAB PO DAILY 16. Sodium Chloride Nasal [**1-7**] SPRY NU DAILY:PRN dry 17. Furosemide 40 mg PO BID Duration: 7 Days RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 18. Docusate Sodium 100 mg PO BID Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Aortic stenosis s/p Aortic valve replacement Past medical history: Coronary artery disease s/p LAD BMS x 1 and RCA stent BMS x 2, ISR LAD [**12-17**] treated with 2 Promus stents Dysplipidemia Heart Murmur since age 9 Syncope [**2181**] Hypertension Hypothyroidism MVA in [**2161**] with multiple fractures in chest Full thickness tear in right rotator cuff Kidney Stones Severe Anxiety/Depression Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with dilaudid. Incisions: Sternal - healing well, no erythema or drainage Trace lower extremity 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: [**2193-8-27**] at 10:45AM in [**Hospital Ward Name **] buidling, [**Hospital Unit Name **] Surgeon: Dr. [**Last Name (STitle) **] on [**2193-10-2**] at 1PM Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2193-9-18**] 11:30AM Please call to schedule appointments with your Primary Care Dr. [**Known firstname **] [**Last Name (NamePattern1) **] in [**4-11**] 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:[**2193-8-20**]

[ "244.9", "401.9", "414.01", "272.4", "285.9", "V45.82", "311", "300.00", "424.1" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61" ]

icd9pcs

[ [ [] ] ]

6344, 6399

3069, 4065

352, 486

6840, 7027

7950, 8611

2111, 2332

4858, 6321

6420, 6465

4091, 4835

7051, 7927

2347, 3046

271, 314

514, 1096

6487, 6819

1482, 2095

11,335

177,530

2222

Discharge summary

report

Admission Date: [**2174-7-8**] Discharge Date: [**2174-7-11**] Date of Birth: [**2133-6-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2817**] Chief Complaint: DKA, hypotension Major Surgical or Invasive Procedure: cardiac catheterization [**2174-7-8**] History of Present Illness: Mrs. [**Known lastname 11818**] is a 41-year-old female with history of type 1 DM Type 1, coronary artery disease (CAD) s/p MI and cardiac catheterization with bare metal stent to her left anterior descending in [**2173-2-20**] who presented with acute onset of nausea and vomiting at 8 AM this AM. She reports that she was jogging at the time. In the [**Location (un) 620**], emergency department she was found to have an elevated blood sugar of 420 with an anion gap of 17. She had trace ketones in her urine. She was started on an insulin drip for diabetic ketoacidosis. She was given IV fluids and transferred to the [**Location (un) 620**] ICU. . At the [**Location (un) 620**] intensive care unit, she developed [**3-31**] substernal chest pain radiating to her arms associated with nausea and vomiting; her chest pain was similar to prior MI in [**2173-2-20**]. She denied palpitations but did endorse the sudden onset of dyspnea. She became diaphoretic; her systolic blood pressure decreased to the 80s. In the first set of cardiac enzymes, troponin was less than 0.01. Second set of cardiac enzymes: CK of 137, MB of 1.2, index 0.9, troponin < 0.01. She was given 2 sublingual nitroglycerine which caused a further decrease in her blood pressure without improvement of her chest pain which continued to be [**3-31**] and substernal. Fluids were started through two peripheral IV's (approx. 2.5 L). Her SBP decreased to the low 70's and she was then started on dopamine drip. . She was given morphine 0.5 mg for her chest pain. She was placed on supplemental oxygen, 2 liters nasal cannula. EKG did not reveal acute ST changes. She was transferred to [**Hospital1 771**] for cardiac catheterization on heparin and integralin drip given her ongoing chest pain. (Initial heparin bolus of 3600 units followed by 600 units per hour. Initial integrelin bolus of 180 followed by 10 ml/hr.) She also received 325 mg of aspirin PR but did not take Plavix as her blood pressure decreased when she sat up. She was given a dose of levofloxacin 500 mg IV. Blood cultures were not obtained prior to transfer. . On review of systems, she reported a recent diagnosis of hepatitis A in sister's child recently adopted from [**Country 4812**]. Pt. not previously tested for hepatitis but concerned recent nausea, vomiting could be related. She denied weight loss, fatigue, fever or chills, night sweats, visual changes, dry mouth, chest pain, hematemesis, abdominal pain, diarrhea, hematochezia, rashes, or weakness. . Past Medical History: - DM, type I: dx 10y ago, on insulin pump, followed at [**Last Name (un) **] - HTN: reports SPBs in high 130s, on quinapril - Major depressive disorder: on bupropion and Trileptal - Cervical disc herniation: C5-6, moderate spinal stenosis, stable - vitamin B12 deficiency: monthly injections Social History: married, 2 children, works at [**Company 2267**], exercises daily, denies tobacco and drugs; her husband is involved in her care. Family History: no heart disease or DM Physical Exam: VITAL SIGNS: Temperature 99.1, blood pressure 108/52, heart rate 100, respiratory rate 21. . GENERAL: She was alert and oriented x3. HEENT: Sclerae anicteric. Pupils are equal, round and reactive to light. Neck supple. No LAD. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm. Normal S1 and S2. No JVD. ABDOMEN: Soft, nontender, nondistended. NEUROLOGIC: Cranial nerves II through XII intact. Pertinent Results: AT [**Location (un) **], LABORATORY DATA: Sodium 133, K 4.2, chloride 96, bicarbonate 20, BUN 12, creatinine 0.9, glucose 384, anion gap is 17, white count 11.9, hematocrit 35, platelets 259, ALT 29, AST 18, albumin 3.9, calcium 8.7. Urinalysis: Glucose greater than 1000, ketones greater than 80, trace blood. Serum with small ketones. EKG with sinus rhythm at a rate of 114. She had T waves inversions in V1. At [**Location (un) 620**], Chest x-ray was unremarkable, no mediastinal widening. At [**Hospital1 18**]: [**2174-7-8**] 10:39PM GLUCOSE-250* UREA N-11 CREAT-0.8 SODIUM-139 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-17* ANION GAP-16 [**2174-7-8**] 10:39PM estGFR-Using this [**2174-7-8**] 10:39PM WBC-19.2*# RBC-3.06* HGB-10.4*# HCT-29.7* MCV-97 MCH-33.9* MCHC-35.0 RDW-15.3 [**2174-7-8**] 10:39PM WBC-19.2*# RBC-3.06* HGB-10.4*# HCT-29.7* MCV-97 MCH-33.9* MCHC-35.0 RDW-15.3 [**2174-7-8**] 10:39PM NEUTS-93.8* BANDS-0 LYMPHS-3.4* MONOS-2.7 EOS-0.1 BASOS-0.1 [**2174-7-8**] 10:39PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL [**2174-7-8**] 10:39PM PLT SMR-NORMAL PLT COUNT-280 [**2174-7-8**] 10:39PM PT-13.0 PTT-46.0* INR(PT)-1.1 [**2174-7-8**] 09:20PM O2 SAT-96 [**2174-7-8**]: [**Hospital1 18**] Cardiac catherization- mean PA pressure 20, RA 18, Wedge 25, MAP 77. By report decreased SVR. No flow limiting lesions were seen but mild restonsis of LAD was noted. Brief Hospital Course: 41-year-old female with type 1 diabetes, coronary artery disease, hypertension, and depression who presents with an acute episode of nausea and vomiting. . #. Diabetic Ketoacidosis/DM: h/o DM1 x 10 years, mild HTN, mild hyperlipidemia. Patient initially with FS glucose in 300-400 range at [**Location (un) 620**] ED, (BS >400 on presentation), with low bicarbonate, and anion gap, consistent with DKA. She was placed on a insulin drip in ED and then continued on insulin pump in ICU at [**Location (un) 620**], which was continued upon transfer. Pt was also supported with IV fluids. Her anion gap had closed by the time the patient was admitted to [**Hospital1 18**] MICU and the patient was started on an insulin drip for better glucose control. She was transitioned back to home insulin pump on [**8-3**] and given glargine 3 hours before transfer to pump. She was continued on glargine 10 units q AM [**First Name8 (NamePattern2) **] [**Last Name (un) **] consult recommendations and was instructed to continue this daily glargine regimen at home in adddition to her pump. She was instructed also to followup with [**Last Name (un) **]. DKA of unclear etiology. She was admitted last year ([**2-/2173**])to [**Hospital1 18**] with precipitant of DKA thought to be an actue MI. Ruled out at [**Hospital1 18**] for acute MI with negative cardiac catheterization. UA negative for infection but with >1000 glucose, >80 ketones, trace blood. Urine culture were negative. Blood culures showed no growth at discharge (but were drawn after one dose of antibiotics at OSH). However, leukocytosis (19.2) notable on repeat CBC here. No obvious precipitant to DKA- cardiac and infectious workup negative. Of note, hepatitis A assay was negative; pt was concerned she had had an exposure. Considering the presentation of acute nausea and vomiting, DKA may have been precipitated by a gastroenteritis which quickly resolved. . # Hypotension: Hypotension was thought to be secondary to dehydration on admission. Home dosages of beta-blocker and ACE inhibitor (for chronic hypertension) were held as the patient was hypotensive. She was also given NTG at [**Location (un) 620**] for chest pain which likely exacerbated the hypotension. She was volume repleted at [**Location (un) 620**]. A CTA for r/o PE showed pulmonary edema which was likely secondary to fluid overload; we did not replete her volume further. Upon discharge the patient was normotensive off her home antihypertensive regimen. She was instructed to follow up with her cardiologist regarding restarting the beta blocker and ACE inhibitor. . #. Chest pain: Given her negative cardiac enzymes there was concern for PE, dissection,or possible sepsis. BP was equal in both arms. CXR w/o mediastinal widening. A d-dimer VTE was postive at 1.55 (0-0.99 normal [**First Name8 (NamePattern2) **] [**Location (un) 620**] lab) but CTA showed no pulmonary embolism or other concerning findings. . #. CAD: h/o ST elevation myocardial infarction, s/p bare metal stent to mid-LAD [**2173-2-20**]. Repeat cath yesterday negative for new lesion, mild restenosis of LAD. Risk factors include suboptimally managed DM1 x 10 years, mild HTN, mild hyperlipidemia. No tobacco, no family Hx early MI. Cardiac enzymes negative X2 at [**Location (un) 620**]. Third set of cardiac enzymes at [**Hospital1 18**] was not concerning for acute MI. We continued ASA and atorvastatin as an inpatient. Her beta blocker was held secondary to hypertension. . # History of depression: clinically stable. Continued on outpatient trileptal. . # FEN: Maintained on a cardiac, diabetic diet. Electrolytes were repleted as needed. . # Prophylaxis: She was on heparin drip for possible PE until a PE was ruled out with CTA; otherwise, the patient was maintained on SC heparin for DVT prophylaxis. She was eating well so was not on a PPI. . # Assess: peripheral IVs. . # Communication: Patient and husband. . # Code status: FULL CODE. . . Medications on Admission: 1. Insulin pump regular 0.4 units per hour 2. Aspirin 325 mg daily 3. Quinapril 10 mg daily 4. Atenolol 25 mg daily 5. Lipitor 40 mg daily. 6. Oxcarbazepine 300 mg daily 7. Minocycline 50 mg every other day. 8. Vitamin B12 IM qmonth Discharge Medications: 1. Insulin Pump with Novolog 2. Aspirin 325 mg daily 3. Lipitor 40 mg daily. 4. Oxcarbazepine 300 mg daily 5. Minocycline 50 mg every other day. 6. Vitamin B12 IM qmonth 7. Glargine 10u daily Discharge Disposition: Home Discharge Diagnosis: 1. Chest Pain. 2. Diabetic ketoacidosis. 3. Hypotension. Discharge Condition: Stable Discharge Instructions: 1. Please return to the ER if you have symptoms of chest pain, nausea, vomiting, dizziness or any other concerning symptoms. 2. Please call your Endocrinologist at [**Last Name (un) **], Dr. [**Last Name (STitle) 11819**], within one week of discharge for followup. 3. We have changed your insulin pump dosage [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendation, please continue with the current dosing. We have also started you on basal insulin, Glargine 10u daily.

[ "V45.82", "401.9", "266.2", "250.13", "414.01", "412", "722.4", "296.30", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "00.66", "88.56", "99.20", "88.53", "37.23", "00.40" ]

icd9pcs

[ [ [] ] ]

9863, 9869

5381, 9361

331, 371

9970, 9978

3887, 5358

3402, 3426

9647, 9840

9890, 9949

9387, 9624

10002, 10493

3441, 3868

1512, 2922

275, 293

399, 1495

2944, 3238

3254, 3386

109

131,376

14862

Discharge summary

report

Admission Date: [**2142-7-7**] Discharge Date: [**2142-7-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**Last Name (NamePattern1) 293**] Chief Complaint: dyspnea, Hypertension Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24F h/o SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain. She was recently admitted [**Date range (1) 43607**] after presenting for hypertensive urgency and dyspnea for which she was started on nitroglycerin and labetalol drips, which were weaned off in the ICU. She was also received 2U PRBCs during HD. She was discahrged home without any changes to her medical regimen. . On the afternoon of [**7-4**] she notes increased dyspnea, she therefore went to HD on Wednesday, and again on Thursday [**7-5**]. After HD, her BP remained elevated, and she took an extra dose of labetalol 1000mg x 1. On [**7-6**] her VNA noted SBP 250s. She took extra doses of hydralazine, but otherwise felt well. She then woke up this morning with HA. She took all of her BP meds this morning, but remained with HA and SOB, thus prompting her presentation to the ED. . No fevers, productive cough, taking all meds, had chronic diarrhea that is unchanged, some n/v at baseline, no coffee ground emesis, has some abdominal pain unchanged from baseline Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Pertinent Results: 08:00a ALK,ALT,AST,CK,CPIS,LIP,BILI,TNT ADDED 12:29PM 141 103 29 82 AGap=13 3.4 28 6.5 ∆ CK: 59 MB: Notdone Trop-T: 0.18 ALT: 21 AP: 126 Tbili: 0.4 Alb: AST: 51 LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 56 PT: 15.0 PTT: 35.5 INR: 1.3 N:69.8 L:21.9 M:5.5 E:2.5 Bas:0.3 Hypochr: 1+ Anisocy: 2+ Macrocy: 1+ Microcy: 1+ Polychr: 1+ Brief Hospital Course: # Hypertensive Urgency - At the time of admission, the patient denied chest pain but continued to have mild headache. She also had resolving shortness of breath, likely secondary to hypertension. She stated that she did take her PO meds. She was started on a labetalol drip and continued on her home regimen of oral labetolol, nifedipine, hydralazine, and aliskerin. A sent of cardiac enzymes was sent and revealed a CPK of 59 and a troponin of 0.18. The patient also underwent dialysis in the ICU. After dialysis the labetalol drip was weaned off. Overnight, SBP's ranged 109 to 182 mmHg. The following day, her SBP's ranged 133 to 200. Ultimately, she was discharged home on her normal medication regimen. # Abdominal Pain - The patient also presented complaining of adbominal pain. She had recently been treated for SBO; however, at the time of admit, she was without nausea or vomiting. She had a soft abdomen, was passing flatus, and was having daily bowel movements. She did have hypoactive bowel sounds. She was continued of her outpatient pain regimen of PO dilaudid, fentanyl patch, and lidoacine patch. An ultrasound of her abd was also performed and showed ascites in all 4 quadrants with the largest in the left lower quadrant measuring 5.5cm. Considering her history of thrombosis, renal recommended getting an abdominal ultrasound with doppler flow studies. This ultrasound showed mild to moderate ascites, a 9mm hemangioma, and no evidence of thrombosis. After the results of this ultrasound were reviewed, the patient was discharged home with a plan to follow-up with liver regarding her ascites and whether it can be attributed to her recent SBO. # ESRD on HD - The patient gets hemodialysis on a Tu/Th/Sa schedule. On admit, the patient was continued on her home does of sevalemer. Renal was consulted, and the patient received dialysis on [**7-7**] in the ICU. # Anemia/Pancytopenia - The patient has a chronic anemia and baseline pancytopenia that are likely secondary to her CKD and SLE. On admit she was actually above baseline. She was continued on her home does of epogen. # H/o Gastric Ulcer - The patient was continued on her PPI [**Hospital1 **]. # SLE - The patient was continued on her home regimen of prednisone 4mg po daily. # H/o SVC Thrombosis - The patient has a goal INR of [**2-13**]. However, naticoagulation was stopped after a recent admission secondary to a supratherapeutic INR. On admit, her INR was sub-therapeutic. Therefore, her warfarin was restarted at 3 mg daily. # Seizure Disorder - The patient was continued on her home regimen of keppra 1000 mg PO 3 times a week (Tu/Th/Sa). # Depression - The patient was continued on her home dose of celexa. Medications on Admission: 1.Nifedipine 90 mg PO DAILY (Daily). 2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime). 3.Lidocaine 5 % PATCH Q24HR. 4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H 7.Prednisone 4 mg PO DAILY (Daily). 8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday). 9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday). 10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD 12.Labetalol 1000 mg Tablet Tablet PO TID 13.Hydralazine 100 mg Tablet PO Q8H 14.Warfarin 3 mg Tablet PO Once Daily at 4 PM. 15.Pantoprazole 40 mg PO Q12H (every 12 hours). 16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24HR (). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). Disp:*QS Tablet(s)* Refills:*2* 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QTUTHSA (TU,TH,SA). 17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for abdominal pain. Discharge Disposition: Home Discharge Diagnosis: Hypertensive Urgency Lupus Nephritis End stage renal disease on hemodialysis Ascites Discharge Condition: hemodynamically stable with blood pressures 130-140/70-80s. Discharge Instructions: You were evaluated and treated for you hypertension. You were started on IV medications and transitioned to your home regimen and received a session of hemodialysis. You also had an ultrasound to evaluate the fluid in your belly. There was no evidence of blood clot contributing to the build up of the fluid. Please continue to follow a low sodium diet at home and take all of your blood pressure medications in addition to going to dialysis. Followup Instructions: You have the following appointments scheduled: Please also keep your Tuesday/Thursday/Saturday Dialysis schedule Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-7-30**] 2:00 Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15

[ "285.21", "789.00", "364.3", "425.4", "345.90", "327.23", "287.5", "789.59", "710.0", "V12.54", "585.6", "285.29", "531.90", "582.81", "V58.61", "284.1", "V12.51", "338.29", "443.89", "403.01" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8799, 8805

3663, 6392

328, 342

8934, 8996

3277, 3640

9489, 9850

3228, 3258

7239, 8776

8826, 8913

6418, 7216

9020, 9466

259, 290

370, 1508

1530, 3079

3095, 3212

21,666

121,923

29125+57625

Discharge summary

report+addendum

Admission Date: [**2174-10-26**] Discharge Date: [**2174-11-7**] Date of Birth: [**2103-11-23**] Sex: M Service: SURGERY Allergies: Penicillins / Macrolide Antibiotics / Quinolones / Ursodiol / Tape Attending:[**First Name3 (LF) 668**] Chief Complaint: Pruritis and rash Cirrhosis secondary to ETOH Major Surgical or Invasive Procedure: Liver transplant [**2174-10-29**] History of Present Illness: 70M with ESLD, h/o UGIB s/p variceal banding, s/p TIPS, cholangitis, and recent admission [**8-16**] with candidemia and coag negative staph bacteremia comes in with persistent pruritus and rash worse over the last two days. He was previously evaluated in the ED on [**10-24**] for these complaints and treated symptomatically with benadryl and ranitidine with report of some symptomatic relief. Apparently the rash began ~4 days PTA. At this point it involves most of his body, although with lesser involvement of his lower extremities. The rash begins as small erythematous papules which eventually become more confluent most noticeably on his bilateral upper extremities. He reports the rash is quite painful - even to light touch and is quite itchy. He has not noticed any vesicles or pustules. He denies any mouth sores or other mucus membrane involvement. He denies any arthralgias, myalgias, adenopathy, fevers, chills, or sweats. He has been taking he fluconazole consistently. . In the ED, his triage vitals were T97.8, P 90 Bp 98/55, RR 16, O2 99% on room air. He was given Benadryl 50mg IV once. Dermatology was consulted and obtained a punch biopsy of the rash. Past Medical History: 1. ESLD with portal hypertension, formerly with refractory ascites requiring bimonthly paracentesis (now s/p TIPS, see below) 2. Upper GI bleed ([**2174**]) s/p variceal banding at [**Hospital1 2025**], second UGIB s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and TIPS on [**2174-1-14**] - EGD with varices in lower 3rd of esophagus, portal gastropathy 3. Candidemia [**8-16**] --no evidence of ocular involvement on exam, TTE clean --s/p IV fluconazole, to continue PO fluconazole ppx indefinitely (until transplant) 4. h/o alcohol abuse, quit with dx of liver disease 5. Biliary Colic s/p biliary stenting -- now removed 6. Cholangitis complicated elective ERCP 7. h/o hyponatremia as low as 119 8. Herniated discs between L3/L4 9. Psoriasis 10. Liver transplant [**2174-10-29**] Social History: Significant history of alcohol use, drinking from the age of 25 until recently, stopping approximately one year ago. He has no history of illicit drug use. He smoked half a pack of cigarettes per day for 20 years, but has been off them for 20 years. He never received a blood transfusion prior to [**2157**]. Family History: His father was an alcoholic. There is no known family history of liver disease. Physical Exam: T 98 P 83 BP 110/60 RR 18 O2 100% on room air General: Elderly man sitting up eating dinner in no acute distress HEENT: Sclera white, conjunctiva pale. No oral lesions Neck: No adenopathy CV: Regular rate S1 S2 II/VI HSM LLSB Pulm: Lungs clear bilaterally Abd: Soft, +BS, umbilical and ventral hernia present. Very light touch of the rash over his abdomen is painful. Extrem: Warm, no edema Derm: Jaundice. Small erythematous papular rash diffusely located bilaterally on trunk, arms, and lower extremities to mid-calf. Not in any clear dermatomal or sun-exposed distribution. Palms and soles are spared. Erythema is more confluent over his forearms with bruising. No vesicles/bullae. The rash is - inconsistently - very tender. On Discharge: Gen: no acute distress HEENT: anicteric sclera, mucus membranes moist Neck: no lymphadenopathy CV: RRR Pulm: clear bilaterally Abd: soft, nontender, nondistended, incisions clean and without erythema or drainage Ext: 2+ distal pulses, 2+ pitting edema up to the mid-shin level, echymoses on both arms Pertinent Results: On Admission: [**2174-10-26**] 02:00PM BLOOD WBC-6.1 RBC-2.92* Hgb-9.3* Hct-27.8* MCV-95 MCH-32.0 MCHC-33.5 RDW-15.1 Plt Ct-132* [**2174-10-27**] 06:05AM BLOOD PT-15.5* PTT-40.6* INR(PT)-1.4* [**2174-10-26**] 02:00PM BLOOD Glucose-100 UreaN-10 Creat-1.2 Na-130* K-4.1 Cl-99 HCO3-26 AnGap-9 [**2174-10-26**] 02:00PM BLOOD ALT-32 AST-89* CK(CPK)-130 AlkPhos-416* Amylase-74 TotBili-2.1* [**2174-10-26**] 02:00PM BLOOD Lipase-51 [**2174-10-27**] 06:05AM BLOOD Albumin-2.2* Calcium-8.0* Phos-3.9 Mg-2.0 POD #1 labs: [**2174-10-29**] 08:46AM BLOOD ALT-1532* AST-2306* AlkPhos-181* Amylase-37 TotBili-1.9* DirBili-1.0* IndBili-0.9 On Discharge: [**2174-11-7**] 04:10AM BLOOD WBC-7.1 RBC-3.10* Hgb-9.6* Hct-27.6* MCV-89 MCH-31.1 MCHC-35.0 RDW-19.4* Plt Ct-225# [**2174-11-7**] 04:10AM BLOOD Glucose-89 UreaN-24* Creat-1.2 Na-137 K-4.8 Cl-104 HCO3-26 AnGap-12 [**2174-11-7**] 04:10AM BLOOD ALT-148* AST-39 AlkPhos-115 TotBili-1.2 Brief Hospital Course: ASSESSEMENT/PLAN: 70 yo M with alcoholic cirrhosis admitted with erythematous, pruritic rash with associated hyperesthesia. Urine culture grew bactrim sensitive e. coli. Bactrim was started for a 7 day course. He was monitored for drug reactions. The rash was consistent with prior drug reactions in the past. This rash was worrisome for possible disseminated zoster, therefore he was started on IV acyclovir. Dermatology was consulted, biopsy revealed drug reation (unknown which drug), recommended treatment with Clobatesol cream and followup with dermatology. Provided benadryl, sarna lotion and eucerin cream prn for pruritus. IV acyclovir was discontinued after biopsy results. Alcoholic cirrhosis: Had no evidence of GIB or encephalopathy when initially admitted. Was continued on home regimen diuretics, lactulose & pantoprazole. Was on liver transplant list upon admission when a donor liver became available. He underwent liver transplant [**2174-10-29**]. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please see operative report for full details. Periop antibiotics were vanco and ceftaz. Two 19-[**Doctor Last Name 406**] drains were placed, 1 behind the right lobe of the liver and the 2nd behind the porta hepatis. Postop, he was transferred to the SICU intubated. U/S of the liver was limited exam demonstrating appropriate venous and arterial flow in a post transplant liver. There was a small right lower quadrant ascites and a small right pleural effusion noted. He self extubated or tongued out his ET tube. He was eventually transferred out of the SICU. LFTs continued to trend down. The [**Doctor Last Name 406**] drains were removed and sutured. Diet was advanced and tolerated. He was ambulatory with PT using a rolling walker. The walker was not needed at time of discharge. Vital signs remained stable. His weight was above his preop weight by 15.4kg. IV lasix and albumin were given with weight and edema decreasing. On the day of discharge, his weight was 71.3 Preop weight was 70.9. He had 2+pitting edema to mid tibias. Lasix 20mg [**Hospital1 **] was ordered for home for 5 days. Prograf was started on pod 2. This was adjusted based on levels. On the day of discharge, prograf level was 11.9. He remained on prograf 4mg [**Hospital1 **]. Cellcept 1 gram [**Hospital1 **] continued and solumedrol was tapered to 20mg starting on [**11-4**]. The incision was open to air, well approximated with staples and clean. VNA services were arranged for continuation of insulin/glucose management. Sliding scale insulin was required on a prn basis for mild hyperglycemia secondary to steroids. Medications on Admission: furosemide 20 mg daily spironolactone 50mg daily fluconazole 200mg PO BID lactulose protonix 40mg daily spectavite fluocinonide cream Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day. 2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO prn: q 4 hours. Disp:*30 Tablet(s)* Refills:*0* 3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): stop if loose stool or diarrhea. Disp:*60 Capsule(s)* Refills:*2* 9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection four times a day. Disp:*1 bottle* Refills:*1* 11. Syringes 1 box of low dose insulin syringes for sliding scale insulin qid prn refill: 1 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 13. Test Strips 1 box-One Touch Ultra refill: 1 14. Lancets 1 box refill: 1 Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Rash secondary to drug reaction ETOH cirrhosis Discharge Condition: good Discharge Instructions: Please call the Transplant office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, inability to take any of your medications, jaundice, abdominal pain, incision redness/bleeding/drainage or any concerns Labs every Monday and Thursday [**Month (only) 116**] shower no driving while taking pain medication Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2174-11-17**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2174-11-17**] 1:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2174-11-24**] 1:40 Name: [**Known lastname 3205**],[**Known firstname **] D. Unit No: [**Numeric Identifier 11899**] Admission Date: [**2174-10-26**] Discharge Date: [**2174-11-7**] Date of Birth: [**2103-11-23**] Sex: M Service: MEDICINE Allergies: Penicillins / Macrolide Antibiotics / Quinolones / Ursodiol / Tape Attending:[**First Name3 (LF) 4097**] Addendum: Mr. [**Known lastname **] experienced a short duration of acute renal failure during his hospital stay. His serum creatinine peaked at 2.1 on [**2174-10-31**]. By [**2174-11-3**] his serum creatinine was back to his baseline of 1.1. Discharge Disposition: Home With Service Facility: [**Company 720**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4098**] MD [**MD Number(2) 4099**] Completed by:[**2174-11-25**]

[ "E931.9", "511.9", "789.59", "117.9", "571.2", "572.8", "693.0", "599.0", "584.9", "572.3", "338.19" ]

icd9cm

[ [ [] ] ]

[ "50.59", "38.93", "86.11", "50.4", "00.93" ]

icd9pcs

[ [ [] ] ]

10589, 10795

4890, 7549

373, 409

9134, 9141

3941, 3941

9508, 10566

2780, 2861

7733, 8970

9064, 9113

7575, 7710

9165, 9485

2876, 3606

4582, 4867

288, 335

437, 1612

3955, 4568

1634, 2437

2453, 2764

23,483

176,464

50016

Discharge summary

report

Admission Date: [**2166-4-29**] Discharge Date: [**2166-5-8**] Date of Birth: [**2106-9-14**] Sex: F Service: MEDICINE Allergies: Biaxin / Erythromycin Base / Amiodarone Attending:[**First Name3 (LF) 3326**] Chief Complaint: lethargy Major Surgical or Invasive Procedure: s/p R heart cardiac catheterization for trial of dobutamine. s/p PICC line placement. History of Present Illness: 59 y/o female with PMH significant for severe ischemic cardiomyopathy with a LVEF of 15%, CAD, and pulmonary hypertension admitted through the ED with lethargy and severe laboratory abnormalities. Pt is really unable to give any history. She simply reports that her girlfriend made her come in. She reports that she has been feeling fine and denies any pain. [**Location (un) **] available notes, the pt's neightbor had called Dr. [**First Name (STitle) 2031**] and reported that the pt had been more lethargic over the last day or so. The neighbor called EMS to bring the pt to the [**Hospital1 18**] ED for further evaluation. . In the ED, the pt's initial VS were 96.5 127/50 80 18 100% 0.5L. Her finger stick was 42 and the pt received 1 mg IM glucagon. The pt was found to have multiple laboratory abnormalities including: bicarb of 7, creatinine of 1.9 (baseline 0.7 to 1.1), lactate of 15.7, and a INR of 13.8. She received levaquin, vancomycin, vitamin K 10 mg PO x1, and vitamin K 5 mg IV x1. A cardiology consult was obtained. . Past Medical History: 1. Advanced CHF with a LVEF of 15 to 20% secondary to ischemic cardiomyopathy 2. Severe 4+ MR [**First Name (Titles) **] [**Last Name (Titles) 113**] on [**2166-2-17**] 3. Mild to moderate [**12-29**]+ TR by [**Month/Day (2) 113**] on [**2166-2-17**] 4. [**Hospital1 **]-V/ICD in [**6-/2164**] 5. CAD s/p MI in [**2139**] and CABG in [**2141**] 6. PFTs from [**2166-4-15**] with a mild restrictive ventilatory defect 7. Hypothyroidism secondary to amiodarone toxicity 8. History of paroxysmal atrial fibrillation- Pt is anticoagulated on coumadin and her INR from [**4-28**] was 3.8. 9. S/P cholecystectomy [**70**]. S/P TIA x3 with slurred speech- This was transient and is currently resolved. . Social History: Smoked for 7 years, currently, not smoking. No alcohol use. The patient lives alone and is retired. Family History: Mother - non-alcoholic liver cirrhosis. Father - DM. Father deceased of MI at 50. Sister with SLE. Physical Exam: 97.8 116/74 80 18 98 RA Gen- Alert and oriented x2 ([**Hospital1 18**] and self). Resting comfortably on strecher. Very lethargic and not really able to given a history/answer extensive questions. HEENT- Cardiac- RRR. III/VI SEM loudest at the left lower sternal border. Pulm- CTAB. No wheezes, rales, or rhonchi. Abdomen- Soft. NT. ND. Positive bowel sounds. Extremities- Trace bilateral pedal edema. 1+ DP pulses bilaterally. . Pertinent Results: CXR- Stable appearance of heart and lungs. . Head CT (WET READ)- No intracranial hemorrhage or mass effect. . Liver US- No change from previous studies. No focal abnormalities of the liver. CBD same size at approximately 10 mm. . ECG- Paced at 80 beats per minute. [**2166-4-29**] 05:57PM WBC-10.0 RBC-3.85* HGB-12.1 HCT-41.1# MCV-107*# MCH-31.6 MCHC-29.6* RDW-17.7* [**2166-4-29**] 05:57PM PLT COUNT-199# [**2166-4-29**] 05:57PM NEUTS-84.8* LYMPHS-11.6* MONOS-3.4 EOS-0.2 BASOS-0 [**2166-4-29**] 05:57PM HYPOCHROM-3+ ANISOCYT-1+ MACROCYT-3+ [**2166-4-29**] 05:57PM GLUCOSE-162* UREA N-31* CREAT-1.9*# SODIUM-133 POTASSIUM-5.9* CHLORIDE-94* TOTAL CO2-7* ANION GAP-38* [**2166-4-29**] 05:57PM ALT(SGPT)-41* AST(SGOT)-119* LD(LDH)-604* CK(CPK)-77 ALK PHOS-189* AMYLASE-64 TOT BILI-2.0* [**2166-4-29**] 06:35PM LACTATE-15.7* [**2166-4-29**] 05:57PM LIPASE-22 [**2166-4-29**] 05:57PM ALBUMIN-3.8 [**2166-4-29**] 05:57PM TSH-6.4* [**2166-4-29**] 06:35PM LACTATE-15.7* [**2166-4-29**] 05:57PM DIGOXIN-2.8* [**2166-4-29**] 05:57PM ASA-NEG ETHANOL-NEG ACETMNPHN-6.8 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2166-4-29**] 05:57PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG cocaine-NEG amphetmn-POS mthdone-NEG [**2166-4-29**] 07:31PM TYPE-ART PO2-152* PCO2-20* PH-7.22* TOTAL CO2-9* BASE XS--17 [**2166-4-29**] 07:31PM GLUCOSE-142* LACTATE-15.1* K+-4.9 [**2166-4-29**] 07:31PM freeCa-1.16 . . . . . Cardiology Report C.CATH Study Date of [**2166-5-1**] *** Not Signed Out *** BRIEF HISTORY: The patient is a 59 year old woman with an ischemic cardiomyopathy (EF 15%) and severe mitral regurgitation s/p BiV-ICD placement with PAF, severe pulmonary hypertension, and hypothyroidism who is referred to the catheterization lab for evaluation of hemodynamic measurements with infusion of dopamine and dobutamine. INDICATIONS FOR CATHETERIZATION: Class IV heart failure, pre-cardiac transplant evaluation. PROCEDURE: Right Heart Catheterization: was performed by percutaneous entry of the right femoral vein, using a 7 French pulmonary wedge pressure catheter, advanced to the PCW position through a 8 French introducing sheath. Cardiac output was measured by the Fick method. A 5 French arterial sheath was placed for measurement of arterial pressure and for arterial blood draws. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.87 m2 HEMOGLOBIN: 10.4 gms % ENTRY DOPAMINE 5 DOBUTAMINE 10 **PRESSURES RIGHT ATRIUM {a/v/m} -/13/11 -/19/18 RIGHT VENTRICLE {s/ed} 73/19 65/14 PULMONARY ARTERY {s/d/m} 73/32/47 80/40/55 65/24/38 PULMONARY WEDGE {a/v/m} -/32/32 -/52/40 -/19/18 AORTA {s/d/m} 124/70/82 131/74/93 120/52/73 **CARDIAC OUTPUT HEART RATE {beats/min} 80 88 80 RHYTHM AF AF AF O2 CONS. IND {ml/min/m2} 125 125 125 A-V O2 DIFFERENCE {ml/ltr} 57 52 31 CARD. OP/IND FICK {l/mn/m2} 4.1/2.2 4.5/2.4 7.5/4.0 **RESISTANCES SYSTEMIC VASC. RESISTANCE 1385 587 PULMONARY VASC. RESISTANCE 293 267 213 **% SATURATION DATA (NL) PA MAIN .56, .57, .52, .75, .75 AO .96, .92, .89, .97 **ARTERIAL BLOOD GAS INSPIRED O2 CONCENTR'N .24 OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 1 hour 24 minutes. Arterial time = 1 hour 24 minutes. Fluoro time = 7.4 minutes. Contrast: Premedications: ASA 81 mg P.O. Fentanyl 25 mcg IV Midazolam 0.5 mg IV Anesthesia: 1% Lidocaine subq. Anticoagulation: Other medication: Dobutamine 1-10 mcg/kg/min IV Dopamine 2.5-5 mcg/kg/min IV Cardiac Cath Supplies Used: 300 CM MALLINCRODT, OPTIRAY 100CC COMMENTS: Resting hemodynamics upon entry revealed moderately elevated right and severely elevated left sided filling pressures, with a mean RA of 11, RVEDP of 19, mean PCWP of 32 mm Hg. Severe pulmonary artery systolic hypertension was present, at 73/32 (mean 47 mm Hg). Central systemic arterial pressures were normal (124/70 mean 82 mm Hg). The cardiac index as calculated from the Fick equation was depressed, at 2.2 L/min/m2. The SVR was elevated at 1385 dynes/sec/cm5. With infusion of dopamine (5 mcg/kg/min), there was no significant change in the pulmonary artery pressure (80/40/55 mm Hg). The cardiac index was minimally higher (2.4 L/min/m2). The systemic arterial pressure was likewise unchanged (131/74/93 mm Hg). After stopping dopamine infusion, initiating dobutamine, and titrating the dosage upwards to 10 mcg/kg/min, the patient's pulmonary arterial pressures decreased slightly to 65/24 with a mean of 38 mm Hg. Her mean PCWP decreased significantly to 18 mm Hg (from baseline of 32 mm Hg), and her systemic arterial pressure remained essentially unchanged (120/52/73 mm Hg). Her cardiac index also significantly improved, from a baseline of 2.2 to 4.0 L/min/m2 with dobutamine infusion. Her SVR also significantly decreased from baseline of 1385 to 587 dynes/s/cm2 with dobutamine infusion. The PA saturation at baseline was 56%, which increased to 75% after dobutamine infusion. FINAL DIAGNOSIS: 1. Severe systolic and diastolic ventricular dysfunction. 2. Severe pulmonary artery sytolic hypertension. 3. Marked improvement in hemodynamic measurements with dobutamine infusion. ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] S. ATTENDING STAFF: [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] J. Brief Hospital Course: A/P: 59 y/o female with PMH significant for severe ischemic cardiomyopathy with a LVEF of 15%, CAD, and pulmonary hypertension admitted through the ED with lethargy and severe laboratory abnormalities. . 1. CHF with LVEF of 15 to 20%: Pt does not appear to be in decompensated failure at this time. Hydrated gently without dyspnea. -Had Swan Ganz with dobutamine titration, showing that the patient had decreased SVR and inceased cardiac output with dobutamine. Started dobutamine 5mcg/kg/min after PICC placed but titration up to 10 mcg/kg/min was limited by frequent PVC's 1 every 10 beats, so the patient was decreased to 5 mcg/kg/min. She will likely receive dobutamine 5mcg/kg/min at home when she is stable for discharge. Quadruple concentrated dobutamine (1g/250cc D5W) because of hyponatremia. Titrating up ACEi and transitioning to daily lisinopril. . 2. Hyponatremia: Pt presented with severely decreased oral intake over 1-2weeks. She then was volume repleted partially with saline, but also to a great degree with oral free water. Her sodium worsened further on initiation of dobutamine gtt, which is suspended in free water. -Dobutamine has since been concentrated 4x. -Free water restriction, 1L orally. -Continue 2g/day sodium restriction given severe CHF. -Encourage oral intake up to 1L/day as above. . 3. Thrombocytopenia: Plt 522, [**2166-4-16**] upon last check before this admission. Admitted with Plt 199 on [**2166-4-29**], trending down to 94 on [**2166-5-3**] but up at 115 on [**2166-5-6**]. Heparin flushes d/c'd although HIT Ab negative. DIC labs negative as well. . 4. Dysuria: Foley discontinued. LE and WBC in urine with no epithelial cells and + bacteria. Past micro data shows multiple pan-sensitive E.Coli infections. Will treat with levofloxacin x 10 days. Since foley removed, due to void at 6pm. If no void by then and bladder scan >200cc, straight cath x 1 for residual. . 5. Lactic acidosis: Lactic acidosis- Unclear etiology of pt's lactic acidosis. Does not appear to be septic in nature as afebrile, not tachycardic, not tachypnic. Pt denied taking any new medications or any that don't belong to her. As her lactic acid has quickly improved in the few hours since arrival, could be due to a seizure as this would improve relatively quickly, or to severe dehydration with diarrhea and poor nutrition over 1.5 weeks ("I stopped eating for 12 days") as she received rapid volume resuscitation. - Improved with gentle volume resuscitation, starting with 250 cc NS bolus and gentle maitnance fluids at 75 cc/hr, monitoring carefully given severely depressed LVEF. - Also improved with dobutamine but limited by ectopy on higher doses as below. . 6. Psych: Pt's toxin screen widely positive and there is concern for the patient being suicidal. Psychiatry consult pending to assess for suicidality. Patient's prior history of refusing transplant, her current history of ingestion, and her management as bridge to future transplant make determining her suicidality important. However, pt had hx of taking fioricet (has barbituates); also known to be on benzodiazepines chronically at home. On further history, pt refused transplant due to no social support at home. Psychiatry felt that her changing mental status was delirium. Mental status has since stabilized and no acute concern for SI. . 7. Atrial fibrillation: Pt with a elevated INR on admission. Initially, was concerned about severe hepatic failure/dysfunction causing synthetic dysfunction and other abnormalities. However, does not appear that her liver is dysfunctional, but this may be due to volume resuscitation in the setting of dehydration. Pt denied taking large doses of her coumadin. Got vitamin K in the ED and continued to monitor INR. Started enoxaparin and prior dose of warfarin (2mg0 qhs) on [**2166-5-5**] as transition back to home regimen. . 8. Diarrhea: Possibly secondary to refeeding. No recent antibiotics. Pt was taking oral neutraphos and was not eating for days, which both may have resulted in diarrhea on refeeding. . 9. Dehydration: Pt was extremely dry, now close to euvolemic. Unclear if she became dehydrated for some reason and this led to her current state or she developed the acidosis, etc then became dehydrated. Will rehydrate very gently given severely depressed LVEF. Urine output continues to be low at 20cc/hr. Given 250cc bolus without much response and over a period of days, she received multiple small boluses and returned to euvolemic status with improved urine output. From R heart cardiac cath, her RA pressure was [**11-14**] depending on dobutamine dose, but it may be possible that pt may need relatively high RA filling pressures if RHF severe. . 10.FEN- Initially NPO until the pt became more alert. Agressive electrolyte replacement. Had self-limited episodes of lightheadedness and nausea despite stable vitals and BPs in 120s. Possibly secondary to refeeding or dehydration. Checked albumin, most recently 3.3 from 3.8 on admission; prealbumin pending. Started supplements tid c/w nutrition consultation recommendations. . 11.Proph: Anticoagulated on lovenox-->warfarin; pneumoboots; H2 blocker. . 12.Code: Full. Confirmed with pt's PCP. . 13.Dispo: The patient was discharged in stable condition on dobutamine, lisinopril, amiodarone, aspirin, and her home coumadin dose for atrial fibrillation as her cardiac regimen. She was also discharged on 10 days of ciprofloxacin for UTI and history of pan-sensitive E.coli urinary tract infections. Patient was set up for home dobutamine infusions and was cleared by PT after a number of physical therapy sessions resulted in the patient returning to her baseline functional ability. . 14.Follow-up: The patient will receive VNA at home for nursing needs and to follow her INR until it reaches 2.0. Additionally, she will take daily weights and call her cardiologist for a weight change of 3 lbs. She has a follow-up appointment with Dr. [**First Name (STitle) 2031**] scheduled for [**2166-5-15**]. Medications on Admission: Allergies: 1. Biaxin 2. Erythromycin base 3. Amiodarone . Medications (As pt not able to give, these are from most recent DC summary): 1. ASA 81 mg daily 2. Levothyroxine 137 mcg daily 3. Famotidine 40 mg daily 4. Clonazepam 0.5 mg TID 5. Digoxin 125 mcg daily 6. Spironolactone 25 mg daily 7. Mg oxide 400 mg [**Hospital1 **] 8. Lorazepam 1 mg TID 9. Sertraline 100 mg QHS 10. Tylenol 325 mg [**12-29**] tab Q4-6H 11. Amiodarone 400 mg daily 12. Warfarin 2 mg daily- Was supposed to hold dose today. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 2. Levothyroxine Sodium 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed): Call your doctor if you have more than 10 minutes of chest pain. Disp:*75 Tablet, Sublingual(s)* Refills:*2* 6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 7. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 8. Dobutamine in D5W 4,000 mcg/mL Parenteral Solution Sig: Five (5) mcg/kg/minute Intravenous continuous infusion: Via portable infusion pump. PLEASE MAXIMALLY CONCENTRATE. Hold for chest pain, lightheadedness or arrhythmia. Weight is 77kg. Disp:*qs x 6 months qs x 6 months* Refills:*5* 9. Heparin Sodium Lock Flush 100 unit/mL Solution Sig: Three (3) ml Intravenous once a day: to unsused PICC lumen. Disp:*90 ml* Refills:*2* 10. Famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 12. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Physician [**Name9 (PRE) **] [**Name9 (PRE) **] Discharge Diagnosis: Congestive heart failure Discharge Condition: Stable and improved. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet strictly, but be sure to eat regularly. Fluid Restriction: 1 liter of combined juice, water, soda per day. Please follow up with Dr. [**First Name (STitle) 2031**] at your appointment noted below. Please call your doctor or return to the emergency department with difficulty breathing, shortness of breath, lightheadedness, increased leg swelling, weight change of 3 pounds, or other concern. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2166-5-15**] 3:00 Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2166-6-12**] 1:00

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icd9cm

[ [ [] ] ]

[ "38.93", "37.21", "00.17", "88.55" ]

icd9pcs

[ [ [] ] ]

17031, 17109

8839, 14844

308, 396

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51239+59323

Discharge summary

report+addendum

Admission Date: [**2148-5-5**] Discharge Date: [**2148-5-11**] Date of Birth: [**2073-8-9**] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 74-year-old man with coronary artery disease status post coronary artery bypass graft and PTCA, cirrhosis, who is recently admitted from [**4-25**] to [**2148-5-3**] for recurrent upper GI bleed secondary to duodenal arteriovenous malformation status post argon laser coagulation therapy, who now presents with an episode of dizziness, upper epigastric and mid chest discomfort, shortness of breath, and nausea while climbing stairs on the morning of admission. This vague episode lasted approximately 10 minutes before resolving on its own. The patient denied any chest pain, syncope, palpitations. The patient did say the epigastric discomfort did radiate to his jaw. He denies any further episodes of bright red blood per rectum, melena, and says his appetite has been unchanged. He denies any abdominal pain. He says he did not lose any consciousness. He denies any headaches or visual changes. The patient had been doing some yard work on [**2148-5-4**], and had some chest pain during that time, which lasted approximately 45 minutes. He says this chest pain is different than the sensation that he had on [**5-5**]. He denies any fever or chills, diarrhea, or constipation, cough, urinary symptoms, nausea, vomiting, syncope. In the Emergency Room, the patient was slightly hypotensive with a blood pressure of 84/54, heart rate of 60, and mentating well. He was given 1500 cc of normal saline IV fluids. At baseline, the patient's systolic blood pressure runs from 90s to 110. PAST MEDICAL HISTORY: 1. Coronary artery disease status post CABG and PTCA. 2. Mesenteric thromboses. 3. Cryptogenic cirrhosis versus NASH. 4. Upper gastrointestinal bleed secondary to esophageal varices and duodenal AVMs status post argon coagulation therapy in [**2148-4-4**]. 5. Status post IVC filter for deep venous thromboses. 6. Status post splenectomy. 7. Status post cholecystectomy. 8. Status post gallstone pancreatitis. 9. History of colitis. 10. Abdominal hernia. 11. History of hepatic encephalopathy. ALLERGIES: Aspirin and Coumadin cause a bleed. MEDICATIONS: 1. Protonix 40 mg po bid. 2. Lasix 20 mg po q am, 40 mg po q pm. 3. Aldactone 100 mg po bid. 4. Lactulose 30 cc po tid. 5. Ursodiol 300 mg po bid. 6. Nadolol 20 mg po q day. 7. Iron sulfate 325 mg po q day. 8. Multivitamin one tablet po q day. SOCIAL HISTORY: Patient denies any tobacco and drinks occasional alcohol. PHYSICAL EXAMINATION: General: The patient is a pleasant elderly man lying in bed in no acute distress. Temperature is 96.9, heart rate 60, blood pressure 84/54, respiratory rate 14, and oxygen saturation is 100% on room air. HEENT: Pupils are equal, round, and reactive to light. Oropharynx is clear. Sclerae are anicteric. Mucous membranes moist. Chest was clear to auscultation bilaterally. Cardiovascular: regular, rate, and rhythm with a normal S1, S2 without murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended, positive bowel sounds, left side fluid filled abdominal hernia. Rectal per Emergency Room was guaiac negative. Extremities: No edema. Neurologic: Alert and oriented times three with cranial nerves II through XII intact. Motor examination is grossly within normal limits. No asterixis noted. LABORATORIES: White count 4.6, hematocrit 33.0, platelets 178, differential is 71% neutrophils, 16% lymphocytes, 7% monocytes, 5% eosinophils, INR 1.4, sodium 135, potassium 4.3, chloride 100, bicarbonate 24, BUN 29, creatinine 1.3, glucose 136, LFTs within normal limits. CK 85, troponin 1.5, protein 7.8, albumin 2.8, ammonia 111. CHEST X-RAY: Left effusion noted with bibasilar atelectasis, no evidence of pneumonia or congestive heart failure. ELECTROCARDIOGRAM: Normal sinus rate at 62 beats per minute with a normal axis and right bundle branch block. T-wave inversion in V2 and V3 with the V2 T-wave inversion new compared with electrocardiogram on [**4-24**]. Right sided leads showed no ST elevations in lead V4-R. HOSPITAL COURSE: 1. GI: On the night of admission, the patient had an episode of melena with 600 cc of bright red blood. Patient's blood pressure thereafter was marginal ranging approximately a systolic blood pressure of 70s-90s. In addition, the patient's mental status declined with more evidence of hepatic encephalopathy as the patient was not taking his lactulose. His thoughts were slower, and the patient was not able to respond appropriately to questions, and the patient became much more drowsy and confused. On hospital day #2, the patient had 100 cc of hematemesis noted by the primary care physician. [**Name10 (NameIs) **] that time, the patient's blood pressure was 90/60, however, because of the patient's declining mental status, the Medical Intensive Care Unit was notified. The patient's hematocrit also dropped from 33 on admission to 28.0, and required packed red blood cell transfusions to maintain his hematocrit greater than 30. Because of the patient's tenuous status, and the onset of new hematemesis, the patient was transferred to the Medical Intensive Care Unit on [**2148-5-6**]. The patient was immediately started on an octreotide drip for his gastrointestinal bleed, and an EGD was performed on the evening of [**5-6**]. EGD showed grade II varices in the lower third of the esophagus which were not bleeding, blood clots present in the fundus, and abnormal mucosa throughout the duodenum with contact bleeding. There were many medium localized angiectasias with stigmata of recent bleeding seen in the proximal bulb and distal bulb of the duodenum. Electrocautery was applied with successful hemostasis. Based on the numerous AVMs noted in the duodenum, it was thought that perhaps the patient's bleeding could be prevented by a TIPS being placed to decompress his portal hypertension. A CT scan of the abdomen was obtained prior to evaluation for TIPS procedure which revealed a shrunken cirrhotic liver, and thrombosis of a portal vein with abnormally reconstituted vein within the liver and cavernous transformation. There was evidence of esophageal varices, as well as ascites. An ultrasound of the abdomen was also obtained which was suboptimal and showed hepatofugal flow in the anterior and posterior divisions of the right portal vein, however, the main portal vein was not adequately visualized. The hepatic veins both the right and middle were widely patent as well as the IVC. Based on all the radiographic evidence, Dr. [**First Name4 (NamePattern1) 6339**] [**Last Name (NamePattern1) 106307**] felt that a TIPS procedure by Interventional Radiology was likely not feasible given that there was no mesenteric veins suitable for landing site for a portocaval shunt, and there was no suitable intrahepatic portal vessel to recannulate. The surgical options were explored with Dr. [**Last Name (STitle) **], who felt that surgery in this patient was not an option. In addition, the patient is not a liver transplant candidate. While in the Intensive Care Unit, the patient was continued on his octreotide drip, serial hematocrits were obtained, and the patient was monitored for further evidence of bleeding. Patient's hematocrit remained relatively stable, and he did not have any further episodes of outright bright red blood per rectum or hematemesis. His diet was advanced slowly and his hepatic encephalopathy cleared as he was given lactulose. The patient was also started on ceftriaxone 1 gram IV q24h for SBP prophylaxis as this patient has cirrhosis and history of a gastrointestinal bleed. On [**2148-5-9**], the patient was transferred out of the Medical Intensive Care Unit to the Medical floor as the patient was hemodynamically stable. His blood pressure remained at his baseline levels from 90s-110s systolically. His mentation was good and he had no evidence of hepatic encephalopathy. He was able to tolerate a normal diet without any difficulties. The patient did continue to have guaiac positive stools during his hospital stay. His hematocrits were continually measured and found to be stable within the 30-33 range. After further discussion with the Liver Service, the patient will be started on hormonal therapy given his numerous vascular ectasias in his duodenum. He will be started on ethinyl estradiol 0.035 mg and 1 mg of norethindrone which closely approximates the AGA guidelines. The patient also underwent a repeat EGD on [**2148-5-10**], results of which are pending at the time of this dictation. In addition while the patient was transferred to the Medical Intensive Care Unit, his diuretics and beta blocker were held given his active gastrointestinal bleeding. On the day of discharge, the patient was restarted on low dosed diuretics with Lasix 40 mg po q day and aldactone 100 mg po q day as well as nadolol 20 mg po q day. The patient's primary care physician will gently titrate up his diuretic dose as tolerable within the next week. He was also continued on Protonix 40 mg po bid and sucralfate 1 gram po qid given his upper GI bleed. 2. Cardiovascular: Because of the patient's vague symptoms of epigastric discomfort, the patient was admitted for initially a rule out myocardial infarction. Cardiac enzymes were cycled and the patient's CKs were within normal limits, however, the patient's troponin remained elevated at 1.5. His repeat electrocardiogram was unremarkable and Telemetry revealed no significant events. As noted above, the patient's diuretics and beta blocker were held given that the patient had active gastrointestinal bleeding present. It is unclear exactly what was the source of his epigastric discomfort, but most likely were symptoms that heralded his GI bleeding. 3. Hematology: The patient had evidence of blood loss anemia from his gastrointestinal bleed. He was transfused with a goal hematocrit greater than 30 given his coronary artery disease. Patient continued to have guaiac positive stools on the day of discharge. However, it is likely that the patient will continue to have some guaiac positivity given that he has multiple AVMs present which are status post electrocautery and argon laser coagulation therapy. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Recurrent upper gastrointestinal bleed secondary to duodenal arteriovenous malformations. 2. Cryptogenic cirrhosis versus nonalcoholic steatohepatitis. 3. Hypercoagulable condition with mesenteric thromboses, deep venous thromboses status post IVC filter. 4. Blood loss anemia. 5. Coronary artery disease status post PTCA and CABG. 6. Hepatic encephalopathy. 7. Ascites with abdominal hernia. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po bid. 2. Lasix 40 mg po q day. 3. Aldactone 100 mg po q day. 4. Ursodiol 300 mg po bid. 5. Lactulose 30 cc po tid. 6. Nadolol 20 mg po q day. 7. Iron sulfate 325 mg po q day. 8. Multivitamin one tablet po q day. 9. Sucralfate one tablet po qid. 10. Ciprofloxacin 500 mg po bid x5 days. 11. Norethindrone, ethinyl estradiol 1-0.035 mg one tablet po q day x6 weeks. FOLLOWUP: The patient has a follow-up appointment with Dr. [**Last Name (STitle) **] in approximately 1.5 weeks. The patient will also follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] within the next week to titrate up his diuretic dose. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 26586**] Dictated By:[**Last Name (NamePattern1) 1336**] MEDQUIST36 D: [**2148-5-10**] 14:21 T: [**2148-5-13**] 13:54 JOB#: [**Job Number 106308**] Name: [**Known lastname 3478**], [**Known firstname **] Unit No: [**Numeric Identifier 17306**] Admission Date: [**2148-5-5**] Discharge Date: [**2148-5-11**] Date of Birth: [**2073-8-9**] Sex: M Service: Medicine ADDENDUM: Esophagogastroduodenoscopy performed on [**2148-5-10**] revealed varices of the lower third of the esophagus which were nonbleeding, polyps in the antrum of the stomach, and abnormal vascularity in the anterior bulb, distal bulb, and possible bulb of the duodenum; compatible with friable arteriovenous malformations. Argon plasma coagulator was applied for hemostasis successfully. The duodenum was noted to be extremely friable, and contact bleeding occurred with the endoscopy. The patient was to be discharged home on hormonal therapy with CombiPatch, 0.05 mg of ethinylestrenol and 0.14 mg of norethindrone, to help with his arteriovenous malformations. Please note in the Discharge Summary medications, the patient medication list should include the CombiPatch instead of the norethindrone-ethinylestrenol. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 801**] [**Last Name (NamePattern1) 447**], MD [**MD Number(1) 14655**] Dictated By:[**Last Name (NamePattern1) 1667**] MEDQUIST36 D: [**2148-5-10**] 15:08 T: [**2148-5-10**] 15:14 JOB#: [**Job Number 17312**]

[ "573.3", "537.83", "789.5", "572.2", "285.1", "557.0", "289.8", "456.21", "571.5" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

10341, 10350

10371, 10768

10791, 13127

4162, 10319

2594, 4145

164, 1671

1693, 2495

2512, 2571

42,492

154,822

47092

Discharge summary

report

Admission Date: [**2193-6-20**] Discharge Date: [**2193-6-26**] Date of Birth: [**2106-4-7**] Sex: M Service: MEDICINE Allergies: aspirin Attending:[**Last Name (NamePattern1) 13159**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: This is an 87yoM with history of ESRD on HD (TTSa), CHF, AS, myelodysplastic syndrome who presents from [**Location (un) **] with acute dyspnea. Per report patient was in USOH until this evening when he complained of acute SOB. On evaluation at [**Hospital3 2558**], patient was desatting to 70s on RA. EMS was called and placed patient on NRB mask and transported him to [**Hospital1 18**]. In the ED, initial VS were: 98.5 105 117/61 28 100% 15L NRB. Patient was very tachypneic on arrival and appeared hypervolemic and febrile on exam. LUE was noted to be mildly edematous. Patient was started CPAP with improvement of respiratory status. Labs were significant for leukocytosis to 26.4 with lactate of 2.4. Troponin was 0.52. CXR showed pulmonary edema. CTA chest was completed and showed large pleural effusions without e/o PEs. Patient was then admitted to the MICU for further evaluation. Patient received Vancomycin and levofloxacin while in ED VS prior to transfer were 98.1 86 141/55 25 98%BiPAP. In MICU, patient stated that breathing was feeling better. Denied chest pain, palpitations or abdominal pain. Of note patient was recently admitted to [**Hospital1 18**] from [**Date range (1) **] with similar complaints during which time palliative care was consulted to discuss of end of life issues. During this time, hospice was introduced given that patient did not appear to be tolertating dialysis. Past Medical History: ESRD: unknown etiology, since [**3-26**] Elevated WBC count Polycythemia [**Doctor First Name **] AS CHF HTN HL Dysphagia Hypothyroidism Social History: Previously smoked 2ppd for 30 years, quit in [**2155**]. No EtoH or drug use. Used to live with son at home prior to last d/c from [**Hospital1 2025**] when they sent him to [**Hospital3 2558**] rehab. Family History: non-contributory Physical Exam: ADMISSION EXAM VS:36.8 103/47 96 25 100 on BIPAP General: Alert, slow to respond, mild respiratory distress HEENT: Sclera anicteric, EOMI, PERRL Neck: JVP at angle of jaw of mandible CV: Regular rate and rhythm, normal S1 + S2, III/VI Lungs: decreased breath sounds at bases but otherwise clear Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: wwp, LUE slightly more edematous than RUE, fistula on left with palpable thrill, warm to touch, [**11-19**]+ edema in LE b/l, 8x3cm non infected appearing ulcer on LLE, chronic venous changes b/l . DISCHARGE EXAM VS: T:97.7 BP:118/57 P:84 RR:18 Pox: 97% on 2L GEN Alert, oriented, no acute distress, lying comfortably in bed HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, trachea midline, no JVD, no LAD PULM normal respiratory effort, good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, [**2-22**] holosystolic mumur loudest at RUSB radiating to carotids. ABD soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, left forearm with patent AV fistula (palpable thrill, bruit present), Pt with 1+ pitting edema of lower extremities bilaterally NEURO CNs2-12 intact, motor function grossly normal, no focal deficits SKIN: Left LE lateral area of shin with a 5cm x2cm ulcer present, yellow/white in color with pink edges, Pertinent Results: Admission Labs: [**2193-6-20**] 12:06AM BLOOD WBC-26.4*# RBC-2.18* Hgb-7.9* Hct-25.6* MCV-117* MCH-36.5* MCHC-31.1 RDW-22.0* Plt Ct-131* [**2193-6-20**] 12:06AM BLOOD Neuts-88.7* Lymphs-8.0* Monos-2.5 Eos-0.5 Baso-0.3 [**2193-6-20**] 12:06AM BLOOD Glucose-84 UreaN-32* Creat-3.3* Na-140 K-5.9* Cl-98 HCO3-31 AnGap-17 [**2193-6-20**] 12:06AM BLOOD ALT-98* AST-160* CK(CPK)-113 AlkPhos-151* TotBili-0.3 [**2193-6-20**] 12:06AM BLOOD CK-MB-8 proBNP->[**Numeric Identifier **] [**2193-6-20**] 12:06AM BLOOD cTropnT-0.52* [**2193-6-20**] 12:06AM BLOOD Albumin-3.4* Calcium-9.4 Phos-3.3 Mg-1.8 [**2193-6-20**] 12:16AM BLOOD Type-ART pO2-164* pCO2-47* pH-7.46* calTCO2-34* Base XS-9 [**2193-6-20**] 12:22AM BLOOD Lactate-2.4* [**2193-6-20**] 02:25AM BLOOD Lactate-1.4 K-4.6 [**2193-6-20**] 07:42AM BLOOD Lactate-1.1 K-3.2* . Discharge Labs: [**2193-6-26**] 07:20AM BLOOD WBC-26.6* RBC-2.47* Hgb-8.4* Hct-27.5* MCV-112* MCH-34.1* MCHC-30.5* RDW-22.7* Plt Ct-160 [**2193-6-26**] 07:20AM BLOOD PT-13.1* PTT-37.5* INR(PT)-1.2* [**2193-6-26**] 07:20AM BLOOD Glucose-47* UreaN-26* Creat-3.1* Na-137 K-4.3 Cl-94* HCO3-33* AnGap-14 [**2193-6-26**] 07:20AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.9 . Imaging CXR [**2193-6-20**]: Recurrent, moderately severe, pulmonary edema, worsened since [**6-10**]. Bibasilar opacification, likely edema and atelectasis. . CT chest [**2193-6-20**]: No pulmonary embolism. Evaluation of subsegmental vessels is limited. Moderate to large bilateral pleural effusions with associated atelectasis. Moderate bilateral ground glass opacity likely represents pulmonary edema. Additional findings are present in addition to the original wet read: There appears to be a small amount of gas within the right rectal wall (2:73). Stercoral colitis is suspected given the presence of a large amount of rectal stool. Trace free air is present (2:38). The apparent trace pneumobilia may instead represent intraperitoneal air dissecting along portal veins. Alternatively, portal gas is possible. . CT ABDOMEN AND PELVIS WITH CONTRAST [**2193-6-20**] IMPRESSION: 1. Minimal biliary air in the gallbladder and biliary tree is nonspecific and may the sequelae of prior instrumentation such ERCP/sphinterotomy. Please correlate with patients history. No free air. 2. Comminuted fracture of the left ilium with extension to the superior pubic ramus and acetabulum. Acetabular component has intra-articular extension without femoral head involvement or dislocation. 3. Changes of ankylosing spondylitis with fusion of the right sacroiliac joint and vertebral body. 4. Diffusely abnormal marrow with sclerosis and atrophic kidneys consistent renal osteodystrophy. Osseous sequelae of myeloproliferative disease are also superimposed. 5. Moderate bilateral pleural effusions with subsegmental atelectasis. Difficult to exclude infectious consolidation in the atelectatic lung. 6. Mild fusiform aneurysmal dilatation of the abdominal aorta just proximal to the bifurcation measuring 2.2 cm CXR [**2193-6-26**] In comparison with study of [**6-20**], the degree of bilateral opacification may be slightly less prominent. Substantial enlargement of the cardiac silhouette persists. Brief Hospital Course: 87 year old M with ESRD on HD (T/Th/Sa), renal osteodystrophy, diastolic CHF, severe aortic stenosis, myelodysplastic syndrome, who presented from [**Hospital3 2558**] on [**2193-6-20**] with dyspnea [**12-20**] to pulmonary edema now resolved but with acute/subacute fractures of the left acetabulum and found to have free air which is thought to be [**12-20**] stercoral ulcer. Active Issues: # Acute Respiratory Distress: Pt was hypoxic on admission requiring O2 therapy secondary to pulmonary edema. Inciting event unclear. [**Name2 (NI) **] evidence of PNA or PE on CT scan. No evidence of MI. TTE showed stable severe AS. Pt appeared hypervolemic and was approximately 3kg above last dry wt. Pt respiratory symptoms improved after he received emergent ultrafiltration. Since resolution of acute dyspneic event pt has been asymptomatic and tolerating 2L of O2 with Pox sats > 95. An oxygen weaning trial resulted in O2 sats dropping to around 92%. CXR was obtained which did not show evidence of recurrent pulmonary edema. He will be discharged on 2L of O2. #Left acetabular fracture: This was found incidentally on the CT abd/pelvis. Patient reported a fall 1 week prior with minimal pain. He remembers falling while trying to put on his pants. Orthopedics was consulted to recommended surgery. However given his sever AS and multiple poor outcome comorbidites it was felt that he would survive this type of high risk surgery and it was deferred. He should be touch down weight bearing currently and will need follow up with orthopedics to determine future weight bearing status. #Stercoral ulcer-patient had evidence of stercoral ulcer on his CT abdomen with some air surrounding his portal system, however his abdominal exam was unremarkable and he had no abdominal pain. He was disimpacted and mainatined on an aggressive bowel regimen. The ulcer is thought to be secondary to hard stools. He requires daily bowel movements. #ESRD Pt on three times per week hemodialysis. AV fistula in left forearm is patent. Continued while in hospital (T/Th/Sa). Continued nephrocap, calcium carbonate, vitamin D. Pt will be continued on three times per week dialysis as outpatient. # Goals of care: Pt was seen by palliative care to discuss his goals of care. He decided that he wants to continue with maximal medical care and continue hemodialysis at the present time. He understands that his multiple medical problems put him at risk for recurrent hospitalizations. . Chronic Issues: . #Aortic Stenosis: Severe calcific AS with valve area 0.8-1.0cm2. Pt not a surgical canditate for valve replacement. Current worsening of respiratory status could be secondary to worsening aortic stenosis, however TTE showed stable severe AS. . #Diastolic CHF: Echo on [**2193-6-21**] showed symmetric LVH with normal global and regional biventricular systolic function. Mild calcific mitral stenosis. Moderate pulmonary hypertension. Pulmonary edema in setting of diastolic CHF is likely cause of his respiratory distress. Pt will continue metoprolol succinate XL 12.5 mg PO Daily. Monitor weights daily and notify PCP if there is change in weight greater than 2-3lbs. Pt is very sensitive to fluid overload and should have his fluid balance monitored to prevent future episodes of volume overload. . #Leg Ulcer: Pt with healing ulcer on left lateral shin. S/p debridement and treatment for surperimposed cellulitis on a previous admission and course of Augmentin completed on last admission [**Date range (1) **]. Pt had been followed by vascular surgery on previous admission. Pt denies pain. Wound does not appear infected. Continue with wound care per wound care team recs from [**2193-6-12**]. These include: Commercial wound cleanser or normal saline to irrigate/cleanse all open wounds. Pat the tissue dry with dry gauze. Apply Aloe Vesta to the periwound tissue with each drg change. Apply Hydrogel, cover with NS moistened 2 x 2's Cover with 4 x 4's. Secure with Kerlix (not conform) wrap, Change dressing 1 x a day. . #MDS/Elevated WBC count: Pt has h/o of polycythemia [**Doctor First Name **] and has recently developed MDS. He requires packed red blood cell transfusions weekly to every other week. He also has chronically elevated WBC which is thought to be due to MDS. Pt has been afebrile and does not appear to have an infection. . #BPH: Pt denies urinary symptoms currently. Not sure if pt makes any urine. Continue finasteride 5 mg PO daily . #HTN: Pt was not hypertensive on this admission. We Continue metoprolol succinate XL 12.5 mg PO Daily and amlodipine (5mg PO TU,TH, SA, 7.5mg MO, WE, FR) . #Hypothyroidism: TSH was elevated 2/[**2192**]. TSH was rechecked and found to be elevated to 12 on discharge. Pt was on levothyroxine sodium 75 mcg daily. His levothyrocine should be increased as an outpatient and TSH rechecked. . #Hypoglycemia: Pt experienced morning hypoglycemic on last admission. Pt has been getting bedtime snack which has prevented the morning hypoglycemia. Prior to hypoglycemia on previous admission he had no history of diabetes and not currently on meds known to cause hypoglycemia. Per previous endocrine eval: He should continue to have fingerstick checks QACHS (AM fasting, before meals, and at bedtime). He should receive standing snacks (at least crackers and apple juice) at 10PM. He is being discharged with a glucagon kit. . #HLD: stable. Continued on atorvostatin. . Transitional Issues: -Patient noted to have elevated TSH. He will need T3/T4 checked as an outpatient and adjustment of levothyroxine if needed. -Pt will need to have his acetabular fx followed up by orthopedics in 2 weeks. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from nursing home medication list. 1. Amlodipine 7.5 mg PO Q SUN/MON/WED/FRI hold for sbp<100 or hr<60 2. Amlodipine 5 mg PO QTUTHSA (TU,TH,SA) 3. Metoprolol Succinate XL 25 mg PO BID 4. Mirtazapine 15 mg PO HS 5. Atorvastatin 80 mg PO DAILY 6. Levothyroxine Sodium 75 mcg PO DAILY 7. MethylPHENIDATE (Ritalin) 5 mg PO QAM 8. Nephrocaps 1 CAP PO DAILY 9. Finasteride 5 mg PO DAILY 10. Vitamin D 400 UNIT PO DAILY 11. Bisacodyl 10 mg PO DAILY:PRN constipation 12. Docusate Sodium 100 mg PO DAILY hold for loose stools 13. Polyethylene Glycol 17 g PO DAILY:PRN constipation 14. Fleet Enema 1 Enema PR DAILY:PRN constipation 15. Calcium Carbonate 500 mg PO TID 16. Acetaminophen 650 mg PO Q6H:PRN pain max 3-4g daily 17. Glucagon 1 mg IM PRN hypoglycemia/glucose<50 18. Senna 1 TAB PO BID 19. Artificial Tears Preserv. Free 1 DROP BOTH EYES TID Discharge Medications: 1. Atorvastatin 80 mg PO DAILY 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Calcium Carbonate 500 mg PO TID 4. Docusate Sodium 100 mg PO DAILY hold for loose stools 5. Finasteride 5 mg PO DAILY 6. Fleet Enema 1 Enema PR DAILY:PRN constipation 7. Glucagon 1 mg IM PRN hypoglycemia/glucose<50 8. Levothyroxine Sodium 75 mcg PO DAILY 9. Nephrocaps 1 CAP PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 1 TAB PO BID 12. Vitamin D 400 UNIT PO DAILY 13. Metoprolol Succinate XL 25 mg PO BID 14. Acetaminophen 650 mg PO Q6H:PRN pain max 3-4g daily 15. Amlodipine 7.5 mg PO Q SUN/MON/WED/FRI hold for sbp<100 or hr<60 16. Amlodipine 5 mg PO QTUTHSA (TU,TH,SA) 17. Artificial Tears Preserv. Free 1 DROP BOTH EYES TID 18. MethylPHENIDATE (Ritalin) 5 mg PO QAM 19. Mirtazapine 15 mg PO HS Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: dyspnea Pulmonary Edema Left acetabular fracture ESRD stercoral ulcer Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure caring for you on your recent hospitalization to [**Hospital1 18**]. You came to the hospital because you were having difficulty breathing. We found that you had accumlated fluid in your lungs which we were able to improve with ultrafiltration and hemodialysis. We also found that you had a fracture of your left hip which after discussion with the orthopedic team it was determined that surgery was not a good option given your poor condition and multiple medical problems. The following changes were made to your medications. Added: None Stopped: Amlodipine since your blood pressure has been normal (this may be restarted by your physicians as needed) Followup Instructions: Department: INFUSION/PHERESIS UNIT When: FRIDAY [**2193-6-28**] at 9:15 AM [**Telephone/Fax (1) 14067**] Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: MEDICAL SPECIALTIES When: TUESDAY [**2193-7-9**] at 3:30 PM With: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ADVANCED VASC. CARE CNT When: WEDNESDAY [**2193-8-7**] at 10:00 AM With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**] Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site

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Discharge summary

report

Admission Date: [**2146-8-3**] Discharge Date: [**2146-8-18**] Date of Birth: [**2083-12-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Shortness of breath and weight gain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Patient is a 62 yo man with a h/o cardiomyopathy, AFib, CRI, and DM who presented to OSH with LGIB and was transferred to [**Hospital1 18**] for acute renal failure. Patient originally presented to [**State 20192**] Center on [**7-17**] with a LGIB. Patient was found to have an elevated TnI and Cr. The patient has a long history of chronic kidney disease with CHF and a baseline EF of 35%. Diuresis with Lasix was attempted at the OSH, but patient responded poorly to increasing doses of loop diuretics and HCTZ. Patient underwent Tesio placement on [**2146-7-28**] and has been dialyzed every day since this time. His Cr has decreased from 4.4 to 2.4, and his oxygen requirement has decreased as well. Patient is currently stable and has been transferred for further dialysis and evaluation. Patient states that his weight has increased over the past few weeks, and he has had significant difficulty breathing. He has had LLE cellulitis since his recent discharge from [**Hospital1 18**]. He states that that last time that he was ambulatory he was 290lbs. He was admitted in the evening of [**2146-8-3**] and diuresis was attempted with increasing doses of lasix gtt. However despite lasix gtt at 25mg/hr and diuril 500mg q8 the patient continued to be fluid positive (>600 cc+ on the 24hrs prior to CCU transfer). He was transferred for elective initiation of CVVH for volume control. Patient received CVVH in the CCU for two days. He then began to receive ultrafiltration and has had ~ 8L removed since [**8-7**]. Patient has continued to have minimal UOP. Patient's pacemaker was interrogated by EP, and he was found to be in AFib since [**2146-7-18**]. Past Medical History: PAFib Tachybrady syndrome s/p permanent pacemaker in [**1-25**] Lower GIB Tachy myopathy s/p cath in [**2141**] Renal insufficiency (baseline Cr ~ 3) Morbid obesity Cellulitis ATIII Deficiency CVA Sleep apnea DM2 Social History: The patient is married and has two children. Denies tobacco or IVDA. Consumes 1 alcoholic beverage every 2 weeks. Family History: Mother: Died of MI at 77. Obese. Father: Died age 80 [**2-19**] complication from renal disease. Physical Exam: ADMISSION PHYSICAL EXAM VS - T 99.0, BP 107/70, P 70, R 20, O2 100% on 3L Gen: Middle-aged, obese, man in NAD HEENT: PERRL, EOMI. Neck: Supple, no LAD, with JVP of 11 cm. CV: Distant heart sounds. Nl S1, S2. No m/r/g. No thrills, lifts. Chest: Accessory muscle use. Unable to fully assess respiratory function given patient's inability to move in bed. Abd: Soft, NT. Distended. No abdominial bruits. Ext: 3+ edema in entire leg. Cellulitis on LLE Skin: Cellulitis on LLE. Pulses: Right: Radial 2+ DP 1+ Left: radial 2+, DP 1+ Pertinent Results: ADMISSION LABS: From OSH: Na 133/K 4.3/Cl94/ CO2 29/ Gluc 69/ BUN 33/ Cr 2.4/ Ca 8.8/Phos 2.7/ WBC 11.6/HGB 10.2/Hct 30.5/Plt 423 INR 2.7 From [**Hospital1 18**]: [**2146-8-3**] 11:05PM BLOOD WBC-10.2 RBC-3.70* Hgb-10.5* Hct-35.0* MCV-95# MCH-28.4 MCHC-30.0* RDW-19.5* Plt Ct-355 [**2146-8-3**] 11:05PM BLOOD PT-28.4* PTT-51.2* INR(PT)-2.9* [**2146-8-3**] 11:05PM BLOOD Glucose-195* UreaN-27* Creat-2.6*# Na-133 K-5.1 Cl-97 HCO3-24 AnGap-17 [**2146-8-6**] 11:06AM BLOOD ALT-10 AST-20 LD(LDH)-269* AlkPhos-110 TotBili-0.8 [**2146-8-3**] 11:05PM BLOOD Calcium-8.8 Phos-2.7# Mg-1.9 PERTINENT LABS/STUDIES: Portable TTE (Complete) Done [**2146-8-4**] at 3:45:00 PM FINAL The left atrium is markedly dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is severe regional left ventricular systolic dysfunction with anterior, septal and apical hypokinesis and inferior akinesis. Right ventricular chamber size is moderately dilated with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Moderate to severe (3+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Dilated left ventricle with severe regional systolic dysfunction, c/w multivessel CAD. Dilated right ventricle with moderate systolic dysfunction. Moderate to severe mitral regurgitation. At least mild pulmonary hypertension. CHEST (PORTABLE AP) Study Date of [**2146-8-9**] 1:00 PM Portable AP chest radiograph was compared to [**2146-7-5**]. The double-lumen catheter was inserted through right internal jugular vein with its tip terminating in distal SVC. The pacemaker leads terminate in right atrium and right ventricle. The cardiomegaly is unchanged, moderate. The vascular engorgement is moderate representing volume overload/mild pulmonary edema. No obvious pneumothorax is demonstrated. Small bilateral pleural effusion cannot be excluded. DISCHARGE LABS: [**2146-8-18**] 05:15AM BLOOD WBC-12.2* RBC-3.88* Hgb-11.3* Hct-37.1* MCV-96 MCH-29.0 MCHC-30.3* RDW-18.4* Plt Ct-485* [**2146-8-18**] 05:15AM BLOOD Neuts-71.3* Lymphs-9.9* Monos-11.9* Eos-4.0 Baso-0 Metas-2.0* Myelos-1.0* NRBC-2* [**2146-8-18**] 05:15AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Acantho-1+ [**2146-8-18**] 05:15AM BLOOD Glucose-94 UreaN-38* Creat-3.0* Na-134 K-4.9 Cl-95* HCO3-29 AnGap-15 [**2146-8-6**] 11:06AM BLOOD ALT-10 AST-20 LD(LDH)-269* AlkPhos-110 TotBili-0.8 [**2146-8-11**] 05:10PM BLOOD LD(LDH)-237 [**2146-8-18**] 05:15AM BLOOD Calcium-9.2 Phos-2.4* Mg-1.8 [**2146-8-18**] 05:15AM BLOOD Digoxin-1.9 MICROBIOLOGY: [**2146-8-11**] 05:15AM BLOOD HCV Ab-NEGATIVE [**2146-8-11**] 05:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2146-8-17**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Brief Hospital Course: ASSESSMENT: Patient is a 62 yo man with a h/o CHF, paroxysmal AFib, and CKI who presents from OSH with fluid overload and shortness of breath. #. Congestive Heart Failure: Patient has a history of CHF and has been admitted to the hospital multiple times in the past few months for CHF exacerbation. In the OSH, patient was noted to be unresponsive to medical management and was thus started on hemodialysis for fluid overload. On physical exam, patient had elevated JVP, lower extremity edema, and had gained upwards of above his dry weight. Diuresis had not been achieved with aggressive Lasix gtt with synergistic thiazide diuretic, so he has needed HD for volume control. Patient initially received CVVH and then was transitioned to normal hemodialysis. Approximately 4-5L of ultrafiltration was achieved at each hemodialysis. He is estimated to have an additional 10-20L of excess fluid upon discharge. In addition to hemodialysis for volume control he was continued on Metoprolol at 12.5 mg [**Hospital1 **] and was fluid restricted to 1000 cc daily. He had a heart-healthy, renal, low-Na diet. Digoxin was decreased given elevated levels and he was discharged on QOD dosing. # AFib/Tachy-brady Syndrome: Patient has a h/o paroxysmal AFib s/p conversion. Patient was on amiodarone and had a permanent pacemaker placed in [**2146-1-18**]. Patient was found to be in AFib since [**2146-7-18**]. While in atrial fibrillation his pulse generally ranged 70-80 BPM. He then developed several days of increasing episodes of NSVT. Electrolytes were within normal limits and patient was asymptommatic. Given increased frequency and length of VT runs, the patient was started on Amiodarone 200 mg [**Hospital1 **] since [**2146-8-12**]. Since starting Amiodarone, patient converted out of atrial fibrillation and is now in an A-V paced rythm upon discharge. In addition to Amiodarone, patient will continue Metoprolol, Digoxin 0.125 mg every other day. Plan was to continue on Coumadin with goal INR [**2-20**]. Last INR was 3 on [**2146-8-16**]. Plan to titrate Coumadin dosing as needed to maintain in therapeutic range. #. Acute on Chronic Renal Failure: Patient has a h/o CKI, with a baseline Cr of 3.0, per OSH records. Patient's Cr was 4.4 on admission to OSH. After extensive hemodialysis and diuresis, patient's Cr has decreased to 3.1. DDx of acute on chronic renal failure is pre-renal (poor forward flow due to CHF), hypotension (LGIB), and diabetic nephropathy. Per OSH, patient had a Tesio line placed on [**7-28**]. This line was used for hemodialysis inpatient. Cr varied with each HD session. Plan upon discharge is to have outpatient A-V fistula created for longterm hemodialysis. [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**] will contact the rehab facility with this appointment. #. Dysphagia: Patient reported having difficulty swallowing around [**2146-8-12**]. Speech and swallow evaluated the patient, and he appears to be swallowing effectively. He was continued on a reular diet yesterday. #. DM2: Patient is currently on Humulin N insulin every morning and a Humulog SSI. With fingersticks QID. Upon discharge his fingersticks were ranging 100-150 on this regimen. A sliding scale will be provided to his rehab facility. #. Chronic Cellulitis: Patient has had chronic cellulitis on his left lower extremity for which he recieved atleast 21 days of Augmentin prior to transfer to [**Hospital1 18**]. This was continued for an additional week. He was then transitioned for doxycycline and penicillin for one week and the wound improved significantly. His antibiotics were discontinued [**2146-8-17**] and he has had no signs of infection since. #. Decubitus ulcers: Patient has multiple decubitus ulcers. He was evaluated and followed by wound care throughout his stay. Upon discharge the rehab facility was given our most up to date wound care recommendations. #. Nutrition: The patient has a poor nutritional status. He was seen for this by Nutrition consult who provided dietery recommendations for improved nutrition and wound healing. #. Pain: Patient has significant pain from his many pressure ulcers. He given pain medication PRN and was doing well with his current regimen upon transfer to his rehab. #. Constipation: Senna, Colace, and Miralax daily. Would use Lactulose judiciously as patient had diarrhea after administration and became dehydrated. . #. Code: Full Medications on Admission: CURRENT MEDICATIONS: Acetaminophen 650 mg PO q4h prn Allopurinol 100 mg PO q48h Albuterol inhaler prn ASA 81 mg daily Atorvastatin 20 mg PO daily Calcium Acetate Clotrimazole 1% topically Cyclobenzaprine 10 mg PO qhs Digoxin 0.125 mg every other day Docusate Sodium 100mg [**Hospital1 **] Doxycycline hyclate 100 mg PO daily Flovent Humulin N 18 Units SQ AM Lactulose 10 gm PO daily prn Metoprolol Tartrate 12.5 mg PO BID Pantoprazole Sodium 40 mg PO daily Miralax 17 gm PO BID Senna 17.2 gm PO qhs Warfarin 3mg daily Zinc sulfate 50 mg PO daily Albuterol 2 puffs prn q6h Flexeril 10 mg PO qhs prn Novolog SSI Lorazepam 0.5 mg PO q8h prn Oxycodone 5 mg PO prn q6h Zolpidem 5 mg PO qhs prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every 4 hours) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Polyethylene Glycol 3350 100 % Powder Sig: Five (5) g PO DAILY (Daily): Hold for loose stools. 9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 11. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 16. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for SBP < 70, HR <60 . 19. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 21. Talc Powder Sig: One (1) tablespoon Topical Q12H (every 12 hours) as needed for as needed to back to decrease moisture. 22. Outpatient Physical Therapy Please continue physical therapy as needed. 23. Outpatient Occupational Therapy Please continue occupational therapy as needed. 24. Hemodialysis Patient should continue hemodialysis. He is currently 10-20 L positive. He tolerates SBP 80-90 while in hemodialysis 25. Insulin Sliding Scale Please continue Insulin Sliding Scale per attached sheet. Monitor fingerstick QACHS 26. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Patient has been very susceptible to coumadin. Please monitor INR daily until patient on stable Coumadin regimen. 27. Outpatient Lab Work INR monitoring as needed for titration (last INR [**2146-8-15**] was 3.0), digoxin level qweek Discharge Disposition: Extended Care Facility: Northeast Acute Rehab Discharge Diagnosis: Primary: Chronic renal insufficiency requiring dialysis Congestive heart failure Diabetes mellitus Atrial fibrillation Non-sustained ventricular tachycardia Recurrent cellulitis Discharge Condition: Hemodynamically stable and afebrile. He is tolerating hemodialysis well. Discharge Instructions: You were originally transferred to our hospital for volume management. You have excessive fluid in your body and you had stopped responding to diuretics that we typically give people to remove fluid. Given this, you have begun dialysis to remove the excesss fluid. You also have heart failure that was monitored carefully. You had several small episodes of an unstable heart rhythm, called ventricular tachycardia, you were started on medication for this. You also had infection in your left leg, for which you were given antibiotics. You completed your course of these antibiotics and they were stopped on [**2146-8-17**]. Please take all medications as prescribed. Your facility will be provided with a list of the medications you should be taking and will give you a new list upon discharge from their facility. Please keep all outpatient appointments. Seek medical advice if you notice fevers, chills, difficulty breathing, chest pain, lightheadedness or any other symptom which is concerning for you. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1 L Followup Instructions: Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2146-9-2**] 2:00 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2146-9-5**] 1:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2146-9-6**] 1:50 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2146-9-15**] 4:00 [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**] will be calling your facility to schedule outpatient A-V fistula surgery for longterm dialysis. She may be contact[**Name (NI) **] at ([**Telephone/Fax (1) 20193**].

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

14091, 14139

6311, 10782

358, 373

14361, 14437

3111, 3111

15625, 16486

2451, 2549

11521, 14068

14160, 14340

10808, 10808

14461, 15602

5308, 6288

2564, 3092

283, 320

10829, 11498

401, 2067

3128, 5291

2089, 2304

2320, 2435

6,032

130,989

8848

Discharge summary

report

Admission Date: [**2191-11-6**] Discharge Date: [**2191-12-2**] Date of Birth: [**2130-5-17**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 3507**] Chief Complaint: Pneumonia, Altered mental status, E.coli urosepsis Major Surgical or Invasive Procedure: intubation and mechanical ventilation History of Present Illness: Ms. [**Known lastname 1193**] is a 61 woman with urosepsis and altered mental status transferred from [**Hospital 5583**] Hospital in [**State 3914**]. . Per notes, the patient presented [**2191-11-2**] complaining of [**1-7**] weeks of not feeling well. Her family states that over the last 2 days she developed increasing confusion and difficulty breathing. She did not take any meds for 2 days because she was at her father's funeral in RI. Upon evaluation, she was found to have hypoxia, a right middle lobe infiltrate, and 48 bands. Ceftriaxone and ciprofloxacin were administered. She grew pansensitive e.coli from her blood and urine. During her course, she developed delerium that was evaluated with a head CT and LP, which were both reported as normal. . Transferred to [**Hospital1 18**] for treatment and investigation of delerium and respiratory alkalosis. En route, she was intubated by med flight and an OG tube was placed. Past Medical History: 1. Fibromyalgia. 2. IDDM. 3. Hypercholesterolemia. 4. Left bundle branch block. 5. Tachycardia. 6. Peptic ulcer disease. 7. Status post hernia repair. 8. Status post cesarean section. 9. Status post TAH. 10. Status post bilateral knee replacement. 11. H/o Asthma with intubations Social History: Married with supportive children. No tobacco or alcohol. Quit tobacco 12 years ago. Family History: unable to obtain Physical Exam: (initial presentation to [**Hospital Unit Name 153**]) T 104.4 BP 160/69 HR 120 98% on FiO2 60% Gen: intubated and sedated HEENT: ET tube in place Neck: large Cor: tachy, regular Pulm: rhonchi bilaterally Abd: obese, distended, soft Ext: hot with DP 2+ bilaterally . Micro from OSH: pansensitive e.coli from aerobic and anaerobic bottles. Urine with >100,000 colonies pansensitive e.coli. CSF without growth. CSF: glucose 56 and protein 28, 3 WBCs 157 RBCs Abd CT: perinephric fat stranding . EKG: sinus tach, Q III, F, late R wave progression, left axis deviation, normal intervals. Pertinent Results: [**2191-11-14**] 04:10PM BLOOD TSH-4.8* [**2191-11-6**] 09:31PM BLOOD Type-ART Temp-38.7 Rates-14/4 Tidal V-519 PEEP-5 FiO2-100 pO2-167* pCO2-48* pH-7.26* calTCO2-23 Base XS--5 AADO2-529 REQ O2-85 Intubat-INTUBATED [**2191-11-7**] 03:37AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-POS [**2191-11-6**] 10:26PM BLOOD calTIBC-239* Ferritn-395* TRF-184* [**2191-11-6**] 10:26PM BLOOD CK-MB-2 cTropnT-0.01 [**2191-11-11**] 04:39AM BLOOD CK-MB-2 cTropnT-<0.01 [**2191-11-16**] 03:46PM BLOOD CK-MB-4 cTropnT-<0.01 [**2191-11-20**] 09:27PM BLOOD CK-MB-2 [**2191-11-6**] 10:26PM BLOOD ALT-26 AST-23 LD(LDH)-308* CK(CPK)-41 AlkPhos-327* TotBili-1.0 [**2191-11-24**] 05:00AM BLOOD ALT-13 AST-14 AlkPhos-254* Amylase-59 TotBili-0.7 [**2191-11-6**] 10:26PM BLOOD Glucose-201* UreaN-38* Creat-1.2* Na-146* K-4.6 Cl-111* HCO3-20* AnGap-20 [**2191-11-26**] 07:15AM BLOOD Glucose-193* UreaN-22* Creat-1.0 Na-139 K-3.6 Cl-106 HCO3-22 AnGap-15 [**2191-12-2**] 06:00AM BLOOD UreaN-25* Creat-1.4* Na-143 K-3.3 Cl-107 HCO3-20* AnGap-19 [**2191-11-8**] 04:00AM BLOOD Neuts-73* Bands-9* Lymphs-12* Monos-3 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2191-11-6**] 10:26PM BLOOD WBC-9.4# RBC-4.33 Hgb-11.5* Hct-33.3* MCV-77* MCH-26.5* MCHC-34.5 RDW-16.4* Plt Ct-264 [**2191-12-2**] 06:00AM BLOOD WBC-9.3 RBC-3.81* Hgb-10.2* Hct-30.2* MCV-79* MCH-26.8* MCHC-33.9 RDW-17.2* Plt Ct-363 [**2191-11-7**] 11:39AM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . MRI Brain The posterior fossa structures are unremarkable. There are several small areas of increased signal intensity on the FLAIR images and bilateral cerebral white matter, which are nonspecific but could most likely represent chronic microvascular disease. No abnormality is noted on the diffusion-weighted images to suggest acute infarcts. The ventricles and extra-axial CSF spaces are unremarkable. There is mild smooth enhancement of the pachymeninges diffusely, is likely benign, related to the recent lumbar puncture procedure and is unlikely to explain the patient's presentation. There is no leptomeningeal enhancement. The osseous and the soft tissues structures and visualized portions of the paranasal sinuses and the orbits are unremarkable. . MR ANGIOGRAM OF THE CIRCLE OF [**Location (un) **]: Bilateral cavernous ICA and MCA are patent and normal in caliber. The A1 segment of right ACA is not visualized. Bilateral A2 segments are supplied by single left ACA which is tortuous in course. Visualized segments of bilateral distal vertebral arteries are unremarkable. The basilar artery has an irregular contour, likely due to atherosclerosis. Right fetal equivalent PCA is noted; left PCA appears normal. . IMPRESSION: 1. No acute infarcts. 2. Chronic microvascular disease. 3. Benign appearing pachymeningeal enhancement, most likely related to the recent LP and unlikely to explain the patient's presentation. 4. No leptomeningeal enhancement. 5. Absent A1; bilateral A2 segments supplied by single left ACA; fetal equivalent of right PCA. . CXR [**11-6**] One supine portable view. Comparison with [**2185-2-18**]. Lung volumes are somewhat low. There has ill-defined increased density at the right base and in the retrocardiac area. The cardiac silhouette is prominent but may be exaggerated by portable technique. Mediastinal structures are otherwise unremarkable. An endotracheal tube has been inserted and ends at the thoracic inlet. A nasogastric tube has been inserted and terminates below the diaphragm, off of the bottom of the image. . Renal U/S: RENAL ULTRASOUND: . The right kidney measures 10.6 cm. The left kidney measures 14.5 cm. There is no evidence of hydronephrosis or stones bilaterally. Within the mid pole of the left kidney, there is a focal area of soft tissue that appears isoechoic to the cortex and extending into the renal hilum. This does demonstrate some heterogeneous echoes. Given history of concern for pyelonephritis and/or abscess, abscess cannot be entirely excluded on this study. Note should be made that prior CT and ultrasounds too demonstrate a similar extension of cortical-appearing tissue into this region; however, today these findings appear more prominent and more heterogeneous. The urinary bladder is catheterized. . IMPRESSION: Predominantly isoechoic 3.4 x 2.8 x 2.9 cm area within the left renal hilum in the mid pole which appears to be present to a partial degree on prior CT and ultrasounds from [**2185-2-17**] and [**2185-2-14**] respectively. No vascular flow is visualized within this area. Although not typical of abscess appearance, abscess cannot be ruled out. Another possibility includes growth of a soft tissue mass. Recommend followup CT with contrast for better evaluation. . EEG: IMPRESSION: This is an abnormal EEG in the waking and drowsy states, due to the bursts of generalized delta slowing and slow background activity. These abnormalities suggests an encephalopathy, which may be secondary to infections, medications, toxic metabolic abnormalities or ischemia. There were no EEG changes associated with the right hand tremors. . CT Abdomen Pelvis: CT ABDOMEN WITH IV CONTRAST: There is bibasilar atelectasis. The liver, gallbladder, pancreas, spleen, adrenal glands, and right kidney are unremarkable. The left kidney is slightly enlarged diffusely and heterogeneous in appearance with some perinephric stranding similar to prior study from [**2191-11-3**]. Noted on today's contrast-enhanced exam is heterogeneous enhancement as well as a focal area of both enhancement and mass effect measuring 5.8 x 4.4 cm within the mid portion anteriorly. There is no definite fluid collection present. These findings are very suspicious for renal neoplasm. However, this could represent focal superimposed area of phlegmonous tissue. There is no evidence of hydronephrosis or hydroureter. The small and large bowel are unremarkable. There is no free fluid or free air. There is no retroperitoneal or mesenteric lymphadenopathy. Diffuse aortic and iliac artery calcifications. The urinary bladder is catheterized contains a small of contrast. . 1. Heterogeneous enhancement of the left kidney with focal 4.4 x 5.8 cm area of increased heterogeneity within the mid pole. These findings are concerning for renal neopasm. DDx includes diffuse pyelonephritis with underlying phlegmonous change. There is no specific fluid collection present. There is some surrounding perinephric stranding. There is no hydronephrosis or hydroureter. . CXR [**11-22**]: Mild pulmonary edema has cleared since [**11-18**]. Heart size is now normal, and the lungs are essentially clear. No pleural effusion. A left subclavian and a right PICC catheter both end at the junction of the brachiocephalic veins. No pleural effusion. . CTA 1. No evidence for PE. 2. Atelectasis in both lower lobes. Patchy opacities in the left lower lobe may also represents atelectasis, however, infection cannot be excluded. 3. 1.5 cm lesion in the atelectatic right lower lobe with eccentric calcifications. This may represent an infectious focus, however an underlying mass cannot be excluded and follow-up is necessary to document complete resolution. 4. Calcified granuloma in the right upper lobe. . Echo No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. A patent foramen ovale is present with slight left-to-right shunt across the interatrial septum at rest. There are probably complex nonmobile atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. Biventricullar systolic function appears normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is no pericardial effusion. Normal EF. . MRI Abdomen: The right kidney measures approximately 12.5 cm in size. The left kidney is enlarged, measuring approximately 14.5 cm in size. The degree of cortical- medullary differentiation seen in the left kidney is decreased when compared to the right. In addition, the left kidney shows a diffusely heterogeneous signal intensity when compared to the right. Regions of wedge-shaped signal abnormalities are seen extending to the periphery of the kidney in multiple locations, showing both areas which are of greater T2 signal than the background parenchyma, as well as others which appear somewhat decreased in signal. Some of these lesions are hypoperfusing after the administration of IV gadolinium when compared to the background renal parenchyma. There is no evidence of frank abscess or drainable collection of the left kidney. Minimal left-sided perinephric fat stranding remains present. There is no evidence of hydronephrosis. Within the limits of this motion degraded examination, no mass lesion is identified within the left kidney. . IMPRESSION: 1. Markedly motion-limited. 2. Diffusely enlarged left kidney, with regions of wedge-shaped signal intensity abnormalities extending to the periphery of the kidneys. These findings may be consistent with pyelonephritis, and the differential diagnosis also includes bland versus septic embolic disease. 3. No evidence of drainable abscess. 4. Within the limits of this examination, no mass lesion is identified. However, greater sensitivity for detection of mass can be obtained if a MRI is performed when the patient is able to cooperate and performed multiple breath holds. . Brief Hospital Course: Pt initially was transferred to [**Hospital1 18**] on [**2191-11-6**] with urosepsis. She had presented to OSH on [**2191-11-2**] with 2-3 weeks of not feeling well. Was found to be hypoxic, have a RML infiltrate, and 48% bandemia. She was given ceftriaxone and ciprofloxacin; UCx and BlCx grew pansensitive E coli. Pt developed delirium as well, and head CT and LP were reportedly normal. She was transferred to [**Hospital1 18**] for delirium and respiratory alkalosis, and was intubated en route. . Her hospital course was notable for continued fevers after 5 days of antibiotics, which was concerning given that her cultures had shown pansensitive E coli. A renal u/s to look for perinephric abscess did show a L renal mass of unclear etiology. No Urology felt likely not an abscess, MRI obtained which ruled out abscess. Pt developed hospital-acquired PNA while in the ICU and was treated with Vanco/Cipro. She required reintubation twice, first for the need to get further radiologic tests and her inability to handle these secondary to delirium (reintubated on [**11-7**]); extubated [**11-14**], then reintubated a second time for tachypnea, with new LLL PNA on CXR, thought likely to be a VAP. 3 week course of ABX for urosepsis completed (meropenem/cipro), and 7 days of vanco for hospital-acquired PNA. In addition, TEE on [**11-11**] negative for endocarditis. . In terms of mental status, pt had been delirious at OSH and continued to have delirium here. Neuro followed the patient as well, and toxic-metabolic etiologies were thought most likely causing her delirium. MRI brain was unrevealing, EEG c/w moderate encephalopathy, repeat CT scan without new defects (chronic microvascular disease noted). Delerium improved rapidly during the remained of her stay. . Other outstanding medical issues: #Left Renal abnormality NOS: f/u MRI and Urology appointments have been made for the patient in [**2192-2-2**]. . #Renal Insufficiency, likely med related: the few days prior to discharge the patient had a mild bump in her Cr (1.0-1.4). This needs to be followed closely at rehab. Perhaps secondary to increased dose of [**Last Name (un) **] (was on 160 qd at home; increased to 160 [**Hospital1 **] in house). UA unremarkable; FeNa 3%; Urine EOS mildly positive. ?AIN? Her metformin should be held at this time. Rehab facility instructed to follow Cr closely over next few days. . #1.5 cm atelectatic lung lesion: CT of the chest demonstrated a right lower lobe 1.5 cm nodule with eccentric calcifications that did not enhance with IV contrast. Per [**Hospital1 **], f/u is needed to ensure resolution (thought to be infectious at the time). . #Anxiety: pt restarted on Ativan (was taking prior to admission) for anxiety while in house. This can be titrated prn during her rehab stay. Medications on Admission: lipitor 20 mg QD lyrica 50 TID albuterol 2 puffs QID norvasc 10 mg QD ranitidine 300 HS premarin 0.625 QD ibuprofen 800 mg TID diovan 160/25 QD amitryptiline 100 HS starlix 120 TID metformin 850 TID zetia 10 QD accolate 20 [**Hospital1 **] actose 30 QD paroxetine 30 QD nasonex ativan Discharge Medications: 1. Nateglinide 60 mg Tablet Sig: Two (2) Tablet PO TIDAC (3 times a day (before meals)). 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Lyrica 50 mg Capsule Sig: One (1) Capsule PO three times a day. 6. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inhalation Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Zantac 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Paxil 30 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 13. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Tablet(s) 14. Insulin Regular insulin sliding scale Discharge Disposition: Extended Care Facility: [**Hospital **] Rehabilitation Discharge Diagnosis: Primary Diagnoses 1. Ventilator Associated Pnuemonia 2. UTI 3. E. Coli bacteremia, Urosepsis 4. Delerium, resolving 5. Left Renal abnormality NOS 6. Renal Insufficiency, likely med related 7. 1.5 cm atelectatic lung lesion, f/u needed Secondary Diagnoses: DM, Type 2 h/o Asthma requiring intubations fibromyalgia hypercholesterolemia LBBB PUD s/p hernia repair, C section, TAH Discharge Condition: stable Discharge Instructions: Please contact your primary care provider should you have any fevers, chills, night sweats, abdominal pain, night sweats, burning with urination, or any other serious complaints. It is VERY IMPORTANT to speak with Dr. [**First Name (STitle) **] about obtaining a f/u CT scan of your lungs are there was an abnormality that needs to be followed up on. In addition, you have a follow up MRI scan of your kidneys as well as a urology appointment in [**Month (only) 958**]. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2192-2-23**] 1:00 Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2192-2-16**] 9:20 (Do not eat for 4 hours before the test) . Please make an appointment to see your primary care doctor within 1-2 weeks.

[ "486", "995.92", "785.52", "038.42", "112.2", "349.82", "250.00", "585.9", "729.1", "280.9", "584.9", "793.5", "V43.65", "V58.67", "590.10", "401.9", "518.81", "493.90" ]

icd9cm

[ [ [] ] ]

[ "33.24", "38.93", "96.72", "88.72", "96.04", "96.6" ]

icd9pcs

[ [ [] ] ]

16427, 16484

12115, 14924

319, 358

16913, 16922

2404, 12092

17442, 17821

1767, 1785

15259, 16404

16505, 16748

14950, 15236

16946, 17419

1800, 2385

16769, 16892

229, 281

386, 1325

1347, 1648

1664, 1751

46,039

168,833

22444

Discharge summary

report

Admission Date: [**2136-5-9**] Discharge Date: [**2136-5-16**] Date of Birth: [**2054-11-5**] Sex: M Service: CARDIOTHORACIC Allergies: Lisinopril / Coumadin Attending:[**First Name3 (LF) 165**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: -status post Mitral Valve Replacement (#27mm Porcine)/Aortic Valve Replacement ( #21 Pericardial)/Tricuspid Valve Repair [**5-11**] History of Present Illness: 81 year old gentleman with atrial fibrillation s/p cardioversion in [**2133-7-21**] and [**Month (only) 205**]/[**2134**] presents for preoperative workup for Minimally invasive vs sternotomy MV repair vs replacement Past Medical History: hypertension, atrial fibrillation on coumadin s/p cardioversion in [**2133-7-21**] and a repeat cardioversion in [**2135-6-21**], benign prostatic hypertrophy s/p TURP, s/p cholecystectomy, s/p tonsillectomy Past Surgical History: s/p TURP, s/p cholecystectomy, s/p tonsillectomy Social History: retired electrical engineer - Last Dental Exam [**2136-5-4**] Lives with companion -Race caucasian Tobacco: Denies - ETOH: one glass of wine or beer nightly Family History: noncontributory Physical Exam: Physical Exam Pulse:66 Resp: 18 O2 sat: 99 RA B/P Right:136/84 Height: 67 inches Weight:66 kgs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur IV/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Neuro: Grossly intact[X] Pulses: 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: [**2136-5-15**] 05:30AM BLOOD WBC-7.0 RBC-2.64* Hgb-8.6* Hct-25.3* MCV-96 MCH-32.6* MCHC-34.0 RDW-14.5 Plt Ct-84* [**2136-5-9**] 09:30PM BLOOD WBC-4.9 RBC-3.88* Hgb-12.9* Hct-37.6* MCV-97# MCH-33.1* MCHC-34.2 RDW-13.2 Plt Ct-142* [**2136-5-14**] 05:30AM BLOOD PT-13.1 INR(PT)-1.1 [**2136-5-9**] 09:30PM BLOOD PT-18.0* PTT-28.0 INR(PT)-1.6* [**2136-5-15**] 05:30AM BLOOD Glucose-100 UreaN-24* Creat-1.0 Na-140 K-4.2 Cl-106 HCO3-25 AnGap-13 [**2136-5-9**] 09:30PM BLOOD Glucose-113* UreaN-17 Creat-0.9 Na-139 K-3.8 Cl-106 HCO3-25 AnGap-12 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 58320**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 58321**] (Complete) Done [**2136-5-11**] at 10:34:52 AM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] [**Street Address(2) 15115**] [**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2054-11-5**] Age (years): 81 M Hgt (in): 69 BP (mm Hg): 104/52 Wgt (lb): 140 HR (bpm): 76 BSA (m2): 1.78 m2 Indication: Mitral valve regurgitation, aortic stenosis, tricuspid regurgitation. Intraoperative management ICD-9 Codes: 427.31, 786.05, 440.0, 424.1, 424.0, 424.2 Test Information Date/Time: [**2136-5-11**] at 10:34 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], 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 #: 2009AW2-: Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.4 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.3 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.4 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.3 cm Left Ventricle - Fractional Shortening: 0.33 >= 0.29 Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Aorta - Annulus: 2.1 cm <= 3.0 cm Aorta - Sinus Level: 2.9 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm Aorta - Ascending: 2.7 cm <= 3.4 cm Aorta - Arch: 2.5 cm <= 3.0 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - Peak Velocity: *3.2 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *21 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 14 mm Hg Aortic Valve - LVOT diam: 1.9 cm Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular calcification. Moderate to severe (3+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its severity may be underestimated (Coanda effect). TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Results were personally reviewed with the MD caring for the patient. Conclusions PRE-BYPASS: 1. No spontaneous echo contrast is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is globally mildly depressed (LVEF= 45%). However intrinsic LV systolic function may be further impaired given the degree of MR 4. Right ventricular chamber size is moderately dilated Free wall motion is normal. 5. There are simple atheroma in the aortic arch and descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2) with peak and mean gradients 25 and 14 respectively. Mild (1+) aortic regurgitation is seen. 7. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). 8. Moderate to severe [3+] tricuspid regurgitation is seen with a dilated TV annulus 4.6cm. 9. Dr. [**Last Name (STitle) **] was notified in person of the results during surgery on [**2136-5-11**] at 843. POSTBYPASS 1. Patient is on phenylephrine and epinephrine infusions. 2. A well functioning, well seated tissue valve is noted in the mitral position. A small perivalvular leak is noted. Max pressure gradient 27 and mean PG 9 mmHg. 3. A well functioning, well seated tissue valve is noted in the aortic valve. A small perivalvular leak is noted along the anterior LVOT wall. Max pressure gradient is 19 with a mean gradient of 9 mmHg. 4. A tricuspid annuloplasty ring is noted. Residual mild tricuspid regurgitation is noted. 5. LV EF is similar to prebypass. 6. Aortic contour is smooth after decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician ?????? [**2129**] CareGroup IS. All rights reserved. Brief Hospital Course: [**5-11**] Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a Mitral Valve Replacement (#27mm Porcine)/Aortic Valve Replacement (# 21mm Pericardial/ Tricuspid Valve Repair with Dr.[**Last Name (STitle) **]. Cross clamp time= 143 minutes/ Cardiopulmonary bypass time = 166 minutes. Please refer to Dr[**Doctor Last Name 14333**] operative report for further details. He was transported to the CVICU on Phenylephrine/Epinephrine and Propofol to augment hemodynamic stablity. He awoke neurologically intact and was extubated on POD#1. All lines and drains were discontinued in a timely fashion. POD#2 Mr.[**Known lastname **] was transferred to the stepdown unit for further monitoring. A HIT panel was sent for thrombocytopenia. Coumadin was started for anticoagulation for chronic atrial fibrillation. Beta-blocker was initiated to optimize heart rate and rhythm. Pacing wires were discontinued POD# 4 per Dr.[**Last Name (STitle) **]. Mr.[**Known lastname **] continued to progress, and the remainder of his postoperative course was essentially uncomplicated. His platlet count showed recovery. POD# 5 he was cleared by Dr.[**Last Name (STitle) **] for discharge to home with VNA. All follow up appointments were advised. Dr[**Doctor Last Name **] office was contact[**Name (NI) **]/agreed to resume following Coumadin dosing/INR draws. Medications on Admission: coumadin (for atrial fibrillation) 2-3mg -LD [**5-5**], cyclosporine (eczematous dermatitis)75mg [**Hospital1 **], norvasc 5mg, toprol XL 50mg, triamcinolone acetonide cream (eczematous dermatitis), detrol LA 4mg Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg [**Hospital1 8426**] Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*45 [**Hospital1 8426**](s)* Refills:*0* 2. Aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1) [**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Tolterodine 2 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a day). Disp:*60 [**Hospital1 8426**](s)* Refills:*2* 5. Warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily) as needed for atrial fibrillation . Disp:*90 [**Last Name (Titles) 8426**](s)* Refills:*0* 6. Metoprolol Tartrate 25 mg [**Last Name (Titles) 8426**] Sig: 0.5 [**Last Name (Titles) 8426**] PO BID (2 times a day). Disp:*30 [**Last Name (Titles) 8426**](s)* Refills:*2* 7. Furosemide 20 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2 times a day) for 5 days. Disp:*10 [**Last Name (Titles) 8426**](s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 5 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Warfarin 5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO ONCE (Once) for 1 doses: tonight. Disp:*1 [**Last Name (Titles) 8426**](s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: -status post Mitral Valve Replacement (#27mm Porcine)/Aortic Valve Replacement ( #21 Pericardial)/Tricuspid Valve Repair -HTN/AFib/Benign prostatic hypertrophy, s/p TURP, s/p CCY 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**] **Resume INR checks for Coumadin with Dr.[**Last Name (STitle) 6700**] *VNA to draw INR/Coumadin dosing per Dr.[**Last Name (STitle) 6700**] Followup Instructions: -Dr. [**Name (NI) **] in 4 weeks #([**Telephone/Fax (1) 170**]) please call for appointment -Dr [**Last Name (STitle) **],[**First Name3 (LF) **] M. in 1 week #([**Telephone/Fax (1) **]) please call for appointment -Dr [**Last Name (STitle) 1911**], [**First Name3 (LF) **] in [**1-24**] weeks please call for appointment -Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3071**]) [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2136-5-16**]

[ "692.9", "600.00", "287.5", "396.2", "496", "V58.61", "397.0", "427.31", "401.9" ]

icd9cm

[ [ [] ] ]

[ "35.21", "35.23", "39.61", "35.14" ]

icd9pcs

[ [ [] ] ]

11238, 11294

8014, 9359

306, 440

11517, 11524

1876, 7991

12177, 12731

1192, 1209

9623, 11215

11315, 11496

9385, 9600

11548, 12154

940, 991

1224, 1857

247, 268

468, 687

709, 917

1007, 1176

45,539

152,342

37798

Discharge summary

report

Admission Date: [**2101-9-17**] Discharge Date: [**2101-9-21**] Date of Birth: [**2039-3-9**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 896**] Chief Complaint: Pulmonary embolism Major Surgical or Invasive Procedure: None History of Present Illness: 62 y/o M with hypertension, hyperlipidemia, Crohn's disease, and recent extensive spinal fusion surgery [**08**] days ago, presenting to the ED with dyspnea. Yesterday morning, the patient first noticed feeling dyspnic when walking to his bathroom. The same sensation occurred several times later with minimal activity. The patient called a friend of his who is a physician, [**Name10 (NameIs) **] was recommended to come to the ED to be evaluated for PE. . Since the patient's surgery, he had poor PO intake for the first several days. He eventually was discharged home and was not taking any anticoagulation agents. He was instructed to continue taking his daily aspirin 81 mg, which he had stopped one week prior to his surgery. He measures his blood pressures at home, and noted that several days ago, his systolic BP was measuring in the 80s; he typically has BP's in the 110s/70s. He has had little physical activity, spending much of his days sitting or lying down. . In the ED, triage vital signs were 98.0, 103, 133/64, 18, 100% on room air. The patient reported ongoing dyspnea but denied chest pain or palpitations. On exam, the patient was reportedly comfortable, with a regular heart rate, clear lungs, and no JVD or lower extremity edema. DRE was guaiac negative. Labs were notable for Hct 36.0, troponin T 0.06. ECG reportedly showed T wave inversions in leads V1-V4. CXR was unremarkable, aside from presence of surgical hardware. CTA revealed bilateral saddle pulmonary embolism extending into subsegmental pulmonary arteries, as well as straightening of the interventricular septum. He was started on a heparin drip, and given 2 tabs of oxycodone-acetaminophen for pain. . Upon arrival to the MICU, the patient has no complaints, other than feeling hungry and requesting to be able to sit in a chair. He denies current dyspnea, as long as he is still. Denies significant back pain, in the setting of having received percocet in the ED. Denies chest pain, cough, fever, chills, hematuria, dark stools, or nausea. Past Medical History: -[**2101-8-30**]: Decompressive laminectomy L1, 2, 3, 4 and 5 for decompression of severe lumbar stenosis associated with degenerative scoliosis. Osteotomies L1-2, L3-4, L4-5 for correction of degenerative scoliosis. Transverse process and interlaminar fusion, T10-S1. Sacral pelvic fusion S1 and iliac crest. Segmental titanium [**Last Name (un) **] instrumentation T10-S1 with sacral pelvic fixation to the iliac crest. No reported complications, 800 cc EBL. -Osteoarthritis -Crohns disease, s/p partial colectomy in [**2075**] -Hypertension -Hyperlipidemia Social History: Lives at home in [**Location (un) 538**]. Is separated from his wife. [**Name (NI) 1403**] as college professor in political science at [**University/College 5130**] [**Location (un) **]. Rare etoh, none in last three weeks, since surgery. Never smoked tobacco. Denies other illicits. Family History: Many relatives with hypertension. Sister with history of CVA, which patient believes was hemorrhagic. Father had multi-infarct dementia. Mother [**Name (NI) 84609**] away from pancreatic cancer. Two healthy children. Maternal grandmother had DVT in leg, leading to amputation. Physical Exam: VS: Temp:97.5 BP: 116/80 HR:82 (regular) RR:13 O2sat:96% RA GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly. Well healed vertical abdominal scar from remote colectomy. Well healed vertical surgical scar on back. Fluctuant area without overlying ecchymosis on either side of scar. EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. RECTAL: Deferred. Was reportedly guaiac negative in ED Pertinent Results: EKG: Sinus rhythm @ 87 bpm. Low voltage in limb leads. Normal axis, normal intervals. T wave inversions present in V1-V4 (new from prior ECGs of [**2095**] & [**2099**]). No ST segment elevations or depressions. Borderline pathologic Q waves in V1 (seen on prior ECGs), though sub-mm upward deflection is apparent. . Imaging: [**2101-9-17**] CXR: PA and lateral views of the chest are obtained. Serial fusion hardware along the lower thoracic and upper lumbar spine is noted. The lungs appear clear bilaterally. No pleural effusion or pneumothorax is seen. Cardiomediastinal silhouette is normal. Bony structures are intact. A tunneled screw is noted in the left humeral head. . [**2101-9-17**] CTA: INDICATION: 62-year-old man with recent surgery. Shortness of breath. Assess for pulmonary embolism. COMPARISON: None. TECHNIQUE: Axially acquired images were obtained through the chest prior to and after the administration of 100 cc of Optiray intravenous contrast. Coronal, sagittal, and right and left oblique reformatted images were also displayed. . FINDINGS: There is a saddle embolus at the bifurcation of main pulmonary artery, extending bilaterally to the subsegmental level. There is relative sparing of the apical segments of both lungs. Otherwise, PE is seen diffusely. In addition, there is flattening of the interventricular septum and enlargement of the right ventricle, concerning for right heart strain. There is no lymphadenopathy. Lungs are clear of nodule, mass, or consolidation. There is no pleural effusion or pericardial effusion. Visualized aspects of the upper abdomen are within normal limits. . BONES: Posterior spinal fusion is seen in the lower thoracic spine, incompletely visualized. . IMPRESSION: Findings compatible with massive PE. Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15785**] immediately after review at approximately 4:45 p.m. on [**2101-9-17**]. . [**2101-9-19**] 06:10AM BLOOD WBC-8.1 RBC-3.46* Hgb-10.5* Hct-30.3* MCV-88 MCH-30.2 MCHC-34.5 RDW-13.7 Plt Ct-343 [**2101-9-17**] 01:58PM BLOOD WBC-8.8 RBC-4.10* Hgb-12.2* Hct-36.0* MCV-88 MCH-29.6 MCHC-33.8 RDW-13.7 Plt Ct-480* [**2101-9-17**] 01:58PM BLOOD Neuts-78.8* Lymphs-14.2* Monos-4.6 Eos-1.9 Baso-0.5 [**2101-9-20**] 07:25AM BLOOD PT-15.9* PTT-30.5 INR(PT)-1.4* [**2101-9-19**] 06:10AM BLOOD PT-13.6* PTT-60.1* INR(PT)-1.2* [**2101-9-18**] 06:00AM BLOOD PT-13.3 PTT-66.7* INR(PT)-1.1 [**2101-9-17**] 01:58PM BLOOD PT-13.1 PTT-26.4 INR(PT)-1.1 [**2101-9-19**] 06:10AM BLOOD Glucose-103* UreaN-8 Creat-0.7 Na-135 K-3.9 Cl-102 HCO3-25 AnGap-12 [**2101-9-17**] 01:58PM BLOOD Glucose-110* UreaN-10 Creat-0.9 Na-139 K-3.9 Cl-102 HCO3-26 AnGap-15 [**2101-9-18**] 06:00AM BLOOD CK(CPK)-47 [**2101-9-17**] 10:00PM BLOOD CK(CPK)-64 [**2101-9-18**] 06:00AM BLOOD CK-MB-4 cTropnT-0.04* [**2101-9-17**] 10:00PM BLOOD CK-MB-5 cTropnT-0.04* [**2101-9-17**] 01:58PM BLOOD cTropnT-0.06* [**2101-9-19**] 06:10AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.9 Brief Hospital Course: 62 y/o M with hypertension, hyperlipidemia, Crohn's disease, presenting with saddle PE, 18 days out from spinal surgery. . # Pulmonary embolism: Main risk factor is post-operative immobilization. Does report family history of DVT in maternal GM and (hemorrhagic) CVA in his sister, but no clotting disorders have been diagnosed. Stable vital signs and oxygen saturation on arrival. Patient did not have indications for thrombolytic therapy (e.g. severe, persistent hypotension), although troponin elevation and flattening of interventricular septum on CTA may indicate RV strain/dysfunction from clot burden. He was admitted from the Emergency departement on a heparin drip and was transitioned to Lovenox and coumadin. Daily INR and coagulation studies were followed. Contact was made with his primary care physician and [**Hospital3 **] with outpatient follow-up established. Mr [**Known lastname 23919**] did not feel as though he would be able to administer the Lovenox on his own. VNA services were established to continue teaching and administration of lovenox until therapeutic INR levels achieved. His INR at the time of discharge was 1.6 . # Troponin elevation / ECG changes: No chest pain but dyspnea could possibly represent anginal equivalent. More likely, elevated troponin was result of ventricular strain, as embolus significant enough to cause flattening of interventricular septum on ECG. No S1Q3T3 pattern visible, in setting of saddle PE. His cardiac enzymes were cycled and he was continued on telemetry. He did develop several asymtomatic events of atrial tachycardia noted on telemetry that were felt to be benign. Telemetry was discontinued. . # Low Grade Fever: Mr. [**Known lastname 23919**] developed low grade fevers to 100.5 F on HD 2, 3. These fevers were likely secondary to his saddle emboli. However, the patient was kept as an inpatient for 24 hours to carefully rule out evolution of a pneumonia given his significan pulmonary embolus. Low grade fevers had resolved by the time of discharge without clinical suspicion of an infection. . # S/p spinal surgery: Patient has reportedly recovered well, although physical activity has been limited. Has fluctuant area surrounding surgical scar, but no ecchymosis or signs of subcutaneous hemorrhage. He had full strength in lower extremities. Planning on starting PT in another week. . # Hypertension: He was continued on amlodipine, hctz, irbesartan, . # Hyperlipidemia: He was continued on Simvastatin. . # Crohn's disease: No active disease at this time. Continued on mesalamine as needed. . # Osteoarthritis: No active joint pains. Major source of discomfort is lower back. . Medications on Admission: -irbesartan 300 mg PO daily -amlodipine 5 mg PO daily -hctz 25 mg PO daily -simvastatin 20 mg PO daily -mesalamine 400 mg PO PRN abdominal pain or stool incontinence -alprazolam XR 1 mg PO daily PRN anxiety -zolpidem 5-10 mg PO QHS PRN insomnia -celecoxib 200 mg PO daily PRN -ASA 81 mg PO Daily Discharge Medications: 1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 4. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 5. irbesartan 300 mg Tablet Sig: One (1) Tablet PO once a day. 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. alprazolam 1 mg Tablet Sig: One (1) Tablet PO once a day as needed. 9. celecoxib 200 mg Capsule Sig: One (1) Capsule PO once a day as needed for pain. 10. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 10 days. Disp:*20 syringe* Refills:*0* 11. warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Take as directed by [**Hospital3 **]. Disp:*40 Tablet(s)* Refills:*2* 12. Outpatient Lab Work Please draw an INR on Friday [**2101-9-23**] and call [**Hospital1 2292**] [**Hospital3 271**] at [**Telephone/Fax (1) 84610**] with the results. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. Pulmonary Embolism 2. Crohns, S/p Spinal Surgery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for evaluation and treatment of a pulmonary embolis. You were initially treated with intravenous heparin to start anticoagulation. Once stabized you were transitioned to oral Coumadin and subcutaneous Lovenox. The lovenox is a bridging therapy that you will need to continue for at least 5 days. Your blood coagulation levels will need to be checked regularly as you start and continue coumadin. You will need to take Coumadin for at least three months and longer if advised by your primary care physician. Please continue your other medications as directed. Followup Instructions: [**Hospital 197**] Clinic at [**Hospital1 **] will be following your care closely. Dr. [**Last Name (STitle) **] [**Name (STitle) **] office has already been in contact with you and will be following your care closely.

[ "415.19", "V43.64", "V45.4", "427.89", "401.9", "272.4", "780.60", "737.30", "555.9", "285.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11587, 11645

7391, 10067

314, 320

11741, 11741

4380, 7368

12498, 12720

3283, 3562

10414, 11564

11666, 11720

10093, 10391

11892, 12475

3577, 4361

255, 276

348, 2380

11756, 11868

2402, 2964

2980, 3267

11,051

150,770

52748

Discharge summary

report

Admission Date: [**2148-5-20**] Discharge Date: [**2148-5-20**] Date of Birth: [**2097-4-9**] Sex: M Service: NEUROSURGERY Allergies: Codeine Attending:[**First Name3 (LF) 1271**] Chief Complaint: skull fx Major Surgical or Invasive Procedure: none History of Present Illness: 51 year old male was transferred from OSH folowing assault, presents with depressed skull fracture. Reportedly involved in an altercation and struck on right side of head. He has minimal recall of event - LOC unkown. On initial eval he complained of a ha and right sided head pain. No other injuried found on exam. CT from OSH revealed displaced temporal bone fractue, which prompted transfer. On arrival to [**Hospital1 18**] Ed, GCS 15 although intoxicated. Past Medical History: pancreatitis, etoh, htn, stab wound left thigh, emergent repair of left superficial femoral ertery with end to end anastomosis and repair fo rleft femoral vein injury. stab wounds to chest x 2 Social History: married etoh history of physical altercations Family History: non contributory Physical Exam: 98 temp bp 153/83, hr 82, resp 15 o2 sat 98% wd/wn nad HEENT: soft tissue swelling and tenderness to right scalp. Pupils: [**2-20**] bilaterally EOMI Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, minimally cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: not done - pt uncooperative. Language: Speech fluent with fair comprehension and repetition. intermittent slurred speech. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3to2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-24**] throughout. No pronator drift Sensation: Intact to light touch, pinprick bilaterally. Toes downgoing bilaterally ON discharge - neurologically non focal Pertinent Results: CT HEAD W/O CONTRAST Study Date of [**2148-5-20**] 5:17 AM Final Report HISTORY: Skull fracture status post assault. TECHNIQUE: Contiguous axial images were obtained through the brain. No intravenous contrast was administered. COMPARISON: Compared to CT head from [**2148-5-19**] at 22:39 p.m. FINDINGS: There is stable appearance of subtle hyperattenuating focus in the right temporal lobe, likely an area of focal contusion, with no significant interval change. There is no shift of midline structures. There is no evidence of hydrocephalus. The ventricles and sulci are normal in size and configuration. Incidental finding of [**Last Name (un) 2432**] cisterna magna. There is soft tissue edema in the right parietal area with associated comminuted fracture of the squamosal portion of the right temporal bone, with 4-5 mm depression of bony fragments. Visualized portion of paranasal sinuses and mastoid air cells are within normal limits. Tubular hyperdense material at the right posterior fossa, likely blood in the transverse venous sinus; less likely, given its stability (including since the [**Hospital 4199**] Hospital study of 10 hours earlier), is small focal subdural hemorrhage. IMPRESSION: 1. Persistent soft tissue edema at right parietal area with underlying comminuted fracture of the squamous portion of the right temporal bone, with 4-5 mm depression of bony fragments, as before. 2. Subtle hyperattenuating focus in the right temporal lobe, unchanged over the 7 hour interval, may represent either very small contusion or diffuse axonal injury. 3. No new hemorrhage. The study and the report were reviewed by the staff radiologist. CT ABDOMEN W/CONTRAST Study Date of [**2148-5-19**] 10:07 PM Wet Read: IPf SUN [**2148-5-19**] 11:02 PM Preliminary Report !! WET READ !! no evidence of acute injury on ct TRAUMA #3 (PORT CHEST ONLY) Study Date of [**2148-5-19**] 9:59 PM Final Report SINGLE UPRIGHT AP PORTABLE VIEW CLINICAL INFORMATION: 51-year-old male with history of trauma. COMPARISON: [**2140-7-9**]. FINDINGS: Single AP upright portable view of the chest was obtained. There are relatively low lung volumes. Mild prominence of the superior mediastinum is without significant change since the prior study and likely relates to AP technique. The cardiac silhouette is unchanged. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. No displaced fracture is identified. IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: Pt was admitted to the icu for close observation and neuro checks. His repeat imaging was stable and his exam non focal. He wishes to go home today. Social work was asked to see pt prior to discharge for history of physical altercations and alcohol intoxication on admission. He was later discharged to home. Medications on Admission: none Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: do not drive while taking this medication. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: right temporal bone fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2148-5-20**]

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27962

Discharge summary

report

Admission Date: [**2129-4-7**] Discharge Date: [**2129-4-8**] Date of Birth: [**2079-10-28**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2712**] Chief Complaint: Lower GI Bleed Major Surgical or Invasive Procedure: EGD, colonoscopy [**2129-4-8**] History of Present Illness: Ms. [**Known lastname **] is a 49 year old female with a history of celiac disease, alcoholic cirrhosis, who initially presented to her regularly scheduled liver clinic appointment where she was complaining of BRBPR for the past few days. She says that over the past few days at home, when she was going to the bathroom she would see what she describes as cherry colored blood on the toilet paper and in the toilet bowl. She has also had some epigastric abdominal pain over the past few days, otherwise she has been feeling pretty well. She was recently started on diuretics for her ascites and that has improved significantly, as has her lower extremity edema. She said that she would not have come in for the bleeding, but thought that she would mention it in the office today. She says that she has been eating and drinking well, and that her only other concern was that she has occasionally been getting bloody noses since her admission with repeated attempts at feeding tube placement. After a discussion between the nurse practitioner and Dr. [**Last Name (STitle) 497**] she was referred into the ER for further evaluation. In the ED, initial VS were: 99.1, 118, 142/79, 20, 100% on RA. Her labs were notable for a HCT of 28.2 from 32 in the end of [**Month (only) 958**] and 36 in the middle of [**Month (only) 958**], her INR was 1.4, platelets 359. A RUQ ultrasound showed stable gallbladder sludge and wall edema, known cirrhosis and no ascites. She received 2L of NS, but remained tachycardic particularly with movement at times up to the 120's, so she was admitted to ICU for closer monitoring. . On arrival to the MICU, her initial VS were: 98.5, 89, 123/73, 18, 100% on RA. Her only current complaint is that she still has some mild epigastric pain, otherwise feels well. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. . Past Medical History: Alcoholic Hepatitis Alcoholic Cirrhosis Celiac disease diagnosed 1 yr ago by biopsy Hx jaundice at birth and 2 episodes at around 9 and 11 yr old for about 2 wks each time that resolved spontaneously. appendectomy diagnostic laparoscopy for ovarian cyst back, ankle, wrist surgeries Social History: Denies tobacco. Admits to heavy EtOH use since the age of 18 yr old, cut back 5 yrs ago, 1 yr ago was only drinking socially and has completely stopped for the past month. Denies illicit drug use. Was recently working as a practice manager, now unemployed. Family History: [**Name (NI) **], mother and 2 brothers have insulin dependent diabetes. Mother died 6 months ago. Father died of heart disease 6 years ago, suffered from recurring GI problems suggestive of celiac dz prior to that. Physical Exam: General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Extremities: Right lower extremity edema: Trace, Left lower extremity edema: Trace Skin: Warm Neurologic: Attentive, Responds to: Verbal stimuli, Oriented (to): person. place, time , Movement: Not assessed, Tone: Increased Pertinent Results: [**2129-4-7**] 08:40PM BLOOD WBC-12.2* RBC-3.18* Hgb-8.8* Hct-28.2* MCV-89# MCH-27.7# MCHC-31.2 RDW-16.3* Plt Ct-397 [**2129-4-7**] 08:40PM BLOOD PT-14.0* PTT-28.1 INR(PT)-1.3* [**2129-4-7**] 08:40PM BLOOD Glucose-126* UreaN-20 Creat-0.9 Na-137 K-4.5 Cl-102 HCO3-24 AnGap-16 [**2129-4-7**] 08:40PM BLOOD ALT-64* AST-70* AlkPhos-135* TotBili-1.3 [**2129-4-7**] 08:40PM BLOOD Albumin-3.6 Phos-3.8 Mg-2.3 . RUQ U/S [**2129-4-7**]: FINDINGS: The liver is diffusely echogenic, compatible with known cirrhosis. The degree of echogenicity limits evaluation for focal liver lesions, but no lesion is identified. There is no intra- or extra-hepatic bile duct dilation. The common duct is not dilated measuring 4 mm. A small amount of layering sludge is seen within the gallbladder, which is not dilated. Mild gallbladder wall edema is nonspecific in the setting of liver disease. Son[**Name (NI) 493**] [**Name2 (NI) 515**] sign is negative. Doppler assessment of the main portal vein shows patency and normal hepatopetal flow. Normal color flow is seen in the left portal, right anterior portal and right posterior portal veins. Single views of the right and left kidneys show no hydronephrosis, measuring 9.5 and 10.6 cm respectively. The spleen is normal measuring 9.9 cm. There is no ascites. IMPRESSION: 1. Echogenic liver compatible with fatty deposition and known cirrhosis. No focal liver lesion identified. 2. Gallbladder wall edema and a small amount of sludge appear longstanding. No specific superimposed evidence for acute cholecystitis. . EGD [**2129-4-8**]: Esophageal candidiasis (biopsy) Abnormal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum. . COLONOSCOPY [**2129-4-8**]: Diverticulosis of the sigmoid colon Grade 1 internal hemorrhoids Prominent rectal veins were noted. No clear rectal varices seen. Otherwise normal colonoscopy to cecum Brief Hospital Course: Ms. [**Known lastname **] is a 49 y/o female with a history of alcoholic cirrhosis, recent alcoholic hepatitis on prednisone who presents from liver clinic with episodes of bright red blood per rectum for the past few days. . #) Likely Lower GI Bleed: based on her description of the bleeding and rectal exam in the ER with red blood in the vault and external hemorrhoids, seems most consistent with lower GI bleed. Colonoscopy confirmed grade 1 internal hemorrhoids as likely source, though not actively bleeding. She also had prominent rectal veins but no varices. She was advised to follow a high fiber diet. She remained hemodynamically stable without need for PRBCs. She was instructed to call the liver center after the weekend of discharge to discuss follow up. She had an EGD in [**Month (only) 958**] with no evidence of varices. . #) Epigastric Pain: stable RUQ ultrasound, no evidence of cholecystitis, she has been on high doses of prednisone which could be causing gastritis. Likely explanation was esophageal candidiasis given findings on EEG. She was loaded with 200mg of PO fluconazole and given a 2 week course of 100mg daily. She was advised to follow a gluten free diet given findings on EGD consistent with her known celiac disease . #) Alcoholic Cirrhosis: no evidence of decompensation at this time. Advised to stop drinking. Held home diuretics. Ttransitioned to solumedrol while prepping for colonoscopy then changed back to prednisone post colonoscopy for her ETOH hepatitis taper. . #) Transitional issues: -Pt to call liver center after the weekend for follow up Medications on Admission: Home Medications: folic acid 1 mg once a day Lasix 20 mg once a day Reglan 5 mg three times a day mirtazapine 15 mg at bedtime omeprazole 20 mg at bedtime prednisone 30 mg daily Aldactone 50 mg once a day, calcium with vitamin D multivitamin Discharge Medications: 1. fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 13 days: Take your next dose tomorrow [**4-9**]. Disp:*13 Tablet(s)* Refills:*0* 2. folic acid Oral 3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Reglan 5 mg Tablet Sig: One (1) Tablet PO three times a day. 5. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO once a day. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. prednisone 20 mg Tablet Sig: 1.5 Tablets PO once a day. 8. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. Calcium+D Oral 10. multivitamin Oral Discharge Disposition: Home Discharge Diagnosis: Hemorrhoids Esophageal candidiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname **], You were admitted to the ICU for concern for GI bleed. You underwent both an upper and lower endoscopy which showed no active bleeding but changes consistent with your celiac disease and likely fungal infection, as well as hemmorhoids which are likely the source of your recent bleeding. Please follow a gluten free, high fiber diet. We strongly advise that you abstain from alcohol. Please call the liver center on Monday to discuss when your next lab draw would be. We started the following medication: Fluconazole 100mg by mouth for 2 weeks for fungal infection in your esophagus Followup Instructions: Please call the liver center on monday to discuss when you should follow up Department: [**Hospital3 249**] When: THURSDAY [**2129-4-14**] at 5:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36070**], LICSW [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: LIVER CENTER When: FRIDAY [**2129-8-5**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2118-2-8**] Discharge Date: [**2118-2-16**] Date of Birth: [**2042-12-20**] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin / Lisinopril Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2118-2-8**] Aortic valve replacement with a [**Street Address(2) 11688**]. [**Hospital 923**] Medical Biocor tissue valve. History of Present Illness: 74 year old female with worsening dyspnea on exertion referred for cardiac catheterization and then referred for surgical evaluation for aortic valve replacement Past Medical History: Hypertension Hyperlipidemia Diabetes Mellitus CAD s/p stenting of RCA and LAD at [**Hospital1 18**] [**5-15**] Aortic Stenosis Right Bundle Branch Block Chronic Right Lower Extremity Edema Histiocystosis in [**2086**], s/p chemo and radiation to abdomen area Stress Incontinence Gout s/p cholecystectomy s/p tonsillectomy Social History: Lives with:husband and son Occupation:Retired Tobacco:Quit [**2110**]; 1ppd since age 14 ETOH:Denies Family History: Father died of MI age 78 Mother died of MI age 75 sister died of MI age 59 Physical Exam: Pulse:75SR Resp:20 O2 sat:98% RA B/P Right:156/75 Left:155/70 Height:5'5" Weight:250 lbs General: WDWN in NAD Skin: Warm, dry and intact. Chronic venous stasis changes of bilateral LE's. Left leg is larger then right. HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. No JVD. Edentulous. Neck: Supple [X] Full ROM [X]. Thyromegally noted left side > right Chest: Lungs clear bilaterally [X] Heart: RRR, IV/VI SEM Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Obese. Extremities: Warm [X], well-perfused [X] + Edema 2+ left 1+ right. Chronic venous stasis changes. Varicosities: Supeficial noted on standing Neuro: Grossly intact, MAE, Slow but steady gait Pulses: Femoral Right:2 Left:2 DP Right:trace Left:trace PT [**Name (NI) 167**]:trace Left:trace Radial Right:1 Left:1 Carotid Bruit Transmitted vs brui bilaterally Pertinent Results: [**2118-2-8**] 07:38AM HGB-10.4* calcHCT-31 [**2118-2-8**] 07:38AM GLUCOSE-99 LACTATE-1.4 NA+-140 K+-4.3 CL--108 [**2118-2-8**] 11:00AM PT-13.9* PTT-35.4* INR(PT)-1.2* [**2118-2-8**] 11:00AM PLT COUNT-269 [**2118-2-8**] 11:00AM WBC-17.5*# RBC-2.83*# HGB-8.0*# HCT-24.6*# MCV-87 MCH-28.2 MCHC-32.5 RDW-16.3* [**2118-2-8**] 11:58AM UREA N-29* CREAT-1.1 CHLORIDE-113* TOTAL CO2-23 [**2118-2-16**] 04:27AM BLOOD WBC-11.3* RBC-3.55* Hgb-9.8* Hct-30.6* MCV-86 MCH-27.5 MCHC-31.8 RDW-16.0* Plt Ct-421 [**2118-2-16**] 04:27AM BLOOD Plt Ct-421 [**2118-2-16**] 04:27AM BLOOD PT-21.0* INR(PT)-1.9* [**2118-2-16**] 04:27AM BLOOD Glucose-86 UreaN-49* Creat-1.5* Na-140 K-3.7 Cl-97 HCO3-33* AnGap-14 [**2118-2-16**] 04:27AM BLOOD ALT-52* AST-44* LD(LDH)-311* AlkPhos-158* Amylase-133* TotBili-0.4 [**2118-2-16**] 04:27AM BLOOD Lipase-220* [**2118-2-16**] 04:27AM BLOOD Albumin-3.1* Mg-2.4 CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 41795**] Final Report HISTORY: Status post AVR, to evaluate for pleural effusion. FINDINGS: In comparison with the study of [**2-13**], there is little change in the bibasilar pleural effusions, more prominent on the left. Engorgement of pulmonary vessels is consistent with elevated pulmonary venous pressure in this patient with mild enlargement of the cardiac silhouette. Central catheter remains in place. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**] Approved: TUE [**2118-2-15**] 9:06 AM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Indication: Aortic valve disease. Coronary artery disease. Left ventricular function. Preoperative assessment. Echocardiographic Measurements Results Measurements Normal Range 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: 5.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Aorta - Annulus: 2.1 cm <= 3.0 cm Aorta - Ascending: 2.9 cm <= 3.4 cm Aortic Valve - Mean Gradient: 62 mm Hg Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild global LV hypokinesis. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Significant AS is present (not quantified) Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. 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. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PREBYPASS A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis (LVEF = 45-50 %). Overall left ventricular systolic function is mildly depressed Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. Significant aortic stenosis is present (not quantified). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS Left ventricular systolic function has improved. LVEF > 55%. RV systolic function is preserved. There is a well seated, well functioning bioprosthesis in the aortic position. No aortic insufficiency is visualized. The study otherwise remains unchanged from prebypass. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2118-2-8**] 11:02 Brief Hospital Course: Admitted same day surgery and underwent aortic valve replacement. See operative report for further details. She received cefazolin for perioperative antibiotics. Post operatively she was transferred to the intensive care unit for management. In the first twenty four hours she was weaned from sedation, awoke neurologically intact and was extubated without complications. In addition she had oliguria with rise in creatitine from baseline 1.1 to 1.6 peak due to hypovolemia, in which she received volume after echocardiogram revealed unchanged left ventricular function. She remained in the intensive care unit for pulmonary management and had required bipap for few hours on post operative day one and was started on bumex drip for diuresis with response. She developed atrial fibrillation that was treated with amiodarone and beta blockers, and she was started on coumadin for anticoagulation. On [**2118-2-12**] she had right upper quadrant abdominal pain with elevated amylase and lipase, surgery was consulted, she was made npo and monitored. Her pain resolved on its own, and her diet was resumed. Her activity level was slow to progress and after she was transferred to the floor. Physical therapy worked with her on strength and mobility. On POD 8 she was ready for transfer to rehabilitation for continued strenghth and activity management. Medications on Admission: Allopurinol 100mg po BID Amlodipine 10mg po daily Bumetanide 2mg po daily Glyburide 2.5mg po BID Levothroxine 50 mcg po daily Lisinopril 2.5mg po daily Metformin 500mg po daily Metoprolol Succinate 50mg po daily Actos 15mg po daily Simvastatin 40mg po daily ASA 325mg po daily Ferrous Sulfate 324 mg po daily MVI 1 tab daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 200mg [**Hospital1 **] x7 days then 200mg QD. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed for wheezing. 12. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day: 1mg on [**2-16**] then adjust dose to keep INR 2.0-2.5. Discharge Disposition: Extended Care Facility: Aberjona Nursing Center - [**Hospital1 2436**] Discharge Diagnosis: aortic stenosis s/p avr([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue) Post operative atrial fibrillation Hypertension Hyperlipidemia Diabetes Mellitus CAD s/p stenting of RCA and LAD at [**Hospital1 18**] [**5-15**] Aortic Stenosis Right Bundle Branch Block Chronic Right Lower Extremity Edema Histiocystosis in [**2086**], s/p chemo and radiation to abdomen area Stress Incontinence Gout Post operatively elevated creatinine post operatively elevated amylase and lipase Discharge Condition: Alert and oriented x3 nonfocal Ambulating, with assistance Sternal pain managed with tylenol prn Sternal wound healing well Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2118-3-17**] 1:00 Please call to schedule appointments Primary Care Dr [**First Name (STitle) **] [**Name (STitle) **] in [**1-15**] weeks [**Telephone/Fax (1) 39260**] Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5686**] [**Telephone/Fax (1) 62**] in [**1-15**] weeks PT/INR for coumadin dosing - three times a week until on steady dose - goal INR 2.0-2.5 for atrial fibrillation Completed by:[**2118-2-16**]

[ "427.31", "424.1", "997.1", "250.00", "401.9", "272.4", "518.5", "278.01", "414.01", "426.4", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

9509, 9582

6685, 8048

312, 440

10124, 10249

2151, 5286

10873, 11426

1113, 1190

8424, 9486

9603, 10103

8074, 8401

10273, 10850

5330, 6662

1205, 2132

252, 274

468, 632

654, 978

994, 1097

9,555

154,441

5564

Discharge summary

report

Admission Date: [**2155-3-2**] Discharge Date: [**2155-3-12**] Date of Birth: [**2106-10-1**] Sex: M Service: [**Doctor Last Name 1181**] CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old male with a history of Crohn's disease, short gut, and multiple line infections. The patient was in his usual state of health until that week prior to admission when he began having frontal headaches and myalgias. For the last two days prior to admission, the patient had increasing shortness of breath first with exertion and then finally also at rest. The patient also complains of orthopnea, but no PND. He denies cough, fevers, but does have chills. No chest pain, no palpitations. No tenderness or erythema at his Port-A-Cath sites. He says his ostomy output is normal. No melena, no bright red blood, and states that his son has had a viral illness the last two weeks. The patient presented to [**Hospital6 33**] on the date of admission. Had a chest x-ray read as being consistent with mild heart failure. Got 20 of IV Lasix with 2 liters of urine output. Had a CTA which was of suboptimal quality showing no evidence of pulmonary embolus. Patient also states he has had lower back pain for one week, and no relief with Tylenol. PAST MEDICAL HISTORY: 1. Crohn's disease. 2. Status post proctocolectomy. 3. Short gut syndrome. 4. History or methicillin sensitive Staphylococcus aureus line infection. 5. History of septic emboli to the lungs in [**2151**] and again in [**2154-10-27**]. 6. Status post cholecystectomy. 7. Status post parathyroidectomy. ALLERGIES: The patient has no known drug allergies. MEDICATIONS AT HOME: 1. Imodium. 2. 6MP. SOCIAL HISTORY: The patient is married. Works at [**Hospital6 3622**]. No tobacco, no alcohol. Is an active runner. FAMILY HISTORY: No history of Crohn's. PHYSICAL EXAMINATION: On admission, the patient's temperature was 100.0, pulse is 90, blood pressure 89/45, breathing at 30x a minute, and sating 98% on room air. Generally, he was ill appearing but alert and oriented times three. HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are intact. Conjunctivae were slightly icteric. Neck: Jugular venous pressure was about 7 cm. Neck was supple. Chest has crackles at the bases bilaterally. Port-A-Cath site in the left chest was clean, no fluctuance or tenderness around the site of the catheter. Cardiovascular examination was regular rate, no murmurs. Abdomen was soft, nontender, nondistended. Ostomy was in place. There is no hepatosplenomegaly. Extremities: No edema. Skin: There is no evidence of splinter hemorrhages, no rash, no evidence of Osler nodes or other embolic phenomenon. Back had no spinal or paraspinal tenderness. LABORATORIES: On admission, the patient's laboratories were notable for a BUN of 25 and creatinine of 1.4 which is elevated from the patient's normal baseline of 0.8 to 1.0. Patient had a white count of 10 with differential of 66 neutrophils and 26 bands, hematocrit of 36.8 and platelets of 70. His INR was 1.2. PTT 30.8. First set of cardiac enzymes: CK of 50, troponin of less than 0.3. Electrocardiogram was notable for sinus at 85 with a normal axis, normal P-R, QTC, and QRS intervals, no ST-T changes. In short, this is a 48-year-old male with a history of Crohn's and recurrent line infections complicated by septic emboli, who recently completed a course of oxacillin in [**12-29**], who now presents with shortness of breath. HOSPITAL COURSE: 1. Infectious Disease: Patient clearly infected on admission without evidence of clear source. Blood cultures were drawn at the time of admission from both ports of his Port-A-Cath as well as from the periphery. After transfer to the floor, the patient became increasingly hypotensive requiring fluid bolusing to maintain blood pressure in the 70s. Patient received a total of 4 liters of fluid on the floor, and at which time he had begun to desaturate and require oxygen. Thus, he was started on dopamine and transferred to the MICU. Patient's cardiovascular course will be discussed below. Patient was covered initially with levofloxacin and Vancomycin. He also received one dose of ceftriaxone 2 grams IV for concern of meningitis. On the morning after admission to the MICU, the patient's blood cultures were positive with gram-positive cocci in pairs and clusters. These were subsequently identified as being methicillin-sensitive Staphylococcus aureus. The patient was treated with oxacillin and gentamicin for synergy. Gentamicin was stopped after three days. The most likely source of the patient's infection was his Port-A-Cath. Thus this was removed while in the MICU without event. Culture tip was positive for methicillin-sensitive Staphylococcus aureus greater than 15 colonies. Over the next several days following admission to the MICU, the patient's chest x-ray showed evidence of infiltrate. The patient was started on levofloxacin for possible community acquired pneumonia. Further review of chest x-ray revealed that these infiltrates are most likely consistent with septic emboli. However, CT scan of his chest was done to better visualize his lung parenchyma. CT scan suggested areas of cavitation consistent with septic emboli as well as areas of more diffuse consolidation consistent with bacterial superinfection. Thus, the patient was continued on a 10 day course of levofloxacin. The patient's blood cultures were clear three days after starting antibiotics. However, he continued to spike fevers for several days. At the time of discharge, the patient had been afebrile for greater than 48 hours. The patient was evaluated by the Infectious Disease consultation service while hospitalized. The patient had a negative transthoracic echocardiogram as well as a negative transesophageal echocardiogram to rule out endocarditis. The patient also had a MRI of his spine. There was a questionable signal abnormality at S3, however, no surrounding changes in the bone. Thus, the patient underwent a tagged white blood cell scan, which showed no evidence of increased that might be seen with infection. The patient will follow up with the Infectious Disease Clinic and continue a six week course of oxacillin for treatment of his bacteremia/septicemia. 2. Cardiovascular: Patient became hypotensive as noted above shortly after admission to the floor. Hypotension was somewhat responsive to fluid bolusing on the floor. However, the patient had increasing oxygen needs, thus he was started on dopamine and transferred to the MICU. Once in the MICU, dopamine was weaned quickly, and patient was aggressively fluid resuscitated. The likely etiology of this patient's hemodynamic compromise due to sepsis and bacteremia. The patient remained normotensive throughout the rest of his hospital course. As noted above, the patient had negative workup for endocarditis. His echocardiogram showed no evidence of valvular abnormalities and a normal ejection fraction. 3. Hematology: The patient's platelets were 70 upon admission. They continued to remain low. The patient's DIC screen were equivocal. However, his coags were also elevated. This is likely due to sepsis after the patient had been treated with antibiotics. The platelets began to rise. These normalized as did his coags after treatment with antibiotics. Both the patient's coags and his platelets were normal at the time of discharge. 4. Renal: The patient had acute renal failure at the time of presentation. Urine electrolytes revealed that this is probably prerenal due to sepsis and hypoperfusion. With aggressive fluid resuscitation, the patient's BUN and creatinine returned to [**Location 213**]. 5. Pulmonary: Patient's presenting complaint was shortness of breath and first chest x-ray at outside hospital was read as being consistent with congestive heart failure. However, more likely, the patient had capillary leak due to his sepsis. The patient also developed septic emboli as a complication of his bacteremia, and was felt to have superinfection as well. Patient's oxygenation improved after treatment with ox and with levofloxacin. The patient will complete a 10 day course of levofloxacin for possible bacterial superinfection. 6. GI: The patient's bilirubin was found to be elevated upon admission at 2.0. This continued to climb in an isolated manner reaching a peak at around 4.0 before trending downward. Isolated bilirubin was thought to be secondary to sepsis. However, patient also developed a slight transaminitis after being started on oxacillin. Although his LFTs remained elevated, they were stable. The patient will follow up with LFTs twice a week while he is on oxacillin to avoid further increase in his transaminases. Patient's Crohn's remains stable throughout his admission with normal ostomy output. 7. Nutrition: The patient was continued on TPN while in-house as well as po intake as desired. CONDITION ON DISCHARGE: The patient is discharged in good condition on [**2155-3-12**]. FOLLOW-UP INSTRUCTIONS: He will follow up with Dr. [**First Name (STitle) 572**] as needed for primary care. He will also followup with Dr. [**Last Name (STitle) 1005**] of Infectious Diseases on [**4-3**]. Patient will follow up with Dr. [**Last Name (STitle) 519**] for wound care and the possibility of new Port-A-Cath placement once he has finished his course of oxacillin and has repeat blood cultures that are negative. FINAL DISCHARGE DIAGNOSES: 1. Line infection. 2. Methicillin-sensitive Staphylococcus aureus bacteremia. 3. Septic emboli to the lungs. 4. Crohn's disease. 5. Short gut syndrome. DISCHARGE MEDICATIONS: 1. Oxacillin 2 grams q4h for 4.5 weeks. 2. 6MP. 3. Imodium. 4. DTO. 5. Levofloxacin 500 mg IV q day for two remaining days. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], M.D. [**MD Number(1) 6243**] Dictated By:[**Name8 (MD) 8330**] MEDQUIST36 D: [**2155-3-12**] 15:10 T: [**2155-3-13**] 05:59 JOB#: [**Job Number 22397**]

[ "287.4", "579.3", "555.9", "038.11", "E879.8", "584.9", "996.62", "V44.3", "486" ]

icd9cm

[ [ [] ] ]

[ "86.05", "38.93", "99.15", "89.68" ]

icd9pcs

[ [ [] ] ]

1860, 1884

9768, 10157

3572, 9045

1701, 1722

1907, 3555

173, 195

9592, 9745

224, 1302

9160, 9565

1324, 1680

1739, 1843

9070, 9135

44,203

148,942

42306

Discharge summary

report

Admission Date: [**2121-10-10**] Discharge Date: [**2121-10-14**] Date of Birth: [**2041-4-1**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: re-do sternotomy AVR (25 tissue) History of Present Illness: Past Medical History: Cornary artery disease Aortic valve stenosis Mild renal insufficiency (Creat 1.4) Hypothyroid Hypertension Obesity Hyperlipidemia Osteoarthritis Varicose veins Depression/Anxiety Recent Teeth Extractions on [**2121-9-26**] Pubovaginal sling Hysterectomy CABGx2 in [**2111**] at [**Hospital3 2358**] - unable to obtain op note Knee replacement (Bilateral) Vein stripping and ligation bilaterally Past Cardiac Procedures: CABG [**2111**] Social History: Race: Caucasian Last Dental Exam: [**2121-9-26**] Lives with: Alone in [**Hospital3 **] Contact: Daughter Phone # Occupation: Retired Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: < 1 drink/week [X] [**1-13**] drinks/week [] >8 drinks/week [] Illicit drug use Family History: non-contributory Physical Exam: Physical Exam BP: 143/69 Pulse: 67 Resp: 16 O2 sat: 96% Height: 63 inches Weight: 194 lbs General: WDWN female in NAD...obese Skin: Warm, Dry and intact. Well healed sternotomy. HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Teeth in fair repair. Partial upper/lower plates noted. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR [X], III/VI SEM Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema Varicosities: ? Incision at left knee. Anterior varicosities bilaterally. 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 Transmitted murmur to carotids R>L Pertinent Results: ECHO [**10-10**] PRE-BYPASS: -No spontaneous echo contrast is seen in the body of the left atrium. -The right atrium is dilated. -The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). with normal free wall contractility. -There are complex (>4mm) atheroma in the aortic arch. There are complex (mobile) 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 severely thickened/deformed. There is critical aortic valve stenosis (valve area 0.7cm2). Mild (1+) aortic regurgitation is seen. -The mitral valve leaflets are moderately thickened. Trace to mild (1+) mitral regurgitation is seen. -Dr. [**Last Name (STitle) 914**] was notified in person of the results in the operating room. POSTBYPASS: There is a bioprosthetic aortic valve in the aortic position. The valve appears well-seated with normal leaflet mobility. There are no paravalvular leaks seen and no AI. LV systolic function remains normal with estimated EF>55%. Other valvular function remains unchanged. There is no evidence of aortic dissection. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2121-10-10**] where the patient underwent re-do sternotomy AVR (25 tissue). See operative note for details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Cefazolin was used for surgical antibiotic prophylaxis. 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 to Heritage nursing in rehab in [**Hospital1 189**] in good condition with appropriate follow up instructions. Medications on Admission: ATENOLOL 25 mg daily, BUPROPION HCL 150 mg daily, CLONAZEPAM 2 mg daily, LEVOTHYROXINE 12.5 mcg daily, PRAVASTATIN 40 mg daily, PENICILLIN - UNKNOWN DOSE, ACETAMINOPHEN 500 mg daily, ASPIRIN 81 mg daily, CHOLECALCIFEROL 1,000 unit [**Hospital1 **], DIPHENHYDRAMINE daily, MULTIVITAMIN-MINERALS-LUTEIN daily, OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. 6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 7. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Disp:*65 Tablet(s)* Refills:*0* 11. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 12. levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. 14. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 15. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 5 days. Discharge Disposition: Extended Care Facility: Heritage Manor Discharge Diagnosis: Cornary artery disease, Aortic valve stenosis, Mild renal insufficiency (Creat 1.4), Hypothyroid, Hypertension, Obesity, Hyperlipidemia, Osteoarthritis, Varicose veins, Depression/Anxiety, Recent Teeth Extractions on [**2121-9-26**], Pubovaginal sling, Hysterectomy CABGx2 in [**2111**] at [**Hospital3 2358**], Knee replacement (Bilateral), Vein stripping and ligation bilaterally, s/p CABG [**2111**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with percocet Incisions: Sternal - 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**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] [**2121-11-17**] at 1pm in the [**Hospital **] medical office building [**Doctor First Name **] [**Hospital Unit Name **]. Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39975**] [**2121-11-4**] at 8:40am Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 74598**] in [**3-11**] weeks Completed by:[**2121-10-14**]

[ "424.1", "593.9", "585.9", "244.9", "272.4", "403.90", "V43.65", "V85.32", "278.00", "414.00", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

6274, 6315

3276, 4488

330, 365

6762, 6932

2070, 3253

7858, 8409

1199, 1217

4893, 6251

6336, 6741

4514, 4870

6956, 7835

1232, 2051

271, 292

394, 394

416, 854

870, 1183

24,431

133,478

48856

Discharge summary

report

Admission Date: [**2197-8-27**] Discharge Date: [**2197-9-6**] Date of Birth: [**2173-1-19**] Sex: M HISTORY OF PRESENT ILLNESS: The patient is a 24-year-old male with a past medical history of obesity and obstructive sleep apnea who presented with complaints of increased swelling and a neck mass times one and half weeks. The six weeks prior to admission when he was operated on for the removal of a lipoma. The operation occurred without incident, and the patient did well. Approximately one and a half weeks prior to admission the patient noticed increased pain and swelling in the lateral aspect of his neck on the left side. He presented to the managed conservatively with pain management. However, the pain and swelling did not resolve. The patient then began to experience fevers and difficulty swallowing and difficulty turning his head. The patient has not had difficulty breathing. He denied trauma, insect bites, or sick contacts. [**Name (NI) **] presents for evaluation of his expanding neck mass. PAST MEDICAL HISTORY: 1. Obesity. 2. Obstructive sleep apnea. 3. Asthma. MEDICATIONS ON ADMISSION: Home medications include albuterol. ALLERGIES: There were no known drug allergies. SOCIAL HISTORY: The patient lives with his girlfriend and works at [**Hospital6 **]. He denied smoking, drug or alcohol use. FAMILY HISTORY: Family history was remarkable for diabetes mellitus in multiple first-degree relatives. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination in the Emergency [**Hospital1 **] revealed vital signs of temperature of 103.9, heart rate 108, respiratory rate 20, blood pressure 156/60. In general, the patient was a morbidly obese African-American male sitting in a chair, breathing with some effort, but in no apparent distress. Head, ears, nose, eyes and throat examination revealed normocephalic and atraumatic. Pupils were equal and reactive to light. Extraocular muscles were intact. Neck examination revealed a warm mass posterior to the left ear about 20 cm X 8 cm long. Pulmonary examination revealed decreased breath sounds throughout. Coronary examination was tachycardic, normal first heart sound and second heart sound. No murmurs, rubs or gallops. The abdomen was obese, soft, nontender, and nondistended, with no rebounding, guarding or hepatosplenomegaly, and there were bowel sounds times four. Extremity examination revealed 2+ peripheral pulses. No clubbing, cyanosis or edema. LABORATORY DATA ON PRESENTATION: Admission laboratories were white blood cell count 19.1, hemoglobin 12.7, hematocrit 35.7, platelets 215. Sodium 131, potassium 4.6, chloride 92, bicarbonate 23, blood urea nitrogen 10, creatinine 0.9. RADIOLOGY/IMAGING: CT scan of the neck revealed a splenius capitus myositis and cellulitis overlying with fluid tracking between plains. There was no evidence of abscess at that time. HOSPITAL COURSE: 1. ENDOCRINE: The patient was newly diagnosed with diabetes mellitus. He was treated with sliding-scales which were adjusted throughout his hospital stay. During his course in the Intensive Care Unit he was maintained on an insulin drip. 2. INFECTIOUS DISEASE: (a) Neck mass: The patient was initially admitted to the general medicine floor for intravenous antibiotics, pain management, and close followup by Otorhinolaryngology. Infectious Disease was consulted for further evaluation of the patient's neck mass, and the consultants recommended the addition of vancomycin, clindamycin, and to continue Unasyn which the patient had been started on. Blood cultures ultimately returned growing coagulase-positive Staphylococcus. The patient's swelling continued to increase, but his respiratory status remained stable. His fevers continued as well. A chest CT examination was checked to examine for extension into the mediastinum, and this was negative. Serial neck CT examinations revealed increase in edema, fat stranding, and possible abscess formation. The patient was then seen on consultation by Neurosurgery to evaluate for extension into the neurologic system. On [**2197-8-29**], the patient was taken to the operating room for drainage of a left posterior neck abscess, and 30 cc to 40 cc of pus was expressed and drained. Extensive necrosis surrounding this are was noted. The patient remained intubated for airway protection following the procedure, and he was transferred in good condition to the Surgical Intensive Care Unit. He was followed by the Medicine consultation team for ongoing diabetes management. Antibiotics were continued and adjusted as required by sensitivities. On [**2197-8-31**], routine laboratories revealed that the patient's hematocrit had been declining, and his white blood cell count had been increasing. Clinically, the patient's neck mass began to increase in size again. That day the patient suffered an episode of hypotension to a systolic blood pressure in the 90s, and he was tachycardic. He was given large volume intravenous fluids and transfusions of packed red blood cells to restore blood volume and blood pressure. He responded well to this treatment; however, over the course of that evening the patient developed atrial flutter. The patient was felt to be septic and extubation was deferred. Antibiotics were readjusted, and pressors were used p.r.n. to maintain blood pressure. On [**2197-9-1**], the patient's fevers continued. The wound was explored at bedside. There was no new drainage, but there were increased adhesions. White blood cell count continued to rise. The patient was seen in consultation by the Cardiology Service to evaluate for his atrial flutter and to receive a transesophageal echocardiogram to rule out endocarditis. Transesophageal echocardiogram was negative for endocarditis. Cardiology recommended cardioversion and flecainide for stabilization of the patient's rhythm. The patient was transferred to the Medical Intensive Care Unit. His fevers persisted. White blood cell count continued to increase. Hypotension continued to be treated with large volume intravenous fluids to maintain blood pressure. Over the evening of [**2197-9-2**], the patient developed atrial fibrillation to the 130s. He was cardioverted to normal sinus rhythm and extubation was again deferred. The patient's urine also was noted to become rust colored, and his liver function tests began to rise. A repeat CT scan was suspicious for persistent pus in the neck. On [**2197-9-3**], the possibility of meningitis was entertained, and a lumbar puncture was attempted to rule out meningitis. The patient's fevers continued, and the patient developed an increasing oxygen requirement. The patient was again taken to the operating room and an incision an drainage was performed, and a drainage of prevertebral collection of fluid was drained as well. On [**2197-9-4**], the fevers continued. The patient continued to require pressors as necessary to maintain blood pressure. Lumbar puncture was again attempted, and this was again unsuccessful. The patient underwent bronchoscopy to remove mucous plugs felt to be contributing to the patient's increasing oxygen requirements. A repeat CT scan revealed a possible persistent neck abscess and possible lower lung collapse, possibly consistent with acute respiratory distress syndrome. On [**2197-9-5**], the patient was noted to continue to require increasing oxygen. A repeat bronchoscopy was performed and some mucous plugs were obtained. The patient continued to have very high fevers with very elevated creatine kinase levels. The diagnosis of malignant hyperthermia was entertained. The patient's urine output declined, and the possibility of acute tubular necrosis secondary to rhabdomyolysis or sepsis was entertained. On [**2197-9-6**], the patient was seen on consultation by Nephrology. CVVHD was recommended and undertaken. For the patient's persistent very high fevers dantrolene was given for possible malignant hyperthermia. This resulted in hypothermia. The patient continued to have a worsening metabolic and respiratory acidosis over the day of [**9-6**]. THAM and bicarbonate were given to treat for this. Additionally, the patient's platelets were declining, and this was felt to be consistent with disseminated intravascular coagulation. During the day of [**9-6**], the patient continued to have hemodynamic instability. On the morning of [**9-6**], the patient suffered an episode of hypotension and asystolic arrest. Advanced cardiac life support protocols were initiated. The patient was successfully revived; however, remained in very critical condition. During that day, further arrests times two occurred with successful revival but continued hypotension, septic physiology, and bradycardia. Family meetings were held throughout the day to update family members as events unfolded. A late day family meeting took place where the patient's critically ill status was discussed with the family. At the end of that meeting the patient again became bradycardic. At that time the patient's family determined that no further resuscitative efforts should be made. At approximately 6:15 p.m. on [**2197-9-6**], the patient became bradycardic and hypotensive. No intervention was undertaken. The patient became asystolic. The patient was pronounced expired at 18:40 on [**2197-9-6**]. An autopsy was performed, per the family's request. DISCHARGE DIAGNOSES: 1. Diabetes mellitus. 2. Staphylococcal sepsis. 3. Neck abscess. [**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D. [**MD Number(1) 8868**] Dictated By:[**Name8 (MD) 2665**] MEDQUIST36 D: [**2197-12-13**] 12:53 T: [**2197-12-16**] 04:33 JOB#: [**Job Number 102628**]

[ "250.02", "486", "584.9", "278.01", "427.32", "682.1", "493.90", "276.6", "038.11" ]

icd9cm

[ [ [] ] ]

[ "86.11", "33.24", "96.72", "03.31", "38.95", "86.04" ]

icd9pcs

[ [ [] ] ]

1374, 2908

9477, 9818

1142, 1228

2926, 9456

146, 1038

1060, 1115

1245, 1356

78,568

106,334

34562

Discharge summary

report

Admission Date: [**2118-8-14**] Discharge Date: [**2118-8-19**] Date of Birth: [**2063-5-16**] Sex: M Service: MEDICINE Allergies: Prochlorperazine / Iodine Attending:[**First Name3 (LF) 3016**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 79353**] is a 55 yo man w/ metastatic melanoma and known mets to brain (incl cerebellum), who presents with one day of headache and altered mental status. History is obtained by the patient's wife due to the patient being sedated from the ED. Over the past few days prior to admission, the pt's wife notes that he had not been sleeping well at night due to increased urinary frequency. However, other than feeling more tired during the day he had been overall doing well. On the morning prior to admission, the patient developed a severe headache, associated with nausea and several episodes of bilious vomiting. He was unable to keep down any POs. Additionally, he had increasing confusion and agitation and so was taken to [**Hospital3 12748**]. In the ED there, head CT revealed hemorrhage of some of his brain mets with 2mm midline shift and mild hydrocephalus. He received 8mg IV dexamethasone, 4mg IV morphine x 2, and zofran. [**Hospital1 18**] oncology fellow was contact[**Name (NI) **] and transfer was arranged. Of note, pt has had 2 recent admissions to [**Hospital1 18**] with nausea, vomiting, dizziness and dehydration. This was felt to be due to combination of Taxol and progression of CNS disease. During admission Mr. [**Known lastname 79353**] was made aware that surgical resection of the cerebellar metastasis may relieve these symptoms, however, he has refused any kind of surgery on more than one occasion on review of the medial record. He was placed on 4 mg every 8 hours of dexamethasone and was discharged with home IV fluids and PICC line on [**2118-7-19**]. In the ED, initial vs were: T 97.5, P 60, BP 166/90, R 15, O2 sat 98% RA. Patient was agitated, but not talking or answering questions. He was given 3mg of ativan for sedation to obtain a repeat CT head. He brady'd to the 30s after receiving sedation, but HR improved up to low 100s spontaneously. Repeat CT head was reviewed by neurosurgery and showed no change from OSH imaging, without hydrocephalus or risk for herniation. Additionally, it was felt there was no significant change since his last imaging 2 months ago. Family declined surgical intervention, per his prior wishes. He was given decadron 10mg IV and transferred to the [**Hospital Unit Name 153**] for close monitoring. On arrival to the [**Hospital Unit Name 153**], the patient is somnolent and unarousable but appears comfortable. His wife is at the bedside. Past Medical History: PMH: 1. Metastatic melanoma: Onc hx adapted from recent onc clinic note by [**Doctor First Name **] [**Location (un) **]: Mr. [**Known lastname 79353**] [**Last Name (Titles) 1834**] wide local excision and left parotid neck node dissection for a 6 mm thick melanoma of his left parietal scalp in [**2116-7-3**], with 3 of 27 nodes being positive. He received adjuvant interferon, but had a soft tissue recurrence in the left neck a few months into therapy. This was resected and interferon therapy was resumed post surgery until [**Month (only) 404**] of [**2117**], when he developed contralateral neck soft tissue recurrence treated with surgical resection and parotidectomy in [**2117-4-3**]. Pathology revealed 4 of 8 nodes positive, and a large lymph node measuring 1.7 cm in the parotid. His interferon therapy was discontinued at this time. A PET CT scan in [**Month (only) 216**] of [**2117**] revealed lung nodules and a 3.3 cm left inguinal mass. Head MRI revealed a single brain metastasis in the right corona radiata. He [**Year (4 digits) 1834**] CyberKnife radiosurgery to this lesion in [**2117-11-3**]. He began high dose IL2 in [**2117-12-4**], without response. He developed deep vein thrombosis in [**Month (only) 404**] of [**2118**], requiring Lovenox. Followup head MRI revealed disease progression in the CNS. He was begun on CTLA4 antibody protocol on [**2118-3-1**], with 6 week scan showing disease progression, particularly in the CNS, and he [**Year (4 digits) 1834**] whole brain radiation therapy started on [**2118-4-12**]. He completed a 4-week course of radiation on [**2118-4-22**]. Repeat CT scan showed evidence of disease progression, particularly in the left inguinal area. Mr. [**Known lastname 79353**] [**Last Name (Titles) 1834**] surgical resection of a mass in his left groin area in [**2118-5-4**]. Surgery was able to remove the mass. Ventriculostomy [**2118-6-23**] for occlusive hydrocephalus. Had first dose of taxol [**2118-6-28**]. 2. s/p appendectomy as a child 3. Degenerative joint disease in the L5 area 4. Cervical neck surgery [**2112**] 5. DVT as above . Social History: Married, 2 children. Lives with wife and has pet dog. Formerly worked as a commercial fisherman, a construction worker, and other odd jobs. Quit smoking 15 years ago after 20 pack-year history. Very occasional EtOH. Family History: Mother passed away with metastatic uterine CA. Physical Exam: Vitals: T: 99.8, BP: 149/69, P: 87, R: 15, O2: 97% RA General: Somnolent, moving all extremities spontaneously but is not responsive to painful stimuli, no acute distress HEENT: Well-healed surgical scar on the superior aspect of the head, sclera anicteric, pupils 2mm and minimally responsive, MMM, oropharynx clear Neck: surgical scar in the left neck, supple, JVP not elevated, no LAD Lungs: coarse upper airway sounds, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; 10cm subcutaneous mass in the left axilla, 6-8cm subcutaneous mass in the left groin near his surgical excision site, and 5cm subcutaneous mass at the internal aspect of the right calf Skin: pinpoint echymoses on his abdomen [**3-7**] lovenox injections Pertinent Results: LABS ON ADMISSION: [**2118-8-13**] 07:00PM BLOOD WBC-9.6 RBC-3.97* Hgb-11.8* Hct-34.4* MCV-87 MCH-29.7 MCHC-34.2 RDW-15.8* Plt Ct-326 [**2118-8-13**] 07:00PM BLOOD Plt Ct-326 [**2118-8-13**] 07:00PM BLOOD Glucose-112* UreaN-23* Creat-0.7 Na-137 K-4.2 Cl-101 HCO3-23 AnGap-17 [**2118-8-13**] 07:00PM BLOOD TSH-2.0 LABS ON DISCHARGE: [**2118-8-17**] 12:00AM BLOOD WBC-6.3 RBC-3.41* Hgb-9.9* Hct-29.8* MCV-87 MCH-29.1 MCHC-33.3 RDW-15.9* Plt Ct-232 [**2118-8-17**] 12:00AM BLOOD Plt Ct-232 [**2118-8-17**] 12:00AM BLOOD Glucose-119* UreaN-32* Creat-0.7 Na-144 K-4.0 Cl-111* HCO3-23 AnGap-14 [**2118-8-17**] 12:00AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.3 CXR [**2118-8-13**]: New opacification at the right lung base accompanied by a greater elevation of the right hemidiaphragm could be atelectasis alone or combination of atelectasis and pneumonia, particularly aspiration. Large nodule in the right mid lung unchanged since [**Month (only) 547**]. Heart size normal. No appreciable pleural effusion. No pneumothorax. EKG [**2118-8-14**]: Sinus tachycardia, rate 140. Vertical axis. Cannot exclude inferior myocardial infarction of indeterminate age. S1-Q3-T3 pattern. Consider acute pulmonary embolism. Compared to the previous tracing of [**2118-8-14**] sinus bradycardia has given way to sinus tachycardia and axis is now vertical. Also, non-specific inferolateral repolarization changes have appeared. HEAD CT [**2118-8-14**]: No new focus of hemorrhage. Overall unchanged picture of hemorrhagic metastases. Brief Hospital Course: 1. ALTERED MENTAL STATUS: Most likely multifactorial but primarily from leptomeningeal involvement and hemorrhagic brain metastases with contributions from over-sedation from home benzodiazepines, PNA and UTI. On admission to the ICU patient was quite sedated and only minimally responsive. Across his stay he became more responsive and was able to follow commands, move all extremities, and at times speak quite coherently, although his mental status continued to wax and wane. During his hospitalization he also developed a left sided facial droop thought likely due to evolving brain metastases and leptomeningeal involvement. 2. GOALS OF CARE/CODE STATUS: The patient code status was made DNR/DNI during this admission and this was confirmed with the patient's wife. A family meeting was held to discuss goals of care, and it was decided to move towards hospice care after discharge. The patient's wife, however, appeared to hold out ongoing hope for the patient's recovery, and the patient himself expressed the desire to attempt one more round of Taxol. Discharged with home VNA and bridge to hospice. 3. METASTATIC MELANOMA WITH HEMORRHAGIC BRAIN METS: Known mets to scalp, neck, groin, brain s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16859**], [**First Name3 (LF) **] mass resection and ventriculostomy for obstructive hydrocephalus. On Taxol at admission, first dose 5/26. In previous discussions, patient has been clear that he did not desire further surgical intervention for control of his brain mets. He repeatedly stated his desire for one more attempt at treatment with Taxol, which was decided against given the patient's disease progression despite taxol therapy. Dexamethasone was continued for cerebral edema and all anticoagulation was held. 4. FEVERS/PNA/UTI: Fever and CXR on admission with consolidation at right base concerning for aspiration pneumonia, as well as WBCs in U/A. No elevation of WBC. Started on Vanc/Zosyn later changed to Vanc/Cefapime after blood cultures remained negative. Urine Cx grew out enterococcus which was sensitive to ampicillin, nitrofurantoin and vancomycin. 5. NAUSEA/VOMITING: Likely related to leptomeningeal involvement and metastatic impingement on fourth ventricle versus recent chemo. No evidence of increased intracranial pressure on head CT but during stay patient did develop left sided facial droop. Could be related to vertigo in setting of additional brain edema as in recent admission. He also has had dizziness and lighthededness with standing and sitting up, and on previous admission patient had orthostatic hypotension. Patient was treated with Ondansetron and Decadron. 6. h/o DVT: Dx in [**2-11**]. Lovenox stopped on admission given hemorrhagic brain mets. Medications on Admission: Dexamethasone 4mg PO q8 Lovenox 80mg SQ [**Hospital1 **] (held since [**8-12**]) Ativan 0.5mg PO TID Vicodin 1-2 tabs q6-8 prn Olanzapine 2.5mg PO BID prn Zofran 8mg PO TID prn Colace 100-200mg PO daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q4H (every 4 hours) as needed for pain. Disp:*500 ml* Refills:*4* 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:*40 Tablet(s)* Refills:*3* 4. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*40 Tablet(s)* Refills:*2* 5. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2 times a day). Disp:*300 ml* Refills:*2* 6. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation, hallucinations: Please take 1 tablet up to 3 times per day as needed for agitation or hallucinations. Disp:*90 Tablet(s)* Refills:*2* 7. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**2-4**] Tablet, Rapid Dissolves PO every four (4) hours: please take 1-2 tablets up to every 4 hours, as needed, to control nausea and vomiting. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2* 8. IVF Resumption of hydration and line per critical care systems. Normal saline as needed for hydration. 9. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 10. Dexamethasone Intensol 1 mg/mL Drops Sig: Six (6) ml PO every eight (8) hours. Disp:*qs 2 weeks* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: PRIMARY: 1. Melanoma, metestatic 2. Leptomeningeal invovlement 3. Mental status changes 4. UTI 5. PNA Discharge Condition: clinicall stable, moderately alert, pain controlled, patient and family aware of diagnosis, on comfort measures and IVF only Discharge Instructions: You were admitted for change in mental status thought to be secondary to progression of your cancer. Your symptoms are consistent with tumor involvement of the fluid in your spinal cord (called leptomeningeal invovlement). We had a family meeting with palliative care and Dr. [**Last Name (STitle) 79354**] team and discussed goals of care. You will be discharged home with VNA services with bridge to hospice. You will have a PICC line with IV fluids. . We have made changes to your medication. Please follow the discharge instruction. . Call your doctor if you have worsening pain or agitation or any other questions. Followup Instructions: Call your doctor if you have worsening pain or agitation or any other questions. [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12127, 12176

7769, 7780

308, 315

12322, 12449

6232, 6237

13118, 13303

5188, 5237

10781, 12104

12197, 12301

10553, 10758

12473, 13095

5252, 6213

247, 270

6567, 7746

343, 2799

6252, 6547

7795, 10527

2821, 4936

4952, 5172